Audrey Chigome1*
Nishana Ramdas1
Stephen M. Campbell1,2†
Márió Gajdács3†Israel Abebrese Sefah4†Ester Hango5†
Amos Massele6†
Brian Godman1,7,8*†
Johanna C. Meyer1,9†- 1Department of Public Health Pharmacy and Management, School of Pharmacy, Sefako Makgatho Health Sciences University, Ga-Rankuwa, South Africa
- 2School of Health Sciences, University of Manchester, Manchester, United Kingdom
- 3Department of Oral Biology and Experimental Dental Research, Faculty of Dentistry, University of Szeged, Szeged, Hungary
- 4Pharmacy Practice Department, School of Pharmacy, University of Health and Allied Sciences, Volta Region, Ho, Ghana
- 5Department of Pharmacy Practice and Policy, School of Pharmacy, University of Namibia, Faculty of Health Sciences, Namibia
- 6Department of Clinical Pharmacology and Therapeutics, School of Medicine Kairuki University, Dar Es Salaam, Tanzania
- 7Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, United Kingdom
- 8Antibiotic Policy Group, Institute for Infection and Immunity, City St. George’s, University of London, London, United Kingdom
- 9South African Vaccination and Immunisation Centre, Sefako Makgatho Health Sciences University, Ga-Rankuwa, South Africa
There are considerable concerns with antimicrobial resistance (AMR) across Africa, enhanced by the inappropriate prescribing of antibiotics in ambulatory care. This includes prescribing for self-limiting conditions and Watch antibiotics. Inappropriate prescribing is enhanced by concerns with ambulatory care prescribers’ knowledge of antibiotics, including their perceived effectiveness for self-limiting conditions, AMR, and antimicrobial stewardship programs (ASPs). Appropriate education of prescribers, including surrounding the AWaRe (Access, Watch, and Reserve) system and guidance, which recommends the prescribing of antibiotics with less resistance potential, alongside introducing ASPs in ambulatory care, can help address these concerns. This will increasingly include instigating agreed quality indicators, and their monitoring, surrounding the AWaRe system and guidance. Improved surveillance of local resistance patterns can help with appropriately updating antibiotic prescribing guidance, including revising the AWaRe guidance based on local resistance patterns. Additional financing is also needed to help attain national goals.
1 Introduction
Antimicrobial resistance (AMR) contributes significantly to increased morbidity and mortality while also escalating healthcare costs (1–4). As a result, AMR is now a critical global public health threat, potentially becoming the next pandemic (5, 6). The concern with the rising AMR is reflected in the recent ambitious reduction targets for AMR agreed at the United Nations General Assembly (UN-GA) in September 2024 (7). Key target countries for reducing AMR are low- and middle-income countries (LMICs) where the burden of AMR is greatest, including among African countries (8–11). It is currently estimated that LMICs are responsible for over three-quarters of the 10 million deaths globally each year attributable to AMR, with the number of deaths due to AMR continuing to grow (8, 12). The high rates of AMR in LMICs, including among African countries, are attributable to the high rates of inappropriate prescribing and dispensing of antibiotics, including those from the Watch list of the World Health Organization (WHO) with their higher resistance potential (13–16).
There are a number of ongoing international, regional, and national initiatives designed to reduce AMR, particularly among LMICs. These include the launch of the Global Action Plan (GAP) by the WHO in 2015 to provide a stimulus to countries to rapidly instigate multiple coordinated activities to improve antibiotic use across sectors in order to reduce AMR, subsequently translated into National Action Plans (NAPs) (17, 18). Other global activities include classifying antibiotics into Access, Watch, and Reserve (AWaRe) groups based on their resistance potential, with the greatest focus on reducing the high and growing use of Watch antibiotics due to their greater resistance potential among LMICs (14, 19). The WHO AWaRe book, launched in 2022, provides treatment guidance for 35 infectious conditions, including alternatives to antibiotics for self-limiting infections (20).
