{"paper_id":"cfdc6e40-02e5-4e0e-8317-654ae2a7913a","body_text":"Barriers and Facilitators to Antimicrobial Stewardship Implementation Across Healthcare Settings in Bangladesh: A Systematic Review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review Barriers and Facilitators to Antimicrobial Stewardship Implementation Across Healthcare Settings in Bangladesh: A Systematic Review Shumonto Mowla Chowdhury, Rasha Abdelsalam Elshenawy This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9123957/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Antimicrobial resistance (AMR) causes 1.27 million deaths annually and is projected to kill 1.91 million people per year by 2050. Bangladesh recorded 26,200 AMR-attributable deaths in 2019, yet a persistent gap exists between its national policy frameworks and frontline antimicrobial stewardship (AMS) practice. This systematic review synthesises evidence on barriers, facilitators, and strategies relating to AMS implementation across healthcare settings in Bangladesh. Methods A systematic search of MEDLINE (PubMed), CINAHL, Scopus, Cochrane Library, and Google Scholar was conducted in August 2025 following PRISMA 2020 guidelines. The PEO (Population, Exposure, Outcome) framework guided eligibility criteria. Study quality was assessed using Critical Appraisal Skills Programme (CASP) checklists. Quantitative descriptive analysis and qualitative thematic analysis were applied for data synthesis. Results Fourteen studies encompassing 34,097 participants (33,538 patients and 559 healthcare professionals) were included. Major barriers identified included absence or weak enforcement of hospital AMS policies (n = 6 studies), entrenched empirical prescribing culture (n = 5), limited diagnostic and laboratory capacity (n = 4), and lack of dedicated AMS teams (n = 3). Key facilitators comprised antimicrobial surveillance systems (n = 6), training and education programmes (n = 5), and leadership commitment and governance (n = 3). Only 31% of prescriptions were culture-guided, and broad-spectrum antibiotic exposure exceeded 70% among hospitalised patients. No study reported a fully functioning, institutionalised AMS programme. Conclusions AMS implementation in Bangladesh remains fragmented, undermined by systemic infrastructure deficits and a persistent policy–practice gap. Training and education offer pragmatic entry points but cannot sustain change without concurrent institutionalisation of core stewardship strategies—audit and feedback, multidisciplinary teams, and formulary controls. Urgent investment in diagnostic capacity, surveillance infrastructure, and regulatory enforcement is needed to translate Bangladesh’s National Action Plan into sustainable clinical impact. antimicrobial stewardship antimicrobial resistance Bangladesh systematic review implementation low- and middle-income countries Figures Figure 1 Figure 2 Figure 3 Introduction Antimicrobial resistance (AMR) represents one of the most urgent threats to global public health. Bacterial AMR directly caused an estimated 1.27 million deaths worldwide in 2019 and contributed to approximately 4.95 million additional deaths, with projections indicating that annual direct mortality could reach 1.91 million by 2050 and that 39 million AMR-related deaths may occur between 2025 and 2050 (Murray et al., 2022 ; Naghavi et al., 2024 ). The World Health Organization (WHO) has consistently ranked AMR among the top ten global public health threats, and the burden is disproportionately concentrated in low- and middle-income countries (LMICs), where approximately 4.3 million AMR-associated deaths occur annually and nearly all AMR-related child deaths occur (Lewnard et al., 2024 ; Saeed & Hall, 2023 ). AMS is defined as a coordinated set of strategies to promote the appropriate use of antimicrobials, preserve their effectiveness and reduce AMR. The concept was first formally described in the 1990s and has since been codified within international frameworks including the WHO Global Action Plan (2015) and national programmes such as England’s ‘Start Smart Then Focus’ toolkit (McGowan & Gerding, 1996 ; Dyar et al., 2017 ; WHO, 2015 ). High-income countries such as the United Kingdom have demonstrated the value of systemic AMS investment: the English Surveillance Programme for Antimicrobial Utilisation and Resistance (ESPAUR) enables systematic monitoring, and the UK’s revised 2024–2029 National Action Plan targets a 5% reduction in total antibiotic use alongside an increase in narrow-spectrum prescribing (UKHSA, 2024 ). Bangladesh, a lower-middle-income country of approximately 170 million people, exemplifies the paradox confronting many LMICs: robust national policy commitments coexist with severe implementation gaps. In 2019, 26,200 deaths were directly attributable to AMR, and 98,800 deaths were AMR-associated (Zujbe et al., 2025 ). Bangladesh ranked 75th globally for age-standardised AMR mortality per 100,000 population according to the WHO Tracking AMR Country Self-Assessment Survey (TrACSS, 2022), though this ranking is confounded by limited surveillance coverage, only 11 hospitals contribute data to the WHO Global Antimicrobial Resistance and Use Surveillance System (GLASS) (GLASS, 2023). Despite the introduction of a comprehensive National Action Plan for AMR Containment (2023–2028) adopting a One Health approach, hospital assessments reveal no formal AMS programmes across tertiary facilities and that fewer than half of physicians demonstrate AMS awareness (Sumon et al., 2024a ). While several narrative reviews and individual empirical studies have examined antimicrobial prescribing practices in Bangladesh, no prior systematic review has synthesised the full scope of barriers, facilitators, and AMS strategies across all healthcare setting types. This evidence gap hampers the design of targeted, scalable stewardship interventions and limits the ability of policymakers to allocate resources effectively. The present systematic review addresses this gap by providing a comprehensive synthesis of the published literature. Aim and Objectives This review aims to identify and synthesise evidence on barriers and facilitators to AMS implementation across healthcare settings in Bangladesh, and to characterise the AMS strategies reported or recommended, in order to generate evidence-based recommendations for sustainable stewardship improvement. The specific objectives were to: Identify barriers and facilitators to AMS implementation across primary, secondary, and tertiary healthcare settings in Bangladesh. Characterise healthcare professionals’ knowledge, attitudes, and prescribing behaviours relating to antimicrobials. Identify core and supplemental AMS strategies reported or recommended in the Bangladesh context. Generate evidence-based recommendations for policymakers, hospital administrators, and professional bodies to strengthen AMS across Bangladesh’s health system. Methods This systematic review was conducted and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA 2020) guidelines (Page et al., 2021 ). The review protocol was approved by the supervising academic prior to the commencement of searches. Eligibility Criteria Eligibility criteria were structured using the PEO (Population, Exposure, Outcome) framework (Table 1 ). Studies were eligible if they examined AMS implementation, antimicrobial prescribing practices, or barriers and facilitators to stewardship within any Bangladesh healthcare context. Eligible study designs included systematic reviews, literature reviews, meta-analyses, cross-sectional studies, cohort studies, case–control studies, qualitative studies, case studies, and conference abstracts. Studies were restricted to those published in English between 2010 and 2025 and reporting on human health settings. Studies exclusively addressing veterinary or environmental antimicrobial use were excluded, as were studies without accessible full text. Table 1 Eligibility criteria using the PEO framework PEO Element Inclusion Criteria Exclusion Criteria Population Studies targeting healthcare professionals, patients, or professional bodies responsible for AMS in Bangladesh healthcare settings Studies focused exclusively on antibiotic use in animals, veterinary, or environmental settings Exposure Studies examining AMS implementation, interventions, challenges, or antibiotic use practices within Bangladesh Studies that do not describe or evaluate antimicrobial stewardship in any form Outcome Studies reporting barriers, facilitators, attitudes, behaviours, motivations, or capacity relating to AMS implementation Studies with outcomes unrelated to AMS implementation or antimicrobial prescribing practices Study Design Systematic reviews, literature reviews, meta-analyses, cross-sectional studies, cohort studies, case–control studies, qualitative studies, case studies, and conference abstracts Non-English language publications; studies without accessible full text Information Sources and Search Strategy Electronic searches were conducted on 22 August 2025 across five databases: MEDLINE (via PubMed), CINAHL, Scopus, Cochrane Library, and Google Scholar. Databases were selected to provide comprehensive coverage of clinical, public health, and grey literature relevant to the research question. Boolean operators (AND/OR) were applied to combine the following search terms: (“antimicrobial stewardship” OR “antibiotic stewardship” OR “AMS” OR “antibiotic use” OR “antibiotic management”) AND (“implementation” OR “strategy” OR “barrier” OR “facilitator” OR “challenge”) AND (“Bangladesh” OR “hospital” OR “primary care” OR “secondary care” OR “community pharmacy”) Retrieved records were exported to ZOTERO and subsequently managed in Microsoft Excel for deduplication and screening. Study Selection Screening and data extraction were performed by the primary reviewer and independently verified by the supervising author, followed by full-text assessment of potentially eligible records against pre-defined inclusion and exclusion criteria. The PRISMA 2020 flow diagram (Fig. 1 ) details the study selection process. Quality Assessment The methodological quality of included studies was assessed using the Critical Appraisal Skills Programme (CASP) checklists, version 2022 (CASP, 2022). Appropriate checklist versions were applied according to the study design: the CASP Qualitative Studies checklist, the Cross-Sectional Studies checklist, and the Cohort Study checklist. Quality ratings (high, moderate, or low) were assigned based on the proportion of appraisal criteria satisfied. Quality assessment was conducted by the primary reviewer. Data Extraction and Synthesis Data were extracted by the primary reviewer into a standardised extraction form capturing: author, year, healthcare setting, study design, population, sample size, barriers to AMS, facilitators of AMS, core AMS strategies, supplemental AMS strategies, AMS outcomes, knowledge and attitudes, and regulatory or policy context. Given the heterogeneity of included study designs and outcome measures, a narrative synthesis approach was adopted, combining quantitative descriptive analysis with qualitative thematic analysis. Qualitative themes were developed inductively from the extracted data using Microsoft Excel for coding. Ethical Approval Ethical approval was not required for this systematic review, as no primary data collection involving human participants was undertaken. Results Study Selection and Characteristics The electronic search identified 9,410 records: PubMed (n=4,971), Scopus (n=2,654), Cochrane Library (n=910), CINAHL (n=815), and Google Scholar (n=60). After removal of 5,139 duplicates, 4,271 records were screened at the title and abstract stage, yielding 102 reports for full-text assessment. After applying the eligibility criteria, 14 studies published between 2014 and 2025 were included in the final review (Figure 1). Figure 1. PRISMA 2020 flow diagram of study selection. The 14 included studies collectively encompassed 34,097 participants, comprising 33,538 patients or clinical specimens and 559 healthcare professionals. Study designs were heterogeneous: point-prevalence surveys and cross-sectional prescribing audits (n=3), retrospective and prospective laboratory or genomic surveillance (n=3), prospective cohort analyses (n=2), cross-sectional surveys of healthcare professionals (n=1), secondary care population surveys (n=1), and narrative reviews or study protocols (n=4). The majority were conducted in tertiary hospital settings (64%; n=9 studies), with mixed secondary and tertiary settings (29%; n=4) and secondary-only settings (7%; n=1) also represented. The full data extraction is presented in Table 2. Table 2. Summary data extraction table Study Setting Design N Key Barriers Key Facilitators Quality Sumon et al., 2024a (JHI) Tertiary Cross-sectional survey 559 HCPs No AMS guidelines; limited training; high workload Clinician interest in AMS; recognition of antibiotic misuse High Harun et al., 2022 Tertiary Study protocol N/A Staffing and governance gaps IPC-AMS integration plan; alignment with NAP Moderate Sumon et al., 2024b (AJIC) Tertiary Point prevalence survey 1,063 patients Empirical prescribing; no microbiology access; no guidelines Staff willingness to engage; PPS feasibility High Rashid et al., 2022 Mixed (2°/3°) Point prevalence survey 1,099 patients Overuse of Watch antibiotics; weak stewardship; poor documentation WHO AWaRe framework applicable High Mia et al., 2017 Tertiary ICU Cross-sectional microbiology 1,670 patients High resistance; empirical treatment; weak enforcement Pilot stewardship programme feasible in ICU Moderate Rubel et al., 2024 Mixed (BD/UK) Protocol/comparative N/A Lower guideline adherence vs UK International benchmarking as leverage Low Haque & Godman, 2021 Mixed Narrative review N/A OTC antibiotic sales; weak regulation; resource shortfalls International experience transferable; policy frameworks exist Moderate Rashid et al., 2017 Tertiary paediatric Cross-sectional 80 children Non-adherence to WHO guidelines; empirical use Pneumonia guidelines available Moderate Boone et al., 2021 Tertiary neonatal Prospective cohort 448 admissions Diagnostic uncertainty; empirical prescribing; no AMS structures Prospective cohort methodology feasible High Ahmed et al., 2018 Secondary (rural) Survey 3,570 children OTC access; caregiver demand; weak enforcement Strong surveillance capacity (icddr,b) High Afroz et al., 2014 Tertiary Retrospective study 3,584 specimens Delayed diagnostics; absent stewardship Laboratory diagnostic capacity present Moderate Zujbe et al., 2025 Mixed Narrative review N/A Poor IPC infrastructure; weak surveillance Policy-level interest; NAP highlighted Low Roy et al., 2025 Tertiary Laboratory surveillance 21,523 specimens MDR prevalence; absent AMS committee Longitudinal surveillance capacity High Farzana et al., 2023 Tertiary Genomic surveillance 643 isolates CRE spread; limited genomic capacity International collaboration; genomic resistance tracking High HCPs = healthcare professionals; AMS = antimicrobial stewardship; NAP = National Action Plan; IPC = infection prevention and control; CRE = carbapenem-resistant Enterobacterales; MDR = multidrug resistant; ICU = intensive care unit; icddr,b = International Centre for Diarrhoeal Disease Research, Bangladesh; N/A = not applicable (protocol or narrative study). AMS Metrics and Measurement None of the 14 included studies reported standardised AMS consumption or outcome metrics, including the specific daily dose (DDD), days of therapy (DOT), length of stay (LOS), or direct antibiotic cost. This represents a critical evidence gap that limits benchmarking and health-economic justification for AMS investment. Studies instead used non-standardised measures including antibiotic prescribing prevalence (n=7), culture-guided prescribing rates (n=3), WHO AWaRe distribution (n=2), multidrug-resistance prevalence (n=4), and proportion of patients receiving broad-spectrum agents. Barriers to AMS Implementation Systematic coding of the included studies identified four principal categories of barrier (Figure 2). The most frequently identified barrier was the absence or weak enforcement of hospital AMS policies or guidelines, reported across six studies (Haque & Godman, 2021; Mia et al., 2017; Rashid et al., 2022; Sumon et al., 2024a; Sumon et al., 2024b; Zujbe et al., 2025). Entrenched empirical prescribing culture, characterised by widespread broad-spectrum antibiotic use without microbiological guidance, was documented in five studies (Boone et al., 2021; Mia et al., 2017; Rashid et al., 2022; Roy et al., 2025; Sumon et al., 2024b); Sumon et al. (2024b) reported that 73.5% of hospitalised patients were receiving antibiotics, with cephalosporins accounting for 54% of defined daily doses. Limited diagnostic and laboratory capacity was identified in four studies (Afroz et al., 2014; Farzana et al., 2023; Mia et al., 2017; Sumon et al., 2024b), with only 31% of prescriptions informed by microbiological culture results (Sumon et al., 2024b). Lack of dedicated AMS staffing and multidisciplinary stewardship teams was highlighted in three studies (Haque & Godman, 2021; Harun et al., 2022; Sumon et al., 2024a). Caregiver demand and unregulated access to over-the-counter (OTC) antibiotics were also identified as community-level barriers in two studies (Ahmed et al., 2018; Rashid et al., 2017). Facilitators of AMS Implementation Despite pervasive implementation barriers, several enabling factors were identified. Existing antimicrobial surveillance capacity was the most frequently cited facilitator, appearing in six studies (Afroz et al., 2014; Farzana et al., 2023; Rashid et al., 2022; Roy et al., 2025; Sumon et al., 2024b; Zujbe et al., 2025). Training and education programmes targeting healthcare professionals were identified as pragmatic facilitators in five studies (Ahmed et al., 2018; Haque & Godman, 2021; Mia et al., 2017; Rubel et al., 2024; Sumon et al., 2024a), and Sumon et al. (2024a) specifically documented high clinician receptivity to AMS engagement. Leadership commitment and institutional governance were highlighted in three studies (Haque & Godman, 2021; Sumon et al., 2024a; Zujbe et al., 2025). International collaboration and expanding genomic and resistance-characterisation capacity were identified as additional facilitators in two studies (Farzana et al., 2023; Harun et al., 2022) (Figure 2). Figure 2. Barriers and facilitators to antimicrobial stewardship implementation identified across included studies (n = 14). AMS Strategies Critically, no included study reported the implementation of a fully functioning, institutionalised AMS programme. Core AMS strategies were recommended rather than implemented in 64% of studies (n=9), and supplemental strategies were reported or recommended in 50% (n=7), but uptake remained inconsistent (Supplementary Table 1 and Figure 3). Among core strategies, antibiotic prescribing audit and surveillance was