Antibiotic utilization in outpatient and inpatient hospitals in Zambia: a systematic review, key findings and public health implications.

This review aimed to document current antibiotic utilization patterns among Zambian hospitals to inform Antimicrobial Stewardship (AMS) policies and practices to help reduce AMR. Published literature was searched from PubMed, Embase and Google Scholar from 1 January 2000 to 13 March 2025. Search terms included antibiotics, utilization, intervention, stewardship and hospital while applying appropriate Boolean Operators. The review was conducted according to the preferred reporting items for systematic reviews and meta-analysis. The search retrieved 913 studies; 19 studies were included in the final analysis, including 17 quantitative descriptive studies and two non-randomized controlled studies. The overall quality of the included studies was good (≥75%). Antibiotic use prevalence was between 50.3% - 82.5% with a pooled estimate of 67.0%, 95% CI (60-73). The highest prevalence were Access antibiotics (34.2%-84.0%). Frequently prescribed antibiotics belonged to the Watch group in 8 out of 11 studies. Two (10.5%) studies assessed antibiotic prescribing appropriateness, overall inappropriateness was 67.0% in one study, while the other study reported appropriateness over 95% across assessed indicators. In 10 studies that reported at least one quality indicator for antibiotic use, guideline compliance was the most reported with compliance ranging from 27.0% to 58.1%. Two studies that evaluated the impact of Antimicrobial Stewardship Programs (ASPs) on antibiotic use reported improvement in use pre to post ASP. In conclusion, despite structural challenges in diagnostics and guideline adherence, sustained multifaceted AMS implementation and integration of the WHO AWaRe framework are improving prescribing patterns and providing a pathway to curb antimicrobial resistance in Zambia.