https://orcid.org/0000-0003-4140-2850
Figures
Abstract
Antimicrobial resistance is a global public health crisis. Effective antimicrobial stewardship requires an understanding of the factors and context that contribute to inappropriate use of antimicrobials. The goal of this qualitative systematic review was to synthesize themes across levels of the social ecological framework that drive inappropriate use of antimicrobials in South Asia. In September 2023, we conducted a systematic search using the electronic databases PubMed and Embase. Search terms, identified a priori, were related to research methods, topic, and geographic location. We identified 165 articles from the initial search and 8 upon reference review (n = 173); after removing duplicates and preprints (n = 12) and excluding those that did not meet eligibility criteria (n = 115), 46 articles were included in the review. We assessed methodological quality using the qualitative Critical Appraisal Skills Program checklist. The studies represented 6 countries in South Asia, and included data from patients, health care providers, community members, and policy makers. For each manuscript, we wrote a summary memo to extract the factors that impede antimicrobial stewardship. We coded memos using NVivo software; codes were organized by levels of the social ecological framework. Barriers were identified at multiple levels including the patient (self-treatment with antimicrobials; perceived value of antimicrobials), the provider (antimicrobials as a universal therapy; gaps in knowledge and skills; financial or reputational incentives), the clinical setting (lack of resources; poor regulation of the facility), the community (access to formal health care; informal drug vendors; social norms), and policy (absence of a regulatory framework; poor implementation of existing policies). This study is the first to succinctly identify a range of norms, behaviors, and policy contexts driving inappropriate use of antimicrobials in South Asia, emphasizing the importance of working across multiple sectors to design and implement approaches specific to the region.
Citation: Murray JL, Leung DT, Hanson OR, Ahmed SM, Pavia AT, Khan AI, et al. (2024) Drivers of inappropriate use of antimicrobials in South Asia: A systematic review of qualitative literature. PLOS Glob Public Health 4(4): e0002507. https://doi.org/10.1371/journal.pgph.0002507
Editor: Ferdinand Mukumbang, University of Washington, UNITED STATES
Received: September 27, 2023; Accepted: February 21, 2024; Published: April 4, 2024
Copyright: © 2024 Murray et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the paper.
Funding: This systematic review was accomplished with support from the National Institutes of Health (R01 AI135114 to DTL; R21 HD109819 to DTL and AIK; K24 AI166087 to DTL) and the Agency for Healthcare Research and Quality (K08 HS086530 to VMV). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
Introduction
The World Health Organization has identified antimicrobial resistance (AMR), the emergence and spread of pathogens resistant to antimicrobial agents, as one of the top ten global public health threats facing humanity [1]. AMR is driven largely by misuse and overuse of antimicrobial agents within both the medical and agricultural sectors, which has increased over the last two decades [2]. AMR threatens the efficacy of commonly used clinical antimicrobial agents, posing significant threats to human health. Infections associated with antimicrobial resistant bacteria, as opposed to a non-resistant form, confers two times the risk of a serious health outcome and three times the risk of mortality [3]. It is estimated that in 2019 AMR directly resulted in 1.2 million deaths and was a contributing factor in almost 5 million additional deaths worldwide [4]. If effective action to curb AMR development is not taken, it is estimated that by 2050, antimicrobial resistant diseases could result in 10 million deaths annually across the globe [5].
South Asia has seen a rapid increase in access to and use of antimicrobials, accompanied by a rise in AMR [6]. Health services in many South Asian countries are fragmented and rely on an uncoordinated mix of private and public services. These fragmented health systems provide a space in which inappropriate antimicrobial use can go unchecked and AMR flourishes [7]. The impact of AMR on human health in South Asia is profound. In India, nearly 60,000 newborns die each year as a direct result of AMR neonatal infections [8]. A 2021 study found that Bangladeshi children with bacteremia resistant to all first- and second-line treatments had an increased risk of death compared to those with susceptible bacteria [9].