reported in three studies (Boone et al., 2021; Roy et al., 2025; Sumon et al., 2024b), microbiology-based or genomic guidance was applied in four studies (Afroz et al., 2014; Farzana et al., 2023; Mia et al., 2017; Sumon et al., 2024a), point prevalence surveys were conducted in two studies (Rashid et al., 2022; Sumon et al., 2024b), and WHO AWaRe benchmarking was utilised in one study (Rashid et al., 2022). Formal AMS committee or team formation was recommended—but not operationalised—in two studies (Haque & Godman, 2021; Harun et al., 2022). Among supplemental strategies, training and education were recommended in five studies, awareness campaigns in three, guideline development in two, international collaboration in two, and public engagement in two. Figure 3. Core and supplemental antimicrobial stewardship strategies reported or recommended across included studies (n = 14). Qualitative Thematic Analysis Thematic analysis of the qualitative data derived from included studies identified four overarching themes. Theme 1: Systemic resource and infrastructure deficits. Across the dataset, infrastructural constraints—including limited laboratory diagnostics, insufficient stewardship staffing, inadequate data systems, and scarce financing—emerged as the foundational drivers of high empirical prescribing and the primary barriers to operationalising core AMS strategies. Only 31% of prescriptions were culture-guided (Sumon et al., 2024b), directly reflecting the diagnostic gap. Four studies explicitly identified laboratory capacity constraints (Afroz et al., 2014; Farzana et al., 2023; Mia et al., 2017; Sumon et al., 2024b), and three studies highlighted stewardship staffing gaps (Haque & Godman, 2021; Harun et al., 2022; Sumon et al., 2024a). Fragmented surveillance and data feedback infrastructure were documented in four studies (Farzana et al., 2023; Rashid et al., 2022; Roy et al., 2025; Sumon et al., 2024b). Theme 2: Practice–policy implementation gap. Formal policies and national frameworks—including the WHO AWaRe classification and Bangladesh’s National Action Plan—existed or were being adopted, yet adherence at the point of care was consistently poor. Four studies reported substantial discordance between guideline availability and actual prescribing practice (Rashid et al., 2017; Rashid et al., 2022; Rubel et al., 2024; Sumon et al., 2024b). Weak regulatory enforcement of antibiotic dispensing restrictions was highlighted in multiple studies (Ahmed et al., 2018; Haque & Godman, 2021), and five studies documented an entrenched culture of empirical broad-spectrum prescribing (Boone et al., 2021; Mia et al., 2017; Rashid et al., 2022; Roy et al., 2025; Sumon et al., 2024b). Theme 3: Healthcare setting-specific challenges. Implementation barriers and feasible stewardship interventions differed meaningfully by clinical setting. In intensive care units, very high multidrug-resistance burdens coexisted with minimal stewardship infrastructure (Farzana et al., 2023; Mia et al., 2017). In paediatric settings, three studies demonstrated high antibiotic exposure and systematic non-adherence to WHO paediatric prescribing guidelines (Ahmed et al., 2018; Boone et al., 2021; Rashid et al., 2017). At the community level, unregulated OTC antibiotic access driven by caregiver demand represented a distinct barrier requiring community-specific interventions (Ahmed et al., 2018). Theme 4: Enabling factors for AMS implementation. Despite the identified constraints, pragmatic facilitators were identified across the dataset. Clinician receptivity to training and structured stewardship support was high (Sumon et al., 2024a), and surveillance capacity—while fragmented—provided a foundation upon which expanded monitoring systems could be built (Rashid et al., 2022; Roy et al., 2025). Leadership commitment at both hospital and policy levels (Haque & Godman, 2021; Harun et al., 2022; Zujbe et al., 2025), combined with international collaboration and genomic surveillance capacity (Farzana et al., 2023), represented additional leverage points for systemic change. Discussion This systematic review provides the first comprehensive synthesis of barriers, facilitators, and strategies related to AMS implementation across all healthcare settings in Bangladesh. The review synthesised evidence from 14 studies encompassing 34,097 participants and employed both quantitative descriptive analysis and qualitative thematic synthesis, revealing a consistent and concerning picture: despite the existence of a national AMR action plan and growing policy commitment, Bangladesh has not yet institutionalised the core infrastructure required for effective, sustainable antimicrobial stewardship. Principal Findings in Global Context The documented antibiotic prescribing rates, exceeding 70% among hospitalised patients, and the near-universal reliance on empirical broad-spectrum therapy are broadly consistent with patterns observed across LMIC healthcare systems (Sulis et al., 2022; WHO, 2019). However, what distinguishes Bangladesh’s situation is the explicit coexistence of a sophisticated national policy framework with an almost complete absence of operational AMS structures at the institutional level. No included study reported a functioning AMS committee, routine audit and feedback cycle, or prescribing formulary with active restriction mechanisms. This represents a deeper structural failure than resource scarcity alone: it reflects insufficient translation machinery between policy design and clinical implementation. By contrast, high-income countries such as the United Kingdom have demonstrated that sustained investment in surveillance systems (ESPAUR), evidence-based toolkits (‘Start Smart Then Focus’), and nationally coordinated audit mechanisms can generate measurable improvements in antimicrobial prescribing, even against a backdrop of rising absolute resistance burden (UKHSA, 2024). The critical difference is not the existence of policies but the availability of the organisational infrastructure, such as staffing, data systems, clinical governance, to enact them at the bedside (Elshenawy et al., 2023). Core and Supplemental AMS Strategies The distinction between core and supplemental AMS strategies is analytically important. Core strategies, such as prospective audit and feedback, multidisciplinary AMS committees, formulary restriction, and microbiology-guided prescribing, represent the structural backbone of effective stewardship and are associated with the most robust evidence for sustained prescribing improvement (Barlam et al., 2016; Davey et al., 2017). In Bangladesh, these strategies existed only as policy recommendations; none was found to be systematically implemented across the included studies. Supplemental strategies , such as training, education, awareness campaigns, and guideline dissemination, were more frequently cited and are undoubtedly valuable, particularly given the documented receptivity of clinicians to AMS engagement (Sumon et al., 2024a). However, global evidence consistently demonstrates that education and awareness alone cannot produce durable changes in prescribing behaviour without the concurrent institutionalisation of structural governance mechanisms (Charani & Holmes, 2019; Limato et al., 2022). The risk in Bangladesh is that supplemental interventions come to substitute for, rather than complement, the core infrastructure that sustains stewardship. Diagnostic and Surveillance Capacity The finding that only 31% of antibiotic prescriptions were informed by microbiological culture is a particularly stark indicator of the diagnostic-prescribing gap in Bangladesh (Sumon et al., 2024b). Without reliable, timely culture and susceptibility results, prescribers cannot de-escalate therapy, prescribing audits cannot identify appropriate targets for intervention, and AWaRe benchmarking cannot be meaningfully acted upon. Strengthening diagnostic laboratory capacity is therefore not merely a technical upgrade but a prerequisite for any culture-change stewardship programme. Similarly, the fragmentation of antimicrobial surveillance across fewer than a dozen GLASS-reporting hospitals limits the national evidence base for resistance monitoring and policy development (GLASS, 2023). Bangladesh’s National Action Plan identifies surveillance strengthening as a priority; this review’s findings underline the urgency and centrality of that commitment. Regulatory Environment and Community Stewardship The documented availability of antibiotics without prescription, affecting an estimated 56.6% of antibiotic dispensing transactions in community pharmacies (Al Masud et al., 2024), represents a dimension of AMS that hospital-focused stewardship programmes cannot address in isolation. Effective regulatory enforcement, community pharmacist engagement, and public education about antimicrobial use are essential complements to facility-based stewardship, particularly given the high rates of caregiver-driven antibiotic demand documented in paediatric community settings (Ahmed et al., 2018; Rashid et al., 2017). A One Health approach—integrating human, animal, and environmental stewardship—as outlined in Bangladesh’s 2023–2028 National Action Plan, is the appropriate strategic framework, provided it is accompanied by the resourcing and enforcement mechanisms necessary to operationalise it across sectors. Strengths and Limitations This review provides the most comprehensive synthesis of AMS implementation evidence specific to Bangladesh