Regional and national initiatives across Africa increasingly incorporate measures to reduce the unnecessary prescribing of antibiotics in primary care, principally for self-limiting conditions such as upper respiratory tract infections (URTIs). Such activities are exacerbated by concerns about limited knowledge regarding antibiotics, AMR, and antimicrobial stewardship (AMS) among prescribers across Africa (Tables 1, 2, 3) (21–24). There are also ongoing initiatives to reduce the high levels of inappropriate dispensing of antibiotics without a prescription across Africa, increasing AMR, which is also observed in other LMICs (25–27). Both situations are not helped by pressure from patients on healthcare professionals (HCPs), including nurses and community pharmacists, to prescribe or dispense antibiotics typically for self-limiting infections (22, 28). Effectively addressing these issues is essential to reducing AMR in LMICs, including African countries, with primary care accounting for up to 95% of antibiotic use in humans (29, 30).
Table 1. Examples of inappropriate prescribing of antibiotics in ambulatory care among African countries.
Table 2. Examples of concerns with knowledge of antibiotics, antimicrobial resistance (AMR), and antimicrobial stewardship (AMS) among prescribers in ambulatory care across Africa.
Table 3. Possible policy options to improve future prescribing of antibiotics in ambulatory care across Africa.
Potential ways forward to reduce the unnecessary prescribing of antibiotics in primary care across Africa are discussed in Section 2, which is based on the considerable knowledge of the co-authors working across Africa. This includes improved education of prescribers, with Balliram et al. (63) stating that educational campaigns targeted at key prescribers, use of and adherence to standard treatment guidelines (STGs)/essential medicine lists, and improved infection control measures are all seen as important strategies to combat AMR.
2 Policy options and the implications for reducing unnecessary prescribing of antibiotics in ambulatory care across Africa
A number of policy options have been proposed to reduce the unnecessary prescribing of antibiotics across Africa (21). These are summarized in Table 3, triangulating available evidence with the resultant implications and potential outcomes included within actionable recommendations. This does not include requests by patients for antibiotics without a prescription (22, 25, 64) or targeted educational campaigns among patients to reduce unnecessary requests to prescribers for antibiotics, especially for self-limiting conditions, which are discussed in Saleem et al. (22) and in Ramdas et al. (65). These key areas are also being explored further in future research projects. However, examples of ASPs undertaken among patients to reduce unnecessary requests and the use of antibiotics are included in Table 4. We are aware that there are concerns with the available funding and personnel in LMICs to undertake ASPs (66). In addition, issues with the limited availability of antibiotics in a number of primary healthcare centers (PHCs) across LMICs, which is exacerbated by challenges in stock control management and procurement, are barriers to the instigation of ASPs. Ongoing resistance to changing antibiotic prescribing practices, and lack of information technology to guide and monitor prescribing habits, as well as limited interprofessional collaboration, are also barriers to the successful implementation of ASPs. The lack of enforcement of possible policies, including routinely documenting and auditing prescribing practices and the lack of robust and well-researched antibiotic guidelines, are also seen as barriers to the successful implementation of ASPs in LMICs (21, 67–70). However, we are seeing an increasing number of ASPs now being undertaken across all sectors of care among African countries to improve future antibiotic use, which will continue and provide exemplars for the future (22, 71–74).
Table 4. Antimicrobial stewardship programs (ASPs) and their impacts among both prescribers and patients across low- and middle-income countries (LMICs) including African countries.
However, to improve future antibiotic prescribing across Africa, all suggested activities must be underpinned with dedicated, ring-fenced, and sustainable funding mechanisms. These include educational activities in universities and post-qualification, NAPs, and ASPs (15, 66, 75, 76). Alongside this, assess and potentially increase funding to address the 40 global research priorities identified by the WHO to reduce AMR among humans, which build on the GAP for AMR (17, 77, 78). We are beginning to see LMICs start to document their progress toward addressing the WHO research priorities, and this is likely to continue, driven by governments and others especially given the urgency to reduce AMR across LMICs (79). Nurses typically play a key role in managing patients within public PHCs across Africa; consequently, they are a critical group to also include in policy initiatives to improve future antibiotic prescribing (22, 80, 81).
3 Actionable recommendations
Actionable recommendations were based on their impacts in published studies across LMICs combined with the considerable experience of the co-authors. These include more general recommendations (Table 5) and among prescribers and patients along with ASPs, with the impact of ASPs documented in Table 4. Table 4 only includes a limited number of educational campaigns among patients to reduce unnecessary requests to prescribers for antibiotics, particularly for self-limiting conditions. This is because such programmes have already been discussed in more detail in Saleem et al. (21, 22) and in Ramdas et al. (28, 65), and potential additional ASPs will also be explored in more detail in future research projects.