Antimicrobial stewardship is a holistic approach to facilitating responsible use and protection of antimicrobial agents through the combined efforts of individuals, organizations, institutions, and policies [10]. The goal of stewardship is to reduce AMR and improve patient outcomes by ensuring that antimicrobials are used only when necessary, that appropriate antimicrobials are chosen considering the risk of AMR, and that antimicrobials are used for the minimal duration necessary to treat infection [11]. Antimicrobial stewardship programs typically focus on efforts in the health care system that promote the appropriate use of antimicrobials within a facility [12]. However, the World Health Organization acknowledges that particularly in low- and middle-income country settings, antimicrobial stewardship requires the participation and buy-in of both formal and informal health care providers, community members, and patients [13]. Reducing the inappropriate use of antimicrobials requires a change in human thought and behavior [14]; therefore, interventions to promote antimicrobial stewardship need to be informed by the behavioral, social, cultural, and structural factors that shape how people use antimicrobials [15]. Understanding the multi-level factors that contribute to inappropriate use of antimicrobials is a key step in designing strategies to combat AMR.
Qualitative methods (e.g. interviews, ethnography, focus groups) are well-suited to generate knowledge about the social determinants of antimicrobial overuse and the context in which AMR flourishes [16]. Qualitative data contain in-depth insight elicited from research subjects in their own words, offering novel understanding of the actionable drivers of antimicrobial misuse. Systematic reviews of qualitative research are valuable in synthesizing across studies to identify commonalities across studies that can efficiently inform the design and implementation of antimicrobial stewardship [17]. In this review paper, we aimed to synthesize themes across levels of the social ecological framework that drive inappropriate use of antimicrobials in South Asia. These findings can help identify areas for future research and intervention to prevent and mitigate AMR in South Asia.
Materials and methods
Overview and study criteria
We conducted a systematic review of the literature and used thematic synthesis [18] to integrate findings across qualitative studies. In conducting this review, we adhered to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines [19], with attention to the unique requirements for reporting qualitative research as outlined in the Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) statement [20].
Studies were eligible to be included in the systematic review if they met the following criteria: 1) English language research paper in a peer-reviewed journal, 2) used qualitative methods (including in-depth interviews, focus group discussions, or ethnographic observations), 3) reported qualitative themes related to factors driving inappropriate use of antimicrobials, or factors impeding antimicrobial stewardship, 4) reported data related to the human consumption of antimicrobials, and 5) reported data collected in South Asia (defined by the World Bank as Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, Sri Lanka) [21]. Systematic reviews, opinion pieces, and editorials were excluded. There were no restrictions with respect to the date of publication.
Search strategy and selection criteria
On September 18, 2023, we conducted a systematic search of the electronic databases PubMed and Embase. The search and selection processes were conducted by the first author (JLM) and repeated by the third author (OH) for consistency. We identified search terms related to research method, topic, and location (Table 1). Search results from both databases were downloaded to Zotero for review. After eliminating duplicates, we reviewed abstracts to eliminate papers that did not meet the inclusion criteria. The full texts of all remaining papers were then reviewed to confirm that they met inclusion criteria. The reference lists of included papers were reviewed to identify any additional papers that missed in our search. Discrepancies were resolved by consulting the last author (MHW).
Data extraction and synthesis
Eligible mixed-methods and multi-site studies were adjusted to only include qualitative findings from World Bank defined South Asian countries in our analysis. We created a memo template to extract the themes reported in each study. The memos included information about the study, and a description of major themes that were reported across the levels of the social ecological framework [22]. The social ecological framework was chosen as an organizing framework to facilitate identification and organization of barriers across different levels of influence. Table 2 describes how we defined each level of the social ecological framework for the purpose of this study.
Each memo was reviewed by a second analyst for review and verification of the capture of findings from the original paper. Disagreements were resolved by consensus. The memos were uploaded into NVivo (version 12 Pro) qualitative data analysis software. Applied thematic analysis [23] was used to identify common themes across studies. We created a coding structure that included the levels of social ecological framework as the codes, and emerging themes under each level as the sub-codes. Two individuals dually coded all memos and met periodically to review and reconcile emerging codes. Discrepancies in coding were resolved by JM and MHW. After all memos were coded, the first author (JLM) and last author (MHW) met to review the coding structure, to merge and split codes as needed. Coding reports were analyzed, with reference to the source material as needed to synthesize and contextualize the findings.
