INTRODUCTION:
Antimicrobial resistance (AMR) is a major and growing public health threat globally and in sub-Saharan Africa, where inappropriate antibiotic use and limited diagnostic capacity drive resistance. In Malawi, empirical antibiotic prescribing remains common in tertiary-level hospitals, potentially undermining treatment outcomes and accelerating AMR.

METHODS:
We analyzed data from biannual Global Point Prevalence Surveys (GPPS) conducted in Malawi’s four central hospitals (Queen Elizabeth, Kamuzu, Mzuzu, and Zomba) during the final quarter of 2024. These findings were triangulated with evidence from a regional systematic review on behavioral and socio-economic determinants of AMR in sub-Saharan Africa to contextualize prescribing practices and diagnostic use.

RESULTS:
Of all antibiotic prescriptions recorded, 94% were empirical, with only 5.9% supported by laboratory diagnostics. Ceftriaxone, a WHO Watch category antibiotic, accounted for 38% of prescriptions, indicating substantial reliance on broad-spectrum agents. These trends mirrored regional evidence showing low utilization of microbiological testing, widespread reliance on clinician experience, gaps in AMR knowledge among healthcare workers, and continued access to antibiotics without prescription.

CONCLUSIONS:
Excessive empirical prescribing and limited diagnostic uptake represent critical barriers to effective antimicrobial stewardship in Malawi. Strengthening diagnostic stewardship through routine culture and sensitivity testing, expanding antimicrobial stewardship committees, and reinforcing pharmaceutical regulation are feasible, cost-effective strategies. Integrating laboratory diagnostics into clinical workflows is essential to improve patient outcomes, reduce inappropriate antibiotic use, and slow the progression of AMR in Malawi.