Table 5. Actionable recommendations.
We are aware of a number of limitations with our policy brief. These primarily include the fact that we have not undertaken a systematic review. However, we have undertaken a narrative review that included several examples of (i) inappropriate prescribing of antibiotics in ambulatory care among African countries; (ii) concerns about knowledge of antibiotics, AMR, and AMS among prescribers; (iii) possible policy options; (iv) actionable recommendations; and (v) ASPs to provide future policy guidance based on robust examples. The guidance was based on the considerable experience of the co-authors working across Africa and other LMICs. We have successfully used this approach previously (21, 22, 25, 71, 112).
4 Conclusions
There are considerable concerns with the level of inappropriate prescribing of antibiotics across Africa, exacerbating the already excessive levels of AMR. These include the high levels of prescribing of antibiotics for essentially self-limiting infections and the high levels of prescribing of Watch antibiotics across a number of African countries. The high levels of inappropriate antibiotic prescribing are exacerbated by concerns about limited knowledge of antibiotics, AMR, and AMS among prescribers across Africa. Key activities going forward include appropriate education of HCPs, including both physicians and nurses, among African universities both before and after graduation, particularly surrounding the WHO AWaRe system and guidance. Alongside this is the introduction and monitoring of quality indicators as part of pertinent ASPs. These are essential to meet the UN-GA targets for Access antibiotics and AMR across Africa.
Author contributions
AC: Writing – original draft, Validation, Formal analysis, Writing – review & editing, Investigation, Data curation, Methodology, Conceptualization. NR: Methodology, Writing – review & editing, Investigation, Data curation, Formal analysis, Validation. SC: Data curation, Methodology, Validation, Formal analysis, Conceptualization, Investigation, Writing – review & editing. MG: Validation, Formal analysis, Writing – review & editing, Methodology, Investigation. IS: Validation, Methodology, Data curation, Formal analysis, Investigation, Writing – review & editing. EH: Formal analysis, Validation, Data curation, Methodology, Investigation, Writing – review & editing. AM: Investigation, Formal analysis, Validation, Methodology, Writing – review & editing. BG: Conceptualization, Writing – original draft, Supervision, Visualization, Validation, Methodology, Data curation, Writing – review & editing, Formal analysis, Investigation. JM: Writing – original draft, Methodology, Formal analysis, Visualization, Investigation, Data curation, Supervision, Validation, Writing – review & editing, Conceptualization.
Funding
The author(s) declare that no financial support was received for the research and/or publication of this article.
Acknowledgments
The authors are thankful for the support of the Study Group for Dental Research Methodology and Health Sciences, University of Szeged.
Conflict of interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Generative AI statement
The author(s) declare that no Generative AI was used in the creation of this manuscript.
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Keywords: antibiotics, AWaRe, antimicrobial resistance, antimicrobial stewardship programs, policy initiatives, primary care, sub-Saharan Africa
Citation: Chigome A, Ramdas N, Campbell SM, Gajdács M, Sefah IA, Hango E, Massele A, Godman B and Meyer JC (2025) Potential activities to improve primary care prescribing of antibiotics across Africa. Front. Trop. Dis. 6:1634182. doi: 10.3389/fitd.2025.1634182
Received: 23 May 2025; Accepted: 15 July 2025;
Published: 26 August 2025.
Edited by:
Sylvia Opanga, University of Nairobi, KenyaReviewed by:
Faiz Ullah Khan, Xi’an Jiaotong University, ChinaGayathri Govindaraju, Rutgers, The State University of New Jersey, United States
Copyright © 2025 Chigome, Ramdas, Campbell, Gajdács, Sefah, Hango, Massele, Godman and Meyer. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Audrey Chigome, YXVkcmV5LmNoaWdvbWVAc211LmFjLnph; Brian Godman, YnJpYW4uZ29kbWFuQHNtdS5hYy56YQ==
†ORCID: Stephen M. Campbell, orcid.org/0000-0002-2328-4136
Israel Abebrese Sefah, orcid.org/0000-0001-6963-0519
Amos Massele, orcid.org/0000-0003-3816-2040
Brian Godman, orcid.org/0000-0001-6539-6972
Johanna C. Meyer, orcid.org/0000-0003-0462-5713
Márió Gajdács, orcid.org/0000-0003-1270-0365
Ester Hango, orcid.org/0000-0002-7112-4049