Critical appraisal
To assess the quality of the included studies, two individuals evaluated each paper using the Critical Appraisal Skills Program (CASP) for qualitative studies [24] and resolved any discrepancies by consensus upon consulting the first (JLM) and last (MHW) authors. Following our CASP review, all studies met quality criteria of research objective, appropriate qualitative methodology, research design, recruitment strategy, and data collection methods.
Registration and protocol
The protocol for the systematic review was registered with PROSPERO (CRD42023456791). Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023456791.
Results
Included studies
The search and selection processes are summarized in Fig 1. The initial literature search yielded 165 results, and 8 additional publications were included upon reference review throughout the process for a total of 173 papers considered. After removing 11 duplicates and 1 preprint, 161 publications underwent abstract review, then 50 to full-text review. 46 publications were included in the final analysis [25–70], with publication dates ranging from 2010 to 2023. Table 3 includes a detailed description of the 46 publications that met criteria and were included in the final analysis.
Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021;372:n71. 10.1136/bmj.n71.
The papers represent 6 of the 8 South Asian countries of interest. India had the highest study representation (n = 20), followed by Pakistan (n = 12), Bangladesh (n = 8), Nepal (n = 4), then Bhutan and Sri Lanka (n = 1 each). No studies were identified from the Maldives or Afghanistan. The studies used a wide variety of qualitative methodologies, the most common being individual interviews (n = 37) and focus group discussions (n = 13). Human subjects included patients, physicians (working in various specialties and sectors), nurses, pharmacists, community members (urban and rural, with various socioeconomic status), caregivers, government employees, national policy advisors, pharmaceutical industry staff, staff of nongovernmental healthcare organizations, international policy body representatives, students and faculty, drug vendors, and informal healthcare providers.
Data extraction and synthesis revealed themes at each level of the social ecological framework (Fig 2). Table 4 provides brief descriptions of each of the 12 themes that emerged.
Individual level: Patients and their caregivers
Two major themes emerged at the individual level, representing the experiences and circumstances of patients and their caregivers: self-treatment with antimicrobials, and the perceived value of antimicrobials.
Drivers of inappropriate use of antimicrobials.
Multiple studies reported that patients self-treat with antimicrobials due to multiple barriers, with socioeconomic status cited most frequently [27,28,30,45,48,53,70]. For example, patients living in rural villages may not have adequate funds to travel to formal health care facilities and obtain diagnostic testing and prescriptions [26,37,51]. Additionally, it was noted that patients and caregivers may be hesitant to seek medical care when they have “minor ailments,” due to the increased practice of referring out to specialized physicians which costs more money, additional time, and travel [71–73]. Limited access to the formal health care system often leads patients to self-treat with antimicrobials when presenting with a wide variety of symptoms including diarrhea, stomach pain, cough, and fever by rationing antimicrobials [74–77]. A patient’s decision to self-treat is informed by the perception that antimicrobials work based on prior therapeutic success with antimicrobials in themselves, family, or friends. Antimicrobials for self-treatment are obtained by receiving medication from a friend or family member, using leftover medication, or directly obtaining medication without a prescription from a pharmacy [65,74,75,78].
Perceived value of antimicrobials.
A number of studies reported the perception held by patients that the receipt of an antimicrobial prescription indicates high quality medical care, as antimicrobials are perceived as offering an objective and rapid solution to their illnesses [75,77,79,80]. Overall, antimicrobials are perceived as powerful drugs that provide a quick solution to a range of ailments [81]. Studies attribute this attitude to a lack of knowledge not only surrounding antimicrobial resistance, but more generally around medicine, diagnostics, and treatments [28,79,82–85]. Additionally, caregivers report feeling a sense of emotional relief receiving an antimicrobial prescription because they believe it will successfully treat their children, elders, and other vulnerable groups [81,86]. The high value placed on antimicrobials and belief in their power leads patients to expect and even demand antimicrobials when seeking medical care [87–89]. Patients will “doctor shop” or seek care only from providers who are known to readily provide antimicrobials or pharmacies that are liberal with their distribution [65,90–92].
Interpersonal level: Formal health care workers
Three major themes emerged at the interpersonal level, representing formal health care workers: antimicrobials as a universal therapy, gaps in knowledge and skills, and financial or reputational incentives.
Antimicrobials as a universal therapy.
