Pharmacist-led antimicrobial stewardship: A systematic review of implementation barriers, facilitators, and policy-to-practice gaps in Bangladesh.

Authors

Shumonto Mowla Chowdhury, Hyacinth Ukuhor, Rasha Abdelsalam Elshenawy

Published in

Journal of the American Pharmacists Association : JAPhA. Pages 103511. Aug 25, 2026. Epub Aug 25, 2026.

Abstract

Antimicrobial resistance (AMR) disproportionately affects low- and middle-income countries (LMICs). Bangladesh has adopted a National Action Plan (2023-2028) yet exemplifies the persistent gap between pharmaceutical policy frameworks and frontline antimicrobial stewardship (AMS) practice. No prior systematic review has synthesised barriers, facilitators, and AMS strategies across all Bangladesh healthcare settings, or positioned findings within a pharmaceutical-policy and pharmacy-practice frame.
To synthesise the documented barriers, facilitators, and core and supplemental antimicrobial stewardship strategies reported across all Bangladesh healthcare settings, and to position the findings within a pharmaceutical-policy and pharmacy-practice frame to inform operationalisation of the National Action Plan.
A systematic review was conducted per PRISMA 2020. Five databases (MEDLINE/PubMed, CINAHL, Scopus, Cochrane Library, Google Scholar) were searched on 22 August 2024 combining terms for AMS, implementation, and Bangladesh. Eligibility followed the Population-Exposure-Outcome framework. Records were screened by the primary reviewer and verified by the supervising author. Quality was appraised using CASP checklists (2022). Narrative synthesis combined frequency tabulation with inductive thematic analysis; meta-analysis was not appropriate given heterogeneity.
Fourteen studies (2014-2025) were included: ten empirical studies contributing primary data and four narrative reviews or study protocols, which contributed no participants and were included for their analysis of policy and implementation context. The empirical evidence base comprised 8,489 individuals (7,930 patients or children and 559 healthcare professionals), 25,107 clinical specimens, and 643 bacterial isolates; these denominators represent distinct units of observation and are not aggregated. Principal barriers were absent or weakly enforced AMS policies (n=6), entrenched empirical prescribing (n=5), limited diagnostic capacity (n=4), and absent AMS teams (n=3). Key facilitators were surveillance infrastructure (n=6), training and education (n=5), leadership commitment (n=3), and international collaboration (n=2). Only 31% of prescriptions were culture-guided. No included study reported an AMS programme meeting all five criteria of the a priori operational definition of a functioning institutionalised programme, and findings were unchanged in a sensitivity analysis restricted to the ten studies published from 2020 onwards.
AMS implementation in Bangladesh remains fragmented, reflecting a structural disjuncture between pharmaceutical-policy ambition and operational delivery. Education-led initiatives cannot sustain change without parallel investment in diagnostic infrastructure, multidisciplinary AMS teams including clinical pharmacists, and enforcement of community-pharmacy dispensing regulation. Strengthening pharmacy-led AMS is an underutilised entry point for operationalising the National Action Plan.

PMID:
42641923
Bibliographic data and abstract were imported from PubMed on 26 Aug 2026.

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