Amphotericin B and Antifungal Stewardship in Somalia: Irrational Use, Misconceptions, and Emerging Challenges.

This commentary examines the rapidly escalating global health crisis of antimicrobial resistance (AMR). While widespread attention has historically focused on antibacterial resistance, the emergence of antifungal resistance represents an underrecognized and increasingly severe threat, particularly in resource-limited and fragile health systems. Amphotericin B is a critical, last-line antifungal agent essential for treating life-threatening invasive fungal infections, including cryptococcal meningitis and visceral leishmaniasis. However, due to its severe toxicity profile including nephrotoxicity and severe infusion reactions its administration requires stringent clinical oversight. In fragile health systems such as Somalia, weak pharmaceutical regulation and the proliferation of informal medicine markets have facilitated the irrational use of prescription-only medications. Recently, there are growing concerns regarding public misconceptions surrounding injectable medications, including the potential off-label, non-medical use of high-risk antifungals for purported cosmetic or body-enhancing purposes. While these concerns are currently based on anecdotal observations rather than documented epidemiological evidence, inappropriate community access to Amphotericin B poses severe patient safety risks while potentially accelerating antifungal selection pressure. This commentary explores the clinical importance of Amphotericin B, examines the intersection of public misinformation and irrational drug use, and outlines the urgent need for targeted antifungal stewardship (AFS). Furthermore, it provides a practical framework for facility-level priorities, pharmaceutical regulation, pharmacovigilance, and public health communication. Safeguarding critical antifungal agents in low-resource settings requires immediate, coordinated stewardship and regulatory interventions.