undertaken to date, spanning empirical hospital-based studies, laboratory and genomic surveillance, healthcare professional surveys, and narrative policy analyses. The dual quantitative-qualitative synthesis method enabled both descriptive characterisation of prescribing metrics and deeper interpretive analysis of implementation processes. Several limitations must be acknowledged. The absence of standardised AMS metrics (DDD, DOT, LOS, cost) across all included studies limits comparability and precludes economic analysis. Most included studies were conducted in tertiary urban hospitals, with limited primary care and rural representation, which may underestimate the burden of inappropriate antibiotic use in community settings where most of the population receives care. The restriction of the search to English-language publications may have excluded relevant grey literature or studies published in Bangla. Finally, with only a single reviewer conducting screening and extraction, the risk of selection bias cannot be fully excluded. Recommendations Based on the synthesised evidence, this review makes the following recommendations for policymakers, hospital administrators, and professional bodies: Establish functioning multidisciplinary AMS committees in all tertiary and secondary hospitals, comprising infectious disease physicians, clinical pharmacists, microbiologists, and infection control practitioners, aligned with WHO and Infectious Diseases Society of America guidelines (Barlam et al., 2016; WHO, 2019). Implement routine prospective audit and feedback programmes, drawing on point prevalence survey data and linked to locally adapted antibiotic formularies informed by resistance surveillance data (Davey et al., 2017). Prioritise investment in diagnostic microbiology laboratory capacity to increase the proportion of culture-guided prescribing from the current 31% toward international benchmarks. Enforce existing regulatory frameworks for antibiotic dispensing in community pharmacies and integrate pharmacist-led AMS into primary care and community settings. Adopt standardised AMS outcome metrics (DDD, DOT, LOS, cost per episode) to enable national benchmarking and health-economic justification for stewardship investment. Leverage international collaborations and adapt successful stewardship models from high-income countries, contextualising them appropriately for Bangladesh’s healthcare infrastructure and resource constraints. Conclusion AMS implementation in Bangladesh remains at an early and fragmented stage, characterised by a critical gap between national policy ambition and institutional practice. Core stewardship strategies—audit and feedback, multidisciplinary AMS committees, culture-guided prescribing, and formulary controls—are absent from frontline settings despite their proven effectiveness. Training and education offer important and pragmatic entry points, and clinician receptivity is high, but supplemental strategies alone are insufficient to change prescribing norms sustainably. Translating Bangladesh’s progressive National Action Plan into clinical impact will require urgent investment in diagnostic laboratory infrastructure, antimicrobial surveillance systems, AMS staffing, and regulatory enforcement. Future research should evaluate stewardship interventions across primary, secondary, and rural settings using standardised outcome metrics, and explore implementation science frameworks to understand how successful models can be adapted and scaled within Bangladesh’s health system. Declarations Author Contributions SMC: Conceptualisation, literature search, screening, data extraction, quality assessment, formal analysis, writing – original draft. RAE: Conceptualisation, supervision, methodology, validation, writing – review and editing, project administration. All authors approved the final manuscript. Competing Interests The authors declare no competing interests. RAE is a Senior Lecturer at the University of Hertfordshire and serves as Associate Editor at JAC–Antimicrobial Resistance (Oxford University Press); these roles did not influence the conduct or reporting of this review. Data Availability All data supporting the findings of this review are available within the article and its supplementary materials. The full search strategies and CASP quality assessment tables are available from the corresponding author upon request. Funding This systematic review received no specific funding. References Ahmed S, Korpe P, Ahmed T, Chisti MJ, Faruque ASG. Burden and Risk Factors of Antimicrobial Use in Children Less Than 5 Years of Age with Diarrheal Illness in Rural Bangladesh. Am J Trop Med Hyg. 2018;98(6):1571–1576. https://doi.org/10.4269/ajtmh.17-0988 Afroz H, Hossain MM, Fakruddin M. 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Antibiotic Resistance Pattern and Stewardship Programme in Critical Care Settings. Bangladesh Med Res Counc Bull. 2017;43(3):131–137. https://doi.org/10.3329/bmrcb.v43i3.36417 Murray CJL, Ikuta KS, Sharara F, et al. Global burden of bacterial antimicrobial resistance in 2019: A systematic analysis. Lancet. 2022;399(10325):629–655. https://doi.org/10.1016/S0140-6736(21)02724-0 Naghavi M, Vollset SE, Ikuta KS, et al. Global burden of bacterial antimicrobial resistance 1990–2021: A systematic analysis with forecasts to 2050. Lancet. 2024;404(10459):1199–1226. https://doi.org/10.1016/S0140-6736(24)01867-1 National Strategy and Action Plan for Antimicrobial Resistance Containment in Bangladesh 2023–2028. Directorate General of Health Services, Bangladesh. 2023. Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. BMJ. 2021;372:n71. https://doi.org/10.1136/bmj.n71 Rashid MM, Akhtar Z, Chowdhury S, et al. Pattern of Antibiotic Use among Hospitalized Patients according to WHO Access, Watch, Reserve (AWaRe) Classification: Findings from a Point Prevalence Survey in Bangladesh. Antibiotics. 2022;11(6):810. https://doi.org/10.3390/antibiotics11060810 Rashid MM, Chisti MJ, Akter D, Sarkar M, Chowdhury F. Antibiotic use for pneumonia among children under-five at a pediatric hospital in Dhaka city, Bangladesh. Patient Prefer Adherence. 2017;11:1335–1342. https://doi.org/10.2147/PPA.S140002 Roy S, Barua HT, Sujan MJ, et al. Trends and Patterns of Antimicrobial Resistance in a Tertiary Care Hospital in Bangladesh. Microbiol Res. 2025;16(2):30. https://doi.org/10.3390/microbiolres16020030 Rubel AMSA, Dey M, Islam T, et al. Pattern of Following Antibiotic Guidelines: The UK and Bangladesh Perspective. SSRN. 2024. https://doi.org/10.2139/ssrn.4996810 Saeed MH, Hall LJ. Early-life antibiotic usage and impact on the gut microbiota, including emergence of antimicrobial resistant Enterococcus. 2023. https://doi.org/10.1530/MAH-23-0002 Sulis G, Sayood S, Gandra S. Antimicrobial resistance in low- and middle-income countries: Current status and future directions. Expert Rev Anti Infect Ther. 2022;20(8):1081–1093. Sumon SA, Anwar MMU, Akther FM, et al. Perceptions of antibiotic stewardship programmes and determinants of antibiotic prescribing patterns among physicians in tertiary hospitals in Bangladesh: Implications for future policy and practice. J Hosp Infect. 2024a;144:56–65. https://doi.org/10.1016/j.jhin.2023.11.010 Sumon SA, Sarker S, Chowdhury ABMA, et al. Antibiotic use in tertiary care hospitals in Bangladesh: Revealing the extent through a point prevalence survey. Am J Infect Control. 2024b;52(9):1052–1059. https://doi.org/10.1016/j.ajic.2024.05.013 Tracking AMR Country Self-Assessment Survey (TrACSS) 2022 Country Report: Bangladesh. World Health Organization; 2022. https://cdn.who.int/media/docs/default-source/antimicrobial-resistance/amr-spc-npm/tracss/2022/tracss-2022-bangladesh.pdf UKHSA. English Surveillance Programme for Antimicrobial Utilisation and Resistance (ESPAUR) Report 2023–2024. UK Health Security Agency; 2024. WHO. Antimicrobial Stewardship Programmes in Health-Care Facilities in Low- and Middle-Income Countries. World Health Organization; 2019. WHO. Global Action Plan on Antimicrobial Resistance. World Health Organization; 2015. Zujbe Z, Tabassum N, Kibria G, et al. The burden of hospital-acquired infections and antibiotic resistance in Bangladesh: Current trends and policy implications. Discov Public Health. 