In multiple studies, participants spoke about how antimicrobials provide a cheap and accessible treatment plan for a wide variety of medical conditions, particularly in the absence of diagnostic and treatment options [71,82,90]. Clinician participants described that it is common practice for providers to prescribe antimicrobials when they are unsure of a patient’s medical diagnosis, waiting for laboratory testing results, or even as a preventative measure to reduce the occurrence of secondary infections [71,89,93]. Dispensing antimicrobials based on prior therapeutic success was described as an appropriate treatment for patients presenting with similar symptoms [82,89]. Therefore, in many countries broad-spectrum antimicrobials was perceived as universal therapy for any general illness in conjunction with other common medications such as ibuprofen or acetaminophen [71,72,77,82,89]. Some providers directly handed medications to patients without writing a prescription or providing the medication name [77].
Gaps in knowledge and skills.
Many health care workers reported lacking knowledge surrounding antimicrobial stewardship and appropriate prescribing practices. Multiple studies with clinicians and students noted a lack of awareness of existing antimicrobial stewardship programs in their facilities, and an absence of training curricula on appropriate use of antimicrobials [94,95]. Among clinicians with some understanding of antimicrobial resistance and/or stewardship programs, many held misconceptions or denied the severity of the problem [89,96]. Others believed that specific medical specialties (e.g., surgery) or individuals in leadership (e.g., chief physicians) should be responsible for taking action and managing antimicrobial distribution in their own teams and departments [97,98].
Financial or reputational incentives.
Clinicians described the pressures they faced to dispense antibiotics to their patients. They noted that patients associated the dispensing of medications with a high level of care, leading them to dispense antimicrobials in hopes of increasing business and patient satisfaction [28,77,90]. Business success is dependent on positive community reviews and reputation, leading clinicians to prioritize patient demands over clinical guidelines, especially with wealthy or influential patients [28,99]. It was reported that pharmaceutical companies also play a role by providing financial incentives to providers for prescribing high volumes of certain antimicrobials and other medications [28,69,87,90,99–101].
Facility level: Clinical settings
Two major themes emerged at the facility level, representing formal health care facilities: lack of resources, and poor regulation of the facility.
Lack of resources.
Multiple studies reported a widespread shortage of medical infrastructure, equipment, and personnel across diverse settings, resulting in poor access to laboratory testing and diagnostics. In urban settings, there is a shortage of hospital personnel paired with a high volume of patients, leading to the prescription of common antimicrobial regimens without in-depth assessment of patients or laboratory testing [82,88,95,99,102,103]. Additionally, physicians are often unavailable or there are long wait times, prompting individuals to obtain antimicrobials on their own rather than access these formal facilities [28,66,77,84]. Multiple studies also reported that in rural areas, treatment and testing facilities are lacking altogether, requiring patients to travel long distances to reach health facilities. As a response to these resource shortages in the formal health care system, informal medical practices and drug stores are common, where individuals may directly purchase antimicrobials without a prescription [84].
Poor regulation of the facility.
Studies showed conflicting accounts of antimicrobial availability and regulation within facilities. In India, Kotwani et al. report that public sector healthcare facilities will under- or over-prescribe antimicrobials based on their current stock, leading to inconsistent prescription patterns that encourage patients to share or obtain antimicrobials from community and family members [76]. When antimicrobials are formally prescribed, facilities often lack or underuse drug reporting systems and do not maintain clinical documentation. Several studies noted the challenges of developing and implementing antimicrobial stewardship program, depending largely on the prioritization of leadership [81,97]. The hierarchical structure of medical systems can be a barrier in implementing antimicrobial stewardship practices if senior physicians or leadership does not prioritize it [97].
Community level: Community practices and social norms
Three major themes emerged at the community level: access to formal healthcare, informal drug vendors, and social norms.
Access to formal healthcare.
Studies described a multitude of systemic barriers to accessing the formal health care system, including rural areas with limited infrastructure, long wait times, poor quality of care, an inability to pay for services, or the complexity of navigating health systems [73,74,87]. Instead of accessing formal care, many patients reported that they instead relied on informal drug vendors who ran small drug stores that provided consultations and dispensed medications [65,72,74,75].
Informal drug vendors.
