Global Variation in Antibiotic Prescribing Guidelines and the implications for decreasing AMR in the future

Emmama Jamil¹Zikria Saleem^1*Brian Godman^2,3,4*Matti Ullah⁵Afreenish Hassan⁶Abdul Haseeb⁷Johanna Catharina Meyer³Muhammad Usman Qamar⁸Safa Almarzoky Abuhussain⁹

• ¹Bahauddin Zakariya University, Multan, Punjab, Pakistan
• ²Laboratory Medicine Clinical Pharmacology, Strathclyde Institute of Pharmacy and Biomedical Sciences, Faculty of Science, University of Strathclyde, Glasgow, United Kingdom
• ³Sefako Makgatho Health Sciences University, Pretoria, South Africa
• ⁴St George’s Hospital, London, United Kingdom
• ⁵Hamdard University Islamabad, Islamabad, Islamabad, Pakistan
• ⁶National Institute of Health, Islamabad, Pakistan
• ⁷Al Rayan Colleges, Medina, Saudi Arabia
• ⁸University of Faisalabad, Faisalabad, Punjab, Pakistan
• ⁹Umm al-Qura University, Mecca, Saudi Arabia

Introduction: Antimicrobial resistance (AMR) has become a global burden for which inappropriate antibiotic prescribing is an important contributing factor. Antibiotic prescribing guidelines have an important role with improving the quality of antibiotic use if they are evidence based and regularly updated. As a result, help to reduce AMR, which is a critical challenge low- and middle-income countries (LMICs). Consequently, the objective of this study was to evaluate local, national and international antibiotic prescribing guidelines currently available, especially among LMICs, as well as previous challenges, now that the WHO AWaRe book is published providing future direction. Methodology: Google scholar and PubMed searches were complemented by searching official country websites to identify antibiotic prescribing guidelines, especially regarding empiric treatment of bacterial infections, for this narrative review. Data was collected regarding the country of origin, its income level, guideline title, year of publication, development methodology, issuing organization, target population, scope and coverage. In addition, any documentation regarding implementation strategies, compliance and monitoring of outcome measures, as well as any patient education or counselling associated with the guidelines to improve their use. Results/ Findings: 181 guidelines were included, with the majority originating from high-income countries 109 (60.2%), followed by lower-middle-income 40 (22.1%), low-income 18 (9.9%), and upper-middle-income 14 (7.7%) countries. The GRADE methodology was utilized in only 20.4% of the sourced guidelines, predominantly among high-income countries. Patient education was often underemphasized, particularly in LMICs. The findings highlighted significant disparities in guideline development, adaptation, and implementation across the different WHO Regions, confirming previous limited standardization and comprehensiveness of guidelines in LMICs. Conclusion: Significant disparities exist in the availability, structure, and methodological rigor of antibiotic prescribing guidelines across countries with different income levels. Advancing the development and implementation of standardized, context-specific guidelines aligned with the WHO AWaRe framework, and supported by equity-focused reforms, can significantly strengthen antimicrobial stewardship and address the public health challenge of AMR.