2025;22(1):290. https://doi.org/10.1186/s12982-025-00665-9 Additional Declarations The authors declare no competing interests. Supplementary Files SupplementaryTable1.docx Supplementary Table 1. AMS strategies identified across the included studies Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-9123957\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":true,\"archivedVersions\":[],\"articleType\":\"Systematic Review\",\"associatedPublications\":[],\"authors\":[{\"id\":606155024,\"identity\":\"a2827f68-a8c8-439f-beb4-748a318b0ed9\",\"order_by\":0,\"name\":\"Shumonto Mowla Chowdhury\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Department of Medicine, School of Health, Medicine and Life Sciences, University of Hertfordshire, UK\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Shumonto\",\"middleName\":\"Mowla\",\"lastName\":\"Chowdhury\",\"suffix\":\"\"},{\"id\":606155025,\"identity\":\"5f9c5886-f71e-4773-b8b7-c5379bdf3ed4\",\"order_by\":1,\"name\":\"Rasha Abdelsalam Elshenawy\",\"email\":\"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/0lEQVRIiWNgGAWjYHACxgOMDRDGYyTRBLx6YFqYjYGEBEla2KSJ0mLewHzg4M8dNnn8M3LMqgsq7tXJNzA//MDYloZTi8wBtoTDvGfSiiVu5JjdnnGmWMLgAJuxBGNbDk4tEgw8BocZ2w4nNtwGauFtS5AwYGAwY2Bsq8Cjhf/DwZ9t/xPnA7UU8/5LkJBvYP9GQAsPwwHetgOJG4BamHkbEiQYDvCAbMHjMGY2g8O8bcmJG+8/K5bmOZYgueEwT7FEwjnc3pdgb3748GebXeK8M4c3fuapSeCXb2/f+OFDWTJOLQzMcBaHAUIkAbcGZMD+gDh1o2AUjIJRMOIAAOyBUYMiif3KAAAAAElFTkSuQmCC\",\"orcid\":\"https://orcid.org/0000-0002-8954-0817\",\"institution\":\"Department of Medicine, School of Health, Medicine and Life Sciences, University of Hertfordshire, UK\",\"correspondingAuthor\":true,\"prefix\":\"\",\"firstName\":\"Rasha\",\"middleName\":\"Abdelsalam\",\"lastName\":\"Elshenawy\",\"suffix\":\"\"}],\"badges\":[],\"createdAt\":\"2026-03-14 16:33:07\",\"currentVersionCode\":1,\"declarations\":{\"humanSubjects\":false,\"vertebrateSubjects\":true,\"conflictsOfInterestStatement\":false,\"humanSubjectEthicalGuidelines\":false,\"humanSubjectConsent\":false,\"humanSubjectClinicalTrial\":false,\"humanSubjectCaseReport\":false,\"vertebrateSubjectEthicalGuidelines\":true},\"doi\":\"10.21203/rs.3.rs-9123957/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-9123957/v1\",\"draftVersion\":[],\"editorialEvents\":[],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":104876954,\"identity\":\"ab2fcecf-e08d-4683-96a6-37e1df80f578\",\"added_by\":\"auto\",\"created_at\":\"2026-03-18 08:44:15\",\"extension\":\"png\",\"order_by\":1,\"title\":\"Figure 1\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":222034,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003ePRISMA 2020 flow diagram of study selection.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"Figure1.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-9123957/v1/fd0b5473229de2310ed304ed.png\"},{\"id\":104876902,\"identity\":\"4b0e3267-a37b-47e5-b91b-186a5ca74e59\",\"added_by\":\"auto\",\"created_at\":\"2026-03-18 08:44:03\",\"extension\":\"png\",\"order_by\":2,\"title\":\"Figure 2\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":122279,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eBarriers and facilitators to antimicrobial stewardship implementation identified across included studies (n = 14).\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"Figure2.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-9123957/v1/f93b05c987902a41625fb0c3.png\"},{\"id\":104876948,\"identity\":\"b00b38e1-965f-422c-b238-42ab6b0f1725\",\"added_by\":\"auto\",\"created_at\":\"2026-03-18 08:44:14\",\"extension\":\"png\",\"order_by\":3,\"title\":\"Figure 3\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":144955,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eCore and supplemental antimicrobial stewardship strategies reported or recommended across included studies (n = 14).\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"Figure3.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-9123957/v1/40fed7dda5e128c41fdde9bf.png\"},{\"id\":104876993,\"identity\":\"ca058d75-5bb0-4720-a855-dc0607f7a918\",\"added_by\":\"auto\",\"created_at\":\"2026-03-18 08:44:21\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":1284857,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-9123957/v1/8c86f131-9a17-4fa4-b122-c2f70228bf2f.pdf\"},{\"id\":104876774,\"identity\":\"f4e69eac-cbb8-4c8a-84f0-b5b917cd7d1a\",\"added_by\":\"auto\",\"created_at\":\"2026-03-18 08:43:38\",\"extension\":\"docx\",\"order_by\":1,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"supplement\",\"size\":17843,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003e\\u003cstrong\\u003eSupplementary Table 1. \\u003c/strong\\u003eAMS strategies identified across the included studies\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"SupplementaryTable1.docx\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-9123957/v1/e7afb5c0a440a566cc105237.docx\"}],\"financialInterests\":\"The authors declare no competing interests.\",\"formattedTitle\":\"\\u003cp\\u003e\\u003cstrong\\u003eBarriers and Facilitators to Antimicrobial Stewardship Implementation Across Healthcare Settings in Bangladesh: A Systematic Review\\u003c/strong\\u003e\\u003c/p\\u003e\",\"fulltext\":[{\"header\":\"Introduction\",\"content\":\"\\u003cp\\u003eAntimicrobial resistance (AMR) represents one of the most urgent threats to global public health. Bacterial AMR directly caused an estimated 1.27\\u0026nbsp;million deaths worldwide in 2019 and contributed to approximately 4.95\\u0026nbsp;million additional deaths, with projections indicating that annual direct mortality could reach 1.91\\u0026nbsp;million by 2050 and that 39\\u0026nbsp;million AMR-related deaths may occur between 2025 and 2050 (Murray et al., \\u003cspan citationid=\\\"CR20\\\" class=\\\"CitationRef\\\"\\u003e2022\\u003c/span\\u003e; Naghavi et al., \\u003cspan citationid=\\\"CR21\\\" class=\\\"CitationRef\\\"\\u003e2024\\u003c/span\\u003e). The World Health Organization (WHO) has consistently ranked AMR among the top ten global public health threats, and the burden is disproportionately concentrated in low- and middle-income countries (LMICs), where approximately 4.3\\u0026nbsp;million AMR-associated deaths occur annually and nearly all AMR-related child deaths occur (Lewnard et al., \\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e2024\\u003c/span\\u003e; Saeed \\u0026amp; Hall, \\u003cspan citationid=\\\"CR28\\\" class=\\\"CitationRef\\\"\\u003e2023\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eAMS is defined as a coordinated set of strategies to promote the appropriate use of antimicrobials, preserve their effectiveness and reduce AMR. The concept was first formally described in the 1990s and has since been codified within international frameworks including the WHO Global Action Plan (2015) and national programmes such as England\\u0026rsquo;s \\u0026lsquo;Start Smart Then Focus\\u0026rsquo; toolkit (McGowan \\u0026amp; Gerding, \\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e1996\\u003c/span\\u003e; Dyar et al., \\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e2017\\u003c/span\\u003e; WHO, \\u003cspan citationid=\\\"CR35\\\" class=\\\"CitationRef\\\"\\u003e2015\\u003c/span\\u003e). High-income countries such as the United Kingdom have demonstrated the value of systemic AMS investment: the English Surveillance Programme for Antimicrobial Utilisation and Resistance (ESPAUR) enables systematic monitoring, and the UK\\u0026rsquo;s revised 2024\\u0026ndash;2029 National Action Plan targets a 5% reduction in total antibiotic use alongside an increase in narrow-spectrum prescribing (UKHSA, \\u003cspan citationid=\\\"CR33\\\" class=\\\"CitationRef\\\"\\u003e2024\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eBangladesh, a lower-middle-income country of approximately 170\\u0026nbsp;million people, exemplifies the paradox confronting many LMICs: robust national policy commitments coexist with severe implementation gaps. In 2019, 26,200 deaths were directly attributable to AMR, and 98,800 deaths were AMR-associated (Zujbe et al., \\u003cspan citationid=\\\"CR36\\\" class=\\\"CitationRef\\\"\\u003e2025\\u003c/span\\u003e). Bangladesh ranked 75th globally for age-standardised AMR mortality per 100,000 population according to the WHO Tracking AMR Country Self-Assessment Survey (TrACSS, 2022), though this ranking is confounded by limited surveillance coverage, only 11 hospitals contribute data to the WHO Global Antimicrobial Resistance and Use Surveillance System (GLASS) (GLASS, 2023). Despite the introduction of a comprehensive National Action Plan for AMR Containment (2023\\u0026ndash;2028) adopting a One Health approach, hospital assessments reveal no formal AMS programmes across tertiary facilities and that fewer than half of physicians demonstrate AMS awareness (Sumon et al., \\u003cspan citationid=\\\"CR30\\\" class=\\\"CitationRef\\\"\\u003e2024a\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eWhile several narrative reviews and individual empirical studies have examined antimicrobial prescribing practices in Bangladesh, no prior systematic review has synthesised the full scope of barriers, facilitators, and AMS strategies across all healthcare setting types. This evidence gap hampers the design of targeted, scalable stewardship interventions and limits the ability of policymakers to allocate resources effectively. The present systematic review addresses this gap by providing a comprehensive synthesis of the published literature.\\u003c/p\\u003e\\n\\u003ch3\\u003eAim and Objectives\\u003c/h3\\u003e\\n\\u003cp\\u003eThis review aims to identify and synthesise evidence on barriers and facilitators to AMS implementation across healthcare settings in Bangladesh, and to characterise the AMS strategies reported or recommended, in order to generate evidence-based recommendations for sustainable stewardship improvement.\\u003c/p\\u003e \\u003cp\\u003eThe specific objectives were to:\\u003c/p\\u003e \\u003cp\\u003e \\u003cul\\u003e \\u003cli\\u003e \\u003cp\\u003eIdentify barriers and facilitators to AMS implementation across primary, secondary, and tertiary healthcare settings in Bangladesh.\\u003c/p\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cp\\u003eCharacterise healthcare professionals\\u0026rsquo; knowledge, attitudes, and prescribing behaviours relating to antimicrobials.\\u003c/p\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cp\\u003eIdentify core and supplemental AMS strategies reported or recommended in the Bangladesh context.\\u003c/p\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cp\\u003eGenerate evidence-based recommendations for policymakers, hospital administrators, and professional bodies to strengthen AMS across Bangladesh\\u0026rsquo;s health system.