These informal drug vendors report being commercially driven to sell medications and reach sales targets, often resulting in an over prescription of antimicrobials, inaccurate dosing, and the distribution of “half” antimicrobials which may be mixed with other materials (e.g., caffeine, routine pain medications) [28,74,85]. In a study of informal healthcare providers in rural India, Khare et al. explained how informal drug vendors are an essential resource for rural and medically underserved communities, where antimicrobials are often handed out in response to a verbal description of symptoms or patient demand based on prior treatment success [91]. The authors noted that without informal drug vendors, these patients would likely forego healthcare entirely.
Social norms.
Social norms surrounding the use of antimicrobials also emerged as a significant factor promoting inappropriate use. The sharing of antimicrobials between family and friends is a socially accepted and rooted practice in many South Asian settings [74]. Additionally, individuals will often trade medical advice with their social networks and encourage others to obtain specific antimicrobials that treated their own symptoms in the past [86]. In Bangladesh, Lucas et al. explained that women will typically ask their husbands for diagnostic or treatment advice rather than visiting a formal physician [73]. Community norms related to antimicrobial use drive dispensing patterns. As mentioned at the interpersonal level, over-prescription of antimicrobials is common to retain patients and provide the perception of high-quality care that is associated with antimicrobials [28,102].
Policy level: Governance and legislation
Two major themes emerged at the policy level: absence of a regulatory framework to monitor and control antimicrobials, and poor implementation of existing policies of antimicrobial stewardship.
Absence of a regulatory framework.
Studies across various countries noted that national, state, and local governments, and their policy infrastructures, were ultimately responsible for antimicrobial stewardship programs (ASPs) in clinical settings. In a study of ASP development and implementation in India, Charani et al. (2019) conducted interviews with clinical providers in India and noted a lack of national infrastructure to legislate and control access to antimicrobials; strong local leadership and championing was necessary to make up for this shortcoming and create successful ASPs [98]. Similar concerns about regulation and surveillance were identified in Pakistan among physicians [50] and pharmacists [65]. The study by Hayat et al (2019) indicated several barriers in ASP implementation in hospitals, which could be overcome if the government were to provide necessary support, including legislation and funding [50].
Poor implementation and regulation.
Other studies noted that even in countries with existing government regulation and legislation, it is difficult to navigate, understand, and consistently enforce these policies in clinical settings [67,69,70]. In a study of policymakers and clinicians in Bhutan and Nepal, Maki et al. 2020 described policies related to prescription-only sales of antimicrobials, but a lack of enforcement in both the clinical and community settings [95].
Discussion
We report the results of a qualitative systematic review of studies conducted in South Asian countries to examine the factors that drive inappropriate use of antimicrobials. Through the synthesis of findings reported in 46 qualitative studies, we identified multiple factors across five levels of the social ecological framework: the individual patient, the formal provider, the clinical setting, the community, and policy. Drivers of inappropriate use of antimicrobials were evident at all levels, highlighting the importance of working across multiple levels and sectors to address drivers of antimicrobial misuse and build commitment for stewardship in South Asia. These findings align with other systematic reviews and analyses of both qualitative and quantitative research on antimicrobial resistance and stewardship efforts around the world [104–106], emphasizing the need for coordinated global action in addition to region-specific solutions.
The heterogeneity of South Asian healthcare systems presents significant barriers to antimicrobial stewardship. The studies in our analysis described regional differences in facility sizes and accessibility, administration involvement, government influence, licensure and formal education requirements of healthcare workers, pharmacy policies, and drug regulation programs. Further research is needed to assess these factors in countries that were under-represented in the literature, such as Afghanistan and the Maldives, so interventions can be specifically tailored by region. Most studies depicted fragmented systems in which there is little communication amongst formal providers within individual hospitals and clinics, health systems, and their greater communities. Improving this communication is crucial for the success of any intervention. Compared to studies in Sub-Saharan Africa and Latin America, the utilization of informal drug dispensers and unregulated community pharmacies is much more prevalent in South Asia [104,107]. Therefore, it is essential for antimicrobial stewardship efforts in South Asia to target both formal and informal healthcare workers.
