Antimicrobial stewardship in rural Zambia: insights from a two-year primary care prescribing audit
1
On Call Africa, Livingstone, Zambia
Popul. Med. 2026;8(Supplement Supplement 1):
ABSTRACT
INTRODUCTION:
Antimicrobial resistance (AMR) is a growing global public health threat, disproportionately affecting low and middle-income countries.1 High resistance from common bacterial pathogens is reported in Zambian hospitals, but data from rural primary care are limited.2 Understanding prescribing practices in these settings is essential to guide national strategies and support sustainable antimicrobial stewardship.
METHODS:
Three retrospective audit cycles were conducted by a non-governmental organisation working with a rural health facility in Southern Province, Zambia. Prescribing practices were assessed against the Zambian Standard Treatment Guidelines (2020). Outcomes included prescribing frequency, multi-antibiotic use and guideline adherence. In October 2024, 143 patient notebooks were randomly sampled. Following teaching sessions and educational resources over 2 months, 85 notebooks were re-audited. The third cycle in October 2025 captured 491 patient encounters over the preceding 10 months (199 patient notebooks and 292 outpatient logbook entries).
RESULTS:
In 2024, 69% (n=99) of the sample population were prescribed at least 1 antibiotic; post-intervention, this decreased to 42% (n=36). In 2025, 56% (n=273) received antibiotics: 86.8% (n=237) one, 8.8% (n=24) two, 4.4% (n=12) three or more. Metronidazole (n=86) and amoxicillin (n=78) accounted for over 50% of prescriptions. Guideline adherence remained low: in 2024, 8–13% appropriate; in 2025, 16.5% (n=45) fully and 8.8% (n=24) partially adherent. Multi-antibiotic prescribing declined from 78% (2024) to 13% (2025).
CONCLUSIONS:
Antibiotic prescribing remained high, with over half of all prescriptions consisting of broad-spectrum agents, and guideline adherence limited. These prescribing practices contribute to accelerating AMR and reflect persistent barriers in rural healthcare settings, such as minimal diagnostics, stock shortages, staff turnover, and low community awareness. Targeted education can reduce inappropriate prescribing, but sustained improvement requires ongoing mentorship, guideline access, routine surveillance, and community engagement. These findings provide actionable insights for national AMR strategies and emphasise the urgent need for locally driven system-level stewardship interventions.
Antimicrobial resistance (AMR) is a growing global public health threat, disproportionately affecting low and middle-income countries.1 High resistance from common bacterial pathogens is reported in Zambian hospitals, but data from rural primary care are limited.2 Understanding prescribing practices in these settings is essential to guide national strategies and support sustainable antimicrobial stewardship.
METHODS:
Three retrospective audit cycles were conducted by a non-governmental organisation working with a rural health facility in Southern Province, Zambia. Prescribing practices were assessed against the Zambian Standard Treatment Guidelines (2020). Outcomes included prescribing frequency, multi-antibiotic use and guideline adherence. In October 2024, 143 patient notebooks were randomly sampled. Following teaching sessions and educational resources over 2 months, 85 notebooks were re-audited. The third cycle in October 2025 captured 491 patient encounters over the preceding 10 months (199 patient notebooks and 292 outpatient logbook entries).
RESULTS:
In 2024, 69% (n=99) of the sample population were prescribed at least 1 antibiotic; post-intervention, this decreased to 42% (n=36). In 2025, 56% (n=273) received antibiotics: 86.8% (n=237) one, 8.8% (n=24) two, 4.4% (n=12) three or more. Metronidazole (n=86) and amoxicillin (n=78) accounted for over 50% of prescriptions. Guideline adherence remained low: in 2024, 8–13% appropriate; in 2025, 16.5% (n=45) fully and 8.8% (n=24) partially adherent. Multi-antibiotic prescribing declined from 78% (2024) to 13% (2025).
CONCLUSIONS:
Antibiotic prescribing remained high, with over half of all prescriptions consisting of broad-spectrum agents, and guideline adherence limited. These prescribing practices contribute to accelerating AMR and reflect persistent barriers in rural healthcare settings, such as minimal diagnostics, stock shortages, staff turnover, and low community awareness. Targeted education can reduce inappropriate prescribing, but sustained improvement requires ongoing mentorship, guideline access, routine surveillance, and community engagement. These findings provide actionable insights for national AMR strategies and emphasise the urgent need for locally driven system-level stewardship interventions.
| eISSN: | 2654-1459 |
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