\\u003c/p\\u003e \\u003c/li\\u003e \\u003c/ul\\u003e \\u003c/p\\u003e \"},{\"header\":\"Methods\",\"content\":\"\\u003cdiv id=\\\"Sec3\\\" class=\\\"Section2\\\"\\u003e\\n \\u003cp\\u003eThis systematic review was conducted and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA 2020) guidelines (Page et al., \\u003cspan class=\\\"CitationRef\\\"\\u003e2021\\u003c/span\\u003e). The review protocol was approved by the supervising academic prior to the commencement of searches.\\u003c/p\\u003e\\n\\u003c/div\\u003e\\n\\u003ch3\\u003eEligibility Criteria\\u003c/h3\\u003e\\n\\u003cp\\u003eEligibility criteria were structured using the PEO (Population, Exposure, Outcome) framework (Table \\u003cspan class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e). Studies were eligible if they examined AMS implementation, antimicrobial prescribing practices, or barriers and facilitators to stewardship within any Bangladesh healthcare context. Eligible study designs included systematic reviews, literature reviews, meta-analyses, cross-sectional studies, cohort studies, case\\u0026ndash;control studies, qualitative studies, case studies, and conference abstracts. Studies were restricted to those published in English between 2010 and 2025 and reporting on human health settings. Studies exclusively addressing veterinary or environmental antimicrobial use were excluded, as were studies without accessible full text.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003ctable id=\\\"Tab1\\\" border=\\\"1\\\"\\u003e\\n \\u003ccaption language=\\\"En\\\"\\u003e\\n \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 1\\u003c/div\\u003e\\n \\u003cdiv class=\\\"CaptionContent\\\"\\u003e\\n \\u003cp\\u003eEligibility criteria using the PEO framework\\u003c/p\\u003e\\n \\u003c/div\\u003e\\n \\u003c/caption\\u003e\\n \\u003cthead\\u003e\\n \\u003ctr\\u003e\\n \\u003cth align=\\\"left\\\"\\u003e\\n \\u003cp\\u003ePEO Element\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eInclusion Criteria\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eExclusion Criteria\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/thead\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003ePopulation\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eStudies targeting healthcare professionals, patients, or professional bodies responsible for AMS in Bangladesh healthcare settings\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eStudies focused exclusively on antibiotic use in animals, veterinary, or environmental settings\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eExposure\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eStudies examining AMS implementation, interventions, challenges, or antibiotic use practices within Bangladesh\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eStudies that do not describe or evaluate antimicrobial stewardship in any form\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eOutcome\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eStudies reporting barriers, facilitators, attitudes, behaviours, motivations, or capacity relating to AMS implementation\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eStudies with outcomes unrelated to AMS implementation or antimicrobial prescribing practices\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eStudy Design\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eSystematic reviews, literature reviews, meta-analyses, cross-sectional studies, cohort studies, case\\u0026ndash;control studies, qualitative studies, case studies, and conference abstracts\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eNon-English language publications; studies without accessible full text\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n\\u003c/table\\u003e\\n\\u003cp\\u003e\\u003cbr\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cbr\\u003e\\u003c/p\\u003e\\n\\u003ch3\\u003eInformation Sources and Search Strategy\\u003c/h3\\u003e\\n\\u003cp\\u003eElectronic searches were conducted on 22 August 2025 across five databases: MEDLINE (via PubMed), CINAHL, Scopus, Cochrane Library, and Google Scholar. Databases were selected to provide comprehensive coverage of clinical, public health, and grey literature relevant to the research question. Boolean operators (AND/OR) were applied to combine the following search terms:\\u003c/p\\u003e\\n\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\n \\u003cp\\u003e(\\u0026ldquo;antimicrobial stewardship\\u0026rdquo; OR \\u0026ldquo;antibiotic stewardship\\u0026rdquo; OR \\u0026ldquo;AMS\\u0026rdquo; OR \\u0026ldquo;antibiotic use\\u0026rdquo; OR \\u0026ldquo;antibiotic management\\u0026rdquo;) AND (\\u0026ldquo;implementation\\u0026rdquo; OR \\u0026ldquo;strategy\\u0026rdquo; OR \\u0026ldquo;barrier\\u0026rdquo; OR \\u0026ldquo;facilitator\\u0026rdquo; OR \\u0026ldquo;challenge\\u0026rdquo;) AND (\\u0026ldquo;Bangladesh\\u0026rdquo; OR \\u0026ldquo;hospital\\u0026rdquo; OR \\u0026ldquo;primary care\\u0026rdquo; OR \\u0026ldquo;secondary care\\u0026rdquo; OR \\u0026ldquo;community pharmacy\\u0026rdquo;)\\u003c/p\\u003e\\n\\u003c/div\\u003e\\n\\u003cp\\u003eRetrieved records were exported to ZOTERO and subsequently managed in Microsoft Excel for deduplication and screening.\\u003c/p\\u003e\\n\\u003ch3\\u003eStudy Selection\\u003c/h3\\u003e\\n\\u003cp\\u003eScreening and data extraction were performed by the primary reviewer and independently verified by the supervising author, followed by full-text assessment of potentially eligible records against pre-defined inclusion and exclusion criteria. The PRISMA 2020 flow diagram (Fig. \\u003cspan class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e) details the study selection process.\\u003c/p\\u003e\\n\\u003ch3\\u003eQuality Assessment\\u003c/h3\\u003e\\n\\u003cp\\u003eThe methodological quality of included studies was assessed using the Critical Appraisal Skills Programme (CASP) checklists, version 2022 (CASP, 2022). Appropriate checklist versions were applied according to the study design: the CASP Qualitative Studies checklist, the Cross-Sectional Studies checklist, and the Cohort Study checklist. Quality ratings (high, moderate, or low) were assigned based on the proportion of appraisal criteria satisfied. Quality assessment was conducted by the primary reviewer.\\u003c/p\\u003e\\n\\u003cdiv id=\\\"Sec8\\\" class=\\\"Section2\\\"\\u003e\\n \\u003ch2\\u003eData Extraction and Synthesis\\u003c/h2\\u003e\\n \\u003cp\\u003eData were extracted by the primary reviewer into a standardised extraction form capturing: author, year, healthcare setting, study design, population, sample size, barriers to AMS, facilitators of AMS, core AMS strategies, supplemental AMS strategies, AMS outcomes, knowledge and attitudes, and regulatory or policy context. Given the heterogeneity of included study designs and outcome measures, a narrative synthesis approach was adopted, combining quantitative descriptive analysis with qualitative thematic analysis. Qualitative themes were developed inductively from the extracted data using Microsoft Excel for coding.\\u003c/p\\u003e\\n\\u003c/div\\u003e\\n\\u003ch2\\u003eEthical Approval\\u003c/h2\\u003e\\n\\u003cp\\u003eEthical approval was not required for this systematic review, as no primary data collection involving human participants was undertaken.\\u003c/p\\u003e\"},{\"header\":\"Results\",\"content\":\"\\u003ch2\\u003eStudy Selection and Characteristics\\u003c/h2\\u003e\\n\\u003cp\\u003eThe electronic search identified 9,410 records: PubMed (n=4,971), Scopus (n=2,654), Cochrane Library (n=910), CINAHL (n=815), and Google Scholar (n=60). After removal of 5,139 duplicates, 4,271 records were screened at the title and abstract stage, yielding 102 reports for full-text assessment. After applying the eligibility criteria, 14 studies published between 2014 and 2025 were included in the final review (Figure 1).\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eFigure 1.\\u003c/strong\\u003e PRISMA 2020 flow diagram of study selection.\\u003c/p\\u003e\\n\\u003cp\\u003eThe 14 included studies collectively encompassed 34,097 participants, comprising 33,538 patients or clinical specimens and 559 healthcare professionals. Study designs were heterogeneous: point-prevalence surveys and cross-sectional prescribing audits (n=3), retrospective and prospective laboratory or genomic surveillance (n=3), prospective cohort analyses (n=2), cross-sectional surveys of healthcare professionals (n=1), secondary care population surveys (n=1), and narrative reviews or study protocols (n=4). The majority were conducted in tertiary hospital settings (64%; n=9 studies), with mixed secondary and tertiary settings (29%; n=4) and secondary-only settings (7%; n=1) also represented. The full data extraction is presented in Table 2.