Both formal prescribers and informal drug dispensers face immense social and financial pressures from patients and pharmaceutical companies to liberally supply antimicrobials despite knowing about AMR and the resulting health consequences. Our data suggest that it is normative in many hospitals and clinics to order antimicrobials as a universal therapy to cover a variety of potential illnesses, appease patients, and generate pharmaceutical revenue. Shifting norms that are so embedded in the healthcare industry will require a multifaceted, longitudinal approach that encourages provider behavioral change. Potential solutions may include investing in the workforce to remove profit incentive of dispensing drugs, implementation of a regulatory framework to control antimicrobial prescribing in both public and private facilities, and required educational curriculum specific to antimicrobial stewardship in early stages of medical training to facilitate a sense of ownership and responsibility as providers. Community pharmacies and informal drug dispensers should also be formally regulated to control the use of antimicrobials, though alternative opportunities for business revenue must be identified to encourage meaningful and sustainable change.
Patient expectations and demands were universally identified as a significant driver of inappropriate antimicrobial use. This is primarily driven by a larger systemic issue of healthcare inaccessibility, pushing individuals to demand antimicrobials during limited provider visits or seeking them in their communities and social networks instead. To effectively shift this cultural norm, increasing accessibility to care must be prioritized, especially in low-income and geographically isolated communities. Efforts might include investing in public transportation that extends to rural areas and villages, investing in education at all levels, and recruiting medical workers from underrepresented regions who are likely to return to those communities to practice. Existing facilities should expand to formally integrate laboratory testing and diagnostic equipment and should prioritize quality improvement to better serve patients. Additionally, public health campaigns and community health workers can better educate the general public on infection prevention and the negative impacts of antimicrobial overuse as has successfully been done in the Indian state of Kerala [108].
Our data suggested a dearth of policies addressing antimicrobial stewardship, and poor enforcement of existing policies. Interventions might include adopting a national antimicrobial monitoring system, requiring consults with pharmacists who have antimicrobial stewardship-specific expertise, providing financial incentives for infection prevention and reduced antimicrobial prescribing, or developing and requiring a national, standardized educational training for all antimicrobial dispensers [109–112]. Policy reform and legislation alone are not sufficient to facilitate widespread antimicrobial stewardship nor combat resistance; it is also necessary to change individual behaviors and the embedded cultural norms that encourage them. There are multiple public health programs that facilitate social and behavioral change at the individual, family, and community level [113]. For example, water, sanitation and hygiene (WASH) activities are administered by local, regional, national, and international groups and are even embedded in national education curricula in China, the Democratic Republic of the Congo, Nicaragua, and Sudan [114]. These efforts are successful due to a massive global coordination and multi-sector participation in WASH activities. Similar efforts must be made for antimicrobial stewardship to address the global health threat of antimicrobial resistance and its devastating health effects.
It’s important to note some limitations of the study. First, this review focused on overuse and misuse of antimicrobials in human populations, and did not include other significant drivers of AMR, such as antimicrobial use in livestock [115], environmental changes [116], and water and sanitation systems [117,118]. A review of AMR in South Asia in a One Health framework [119] would be a valuable addition to the literature. Second, given the unequal representation of South Asian countries in the existing literature, these findings may not be generalizable to all of South Asia. The limited literature could be in part due to bias in research funding and publication. We only included studies published in English, potentially excluding studies that are otherwise eligible; however, we did not identify any manuscripts in the two databases that were published in a language other than English. Finally, although there was an established and detailed search methodology, it is possible that published studies that fit criteria were missed. However, we are confident that thematic saturation was reached as clear and consistent themes emerged across the included manuscripts.
Conclusions
Antimicrobial resistance is a major threat to individual and population health in South Asia. As common antimicrobials become less efficacious due to antimicrobial-resistant organisms, there is a risk of significant increases in morbidity and mortality in the region. In synthesizing the qualitative literature in South Africa, we identified a range of norms, behaviors, and policy contexts that contribute to antimicrobial resistance in South Asia. The findings point to a need for a multi-pronged approach that works across sectors to improve the surveillance and reporting of antimicrobial use and implement stewardship interventions specific to the unique regions.
Acknowledgments
The following individuals helped to support the review process: Nehal Bakshi, Anya Tiwari, and Maya Stephens.
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