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eTable 2. Summary data extraction table\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003ctable border=\\\"1\\\" cellspacing=\\\"0\\\" cellpadding=\\\"0\\\" width=\\\"602\\\"\\u003e\\n \\u003cthead\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 73px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eStudy\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 60px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eSetting\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 67px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eDesign\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 47px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eN\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 118px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eKey Barriers\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 125px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eKey Facilitators\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 45px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eQuality\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/thead\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 73px;\\\"\\u003e\\n \\u003cp\\u003eSumon et al., 2024a (JHI)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 60px;\\\"\\u003e\\n \\u003cp\\u003eTertiary\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 67px;\\\"\\u003e\\n \\u003cp\\u003eCross-sectional survey\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 47px;\\\"\\u003e\\n \\u003cp\\u003e559 HCPs\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 118px;\\\"\\u003e\\n \\u003cp\\u003eNo AMS guidelines; limited training; high workload\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 125px;\\\"\\u003e\\n \\u003cp\\u003eClinician interest in AMS; recognition of antibiotic misuse\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 45px;\\\"\\u003e\\n \\u003cp\\u003eHigh\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 73px;\\\"\\u003e\\n \\u003cp\\u003eHarun et al., 2022\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 60px;\\\"\\u003e\\n \\u003cp\\u003eTertiary\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 67px;\\\"\\u003e\\n \\u003cp\\u003eStudy protocol\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 47px;\\\"\\u003e\\n \\u003cp\\u003eN/A\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 118px;\\\"\\u003e\\n \\u003cp\\u003eStaffing and governance gaps\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 125px;\\\"\\u003e\\n \\u003cp\\u003eIPC-AMS integration plan; alignment with NAP\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 45px;\\\"\\u003e\\n \\u003cp\\u003eModerate\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 73px;\\\"\\u003e\\n \\u003cp\\u003eSumon et al., 2024b (AJIC)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 60px;\\\"\\u003e\\n \\u003cp\\u003eTertiary\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 67px;\\\"\\u003e\\n \\u003cp\\u003ePoint prevalence survey\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 47px;\\\"\\u003e\\n \\u003cp\\u003e1,063 patients\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 118px;\\\"\\u003e\\n \\u003cp\\u003eEmpirical prescribing; no microbiology access; no guidelines\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 125px;\\\"\\u003e\\n \\u003cp\\u003eStaff willingness to engage; PPS feasibility\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 45px;\\\"\\u003e\\n \\u003cp\\u003eHigh\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 73px;\\\"\\u003e\\n \\u003cp\\u003eRashid et al., 2022\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 60px;\\\"\\u003e\\n \\u003cp\\u003eMixed (2\\u0026deg;/3\\u0026deg;)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 67px;\\\"\\u003e\\n \\u003cp\\u003ePoint prevalence survey\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 47px;\\\"\\u003e\\n \\u003cp\\u003e1,099 patients\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 118px;\\\"\\u003e\\n \\u003cp\\u003eOveruse of Watch antibiotics; weak stewardship; poor documentation\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 125px;\\\"\\u003e\\n \\u003cp\\u003eWHO AWaRe framework applicable\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 45px;\\\"\\u003e\\n \\u003cp\\u003eHigh\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 73px;\\\"\\u003e\\n \\u003cp\\u003eMia et al., 2017\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 60px;\\\"\\u003e\\n \\u003cp\\u003eTertiary ICU\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 67px;\\\"\\u003e\\n \\u003cp\\u003eCross-sectional microbiology\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 47px;\\\"\\u003e\\n \\u003cp\\u003e1,670 patients\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 118px;\\\"\\u003e\\n \\u003cp\\u003eHigh resistance; empirical treatment; weak enforcement\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 125px;\\\"\\u003e\\n \\u003cp\\u003ePilot stewardship programme feasible in ICU\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 45px;\\\"\\u003e\\n \\u003cp\\u003eModerate\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 73px;\\\"\\u003e\\n \\u003cp\\u003eRubel et al., 2024\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 60px;\\\"\\u003e\\n \\u003cp\\u003eMixed (BD/UK)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 67px;\\\"\\u003e\\n \\u003cp\\u003eProtocol/comparative\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 47px;\\\"\\u003e\\n \\u003cp\\u003eN/A\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 118px;\\\"\\u003e\\n \\u003cp\\u003eLower guideline adherence vs UK\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 125px;\\\"\\u003e\\n \\u003cp\\u003eInternational benchmarking as leverage\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 45px;\\\"\\u003e\\n \\u003cp\\u003eLow\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 73px;\\\"\\u003e\\n \\u003cp\\u003eHaque \\u0026amp; Godman, 2021\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 60px;\\\"\\u003e\\n \\u003cp\\u003eMixed\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 67px;\\\"\\u003e\\n \\u003cp\\u003eNarrative review\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 47px;\\\"\\u003e\\n \\u003cp\\u003eN/A\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 118px;\\\"\\u003e\\n \\u003cp\\u003eOTC antibiotic sales; weak regulation; resource shortfalls\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 125px;\\\"\\u003e\\n \\u003cp\\u003eInternational experience transferable; policy frameworks exist\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 45px;\\\"\\u003e\\n \\u003cp\\u003eModerate\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 73px;\\\"\\u003e\\n \\u003cp\\u003eRashid et al., 2017\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 60px;\\\"\\u003e\\n \\u003cp\\u003eTertiary paediatric\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 67px;\\\"\\u003e\\n \\u003cp\\u003eCross-sectional\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 47px;\\\"\\u003e\\n \\u003cp\\u003e80 children\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 118px;\\\"\\u003e\\n \\u003cp\\u003eNon-adherence to WHO guidelines; empirical use\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 125px;\\\"\\u003e\\n \\u003cp\\u003ePneumonia guidelines available\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 45px;\\\"\\u003e\\n \\u003cp\\u003eModerate\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 73px;\\\"\\u003e\\n \\u003cp\\u003eBoone et al., 2021\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 60px;\\\"\\u003e\\n \\u003cp\\u003eTertiary neonatal\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 67px;\\\"\\u003e\\n \\u003cp\\u003eProspective cohort\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 47px;\\\"\\u003e\\n \\u003cp\\u003e448 admissions\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 118px;\\\"\\u003e\\n \\u003cp\\u003eDiagnostic uncertainty; empirical prescribing; no AMS structures\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 125px;\\\"\\u003e\\n \\u003cp\\u003eProspective cohort methodology feasible\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 45px;\\\"\\u003e\\n \\u003cp\\u003eHigh\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 73px;\\\"\\u003e\\n \\u003cp\\u003eAhmed et al., 2018\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 60px;\\\"\\u003e\\n \\u003cp\\u003eSecondary (rural)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 67px;\\\"\\u003e\\n \\u003cp\\u003eSurvey\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 47px;\\\"\\u003e\\n \\u003cp\\u003e3,570 children\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 118px;\\\"\\u003e\\n \\u003cp\\u003eOTC access; caregiver demand; weak enforcement\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 125px;\\\"\\u003e\\n \\u003cp\\u003eStrong surveillance capacity (icddr,b)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 45px;\\\"\\u003e\\n \\u003cp\\u003eHigh\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 73px;\\\"\\u003e\\n \\u003cp\\u003eAfroz et al., 2014\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 60px;\\\"\\u003e\\n \\u003cp\\u003eTertiary\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 67px;\\\"\\u003e\\n \\u003cp\\u003eRetrospective study\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 47px;\\\"\\u003e\\n \\u003cp\\u003e3,584 specimens\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 118px;\\\"\\u003e\\n \\u003cp\\u003eDelayed diagnostics; absent stewardship\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 125px;\\\"\\u003e\\n \\u003cp\\u003eLaboratory diagnostic capacity present\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 45px;\\\"\\u003e\\n \\u003cp\\u003eModerate\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 73px;\\\"\\u003e\\n \\u003cp\\u003eZujbe et al., 2025\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 60px;\\\"\\u003e\\n \\u003cp\\u003eMixed\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 67px;\\\"\\u003e\\n \\u003cp\\u003eNarrative review\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 47px;\\\"\\u003e\\n \\u003cp\\u003eN/A\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 118px;\\\"\\u003e\\n \\u003cp\\u003ePoor IPC infrastructure; weak surveillance\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 125px;\\\"\\u003e\\n \\u003cp\\u003ePolicy-level interest; NAP highlighted\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 45px;\\\"\\u003e\\n \\u003cp\\u003eLow\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 73px;\\\"\\u003e\\n \\u003cp\\u003eRoy et al., 2025\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 60px;\\\"\\u003e\\n \\u003cp\\u003eTertiary\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 67px;\\\"\\u003e\\n \\u003cp\\u003eLaboratory surveillance\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 47px;\\\"\\u003e\\n \\u003cp\\u003e21,523 specimens\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 118px;\\\"\\u003e\\n \\u003cp\\u003eMDR prevalence; absent AMS committee\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 125px;\\\"\\u003e\\n \\u003cp\\u003eLongitudinal surveillance capacity\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 45px;\\\"\\u003e\\n \\u003cp\\u003eHigh\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 73px;\\\"\\u003e\\n \\u003cp\\u003eFarzana et al., 2023\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 60px;\\\"\\u003e\\n \\u003cp\\u003eTertiary\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 67px;\\\"\\u003e\\n \\u003cp\\u003eGenomic surveillance\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 47px;\\\"\\u003e\\n \\u003cp\\u003e643 isolates\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 118px;\\\"\\u003e\\n \\u003cp\\u003eCRE spread; limited genomic capacity\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 125px;\\\"\\u003e\\n \\u003cp\\u003eInternational collaboration; genomic resistance tracking\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 45px;\\\"\\u003e\\n \\u003cp\\u003eHigh\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n\\u003c/table\\u003e\\n\\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eHCPs = healthcare professionals; AMS = antimicrobial stewardship; NAP = National Action Plan; IPC = infection prevention and control; CRE = carbapenem-resistant Enterobacterales; MDR = multidrug resistant; ICU = intensive care unit; icddr,b = International Centre for Diarrhoeal Disease Research, Bangladesh; N/A = not applicable (protocol or narrative study).\\u003c/em\\u003e\\u003c/p\\u003e\\n\\u003ch2\\u003eAMS Metrics and Measurement\\u003c/h2\\u003e\\n\\u003cp\\u003eNone of the 14 included studies reported standardised AMS consumption or outcome metrics, including the specific daily dose (DDD), days of therapy (DOT), length of stay (LOS), or direct antibiotic cost. This represents a critical evidence gap that limits benchmarking and health-economic justification for AMS investment. Studies instead used non-standardised measures including antibiotic prescribing prevalence (n=7), culture-guided prescribing rates (n=3), WHO AWaRe distribution (n=2), multidrug-resistance prevalence (n=4), and proportion of patients receiving broad-spectrum agents.\\u003c/p\\u003e\\n\\u003ch2\\u003eBarriers to AMS Implementation\\u003c/h2\\u003e\\n\\u003cp\\u003eSystematic coding of the included studies identified four principal categories of barrier (Figure 2). The most frequently identified barrier was the absence or weak enforcement of hospital AMS policies or guidelines, reported across six studies (Haque \\u0026amp; Godman, 2021; Mia et al., 2017; Rashid et al., 2022; Sumon et al., 2024a; Sumon et al., 2024b; Zujbe et al., 2025). Entrenched empirical prescribing culture, characterised by widespread broad-spectrum antibiotic use without microbiological guidance, was documented in five studies (Boone et al., 2021; Mia et al., 2017; Rashid et al., 2022; Roy et al., 2025; Sumon et al., 2024b); Sumon et al. (2024b) reported that 73.5% of hospitalised patients were receiving antibiotics, with cephalosporins accounting for 54% of defined daily doses. Limited diagnostic and laboratory capacity was identified in four studies (Afroz et al., 2014; Farzana et al., 2023; Mia et al., 2017; Sumon et al., 2024b), with only 31% of prescriptions informed by microbiological culture results (Sumon et al., 2024b). Lack of dedicated AMS staffing and multidisciplinary stewardship teams was highlighted in three studies (Haque \\u0026amp; Godman, 2021; Harun et al., 2022; Sumon et al., 2024a). Caregiver demand and unregulated access to over-the-counter (OTC) antibiotics were also identified as community-level barriers in two studies (Ahmed et al., 2018; Rashid et al., 2017).\\u003c/p\\u003e\\n\\u003ch2\\u003eFacilitators of AMS Implementation\\u003c/h2\\u003e\\n\\u003cp\\u003eDespite pervasive implementation barriers, several enabling factors were identified. Existing antimicrobial surveillance capacity was the most frequently cited facilitator, appearing in six studies (Afroz et al., 2014; Farzana et al., 2023; Rashid et al., 2022; Roy et al., 2025; Sumon et al., 2024b; Zujbe et al., 2025). Training and education programmes targeting healthcare professionals were identified as pragmatic facilitators in five studies (Ahmed et al., 2018; Haque \\u0026amp; Godman, 2021; Mia et al., 2017; Rubel et al., 2024; Sumon et al., 2024a), and Sumon et al. (2024a) specifically documented high clinician receptivity to AMS engagement. Leadership commitment and institutional governance were highlighted in three studies (Haque \\u0026amp; Godman, 2021; Sumon et al., 2024a; Zujbe et al., 2025). International collaboration and expanding genomic and resistance-characterisation capacity were identified as additional facilitators in two studies (Farzana et al., 2023; Harun et al., 2022) (Figure 2).\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eFigure 2.\\u003c/strong\\u003e Barriers and facilitators to antimicrobial stewardship implementation identified across included studies (n = 14).\\u003c/p\\u003e\\n\\u003ch2\\u003eAMS Strategies\\u003c/h2\\u003e\\n\\u003cp\\u003eCritically, no included study reported the implementation of a fully functioning, institutionalised AMS programme. Core AMS strategies were recommended rather than implemented in 64% of studies (n=9), and supplemental strategies were reported or recommended in 50% (n=7), but uptake remained inconsistent (Supplementary Table 1 and Figure 3).\\u003c/p\\u003e\\n\\u003cp\\u003eAmong core strategies, antibiotic prescribing audit and surveillance was reported in three studies (Boone et al., 2021; Roy et al., 2025; Sumon et al., 2024b), microbiology-based or genomic guidance was applied in four studies (Afroz et al., 2014; Farzana et al., 2023; Mia et al., 2017; Sumon et al., 2024a), point prevalence surveys were conducted in two studies (Rashid et al., 2022; Sumon et al., 2024b), and WHO AWaRe benchmarking was utilised in one study (Rashid et al., 2022). Formal AMS committee or team formation was recommended\\u0026mdash;but not operationalised\\u0026mdash;in two studies (Haque \\u0026amp; Godman, 2021; Harun et al., 2022). Among supplemental strategies, training and education were recommended in five studies, awareness campaigns in three, guideline development in two, international collaboration in two, and public engagement in two.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eFigure 3.\\u003c/strong\\u003e Core and supplemental antimicrobial stewardship strategies reported or recommended across included studies (n = 14).\\u003c/p\\u003e\\n\\u003ch2\\u003eQualitative Thematic Analysis\\u003c/h2\\u003e\\n\\u003cp\\u003eThematic analysis of the qualitative data derived from included studies identified four overarching themes.\\u003c/p\\u003e\\n\\u003cp\\u003eTheme 1: Systemic resource and infrastructure deficits. Across the dataset, infrastructural constraints\\u0026mdash;including limited laboratory diagnostics, insufficient stewardship staffing, inadequate data systems, and scarce financing\\u0026mdash;emerged as the foundational drivers of high empirical prescribing and the primary barriers to operationalising core AMS strategies. Only 31% of prescriptions were culture-guided (Sumon et al., 2024b), directly reflecting the diagnostic gap. Four studies explicitly identified laboratory capacity constraints (Afroz et al., 2014; Farzana et al., 2023; Mia et al., 2017; Sumon et al., 2024b), and three studies highlighted stewardship staffing gaps (Haque \\u0026amp; Godman, 2021; Harun et al., 2022; Sumon et al., 2024a). Fragmented surveillance and data feedback infrastructure were documented in four studies (Farzana et al., 2023; Rashid et al., 2022; Roy et al., 2025; Sumon et al., 2024b).\\u003c/p\\u003e\\n\\u003cp\\u003eTheme 2: Practice\\u0026ndash;policy implementation gap. Formal policies and national frameworks\\u0026mdash;including the WHO AWaRe classification and Bangladesh\\u0026rsquo;s National Action Plan\\u0026mdash;existed or were being adopted, yet adherence at the point of care was consistently poor. Four studies reported substantial discordance between guideline availability and actual prescribing practice (Rashid et al., 2017; Rashid et al., 2022; Rubel et al., 2024; Sumon et al., 2024b). Weak regulatory enforcement of antibiotic dispensing restrictions was highlighted in multiple studies (Ahmed et al., 2018; Haque \\u0026amp; Godman, 2021), and five studies documented an entrenched culture of empirical broad-spectrum prescribing (Boone et al., 2021; Mia et al., 2017; Rashid et al., 2022; Roy et al., 2025; Sumon et al., 2024b).\\u003c/p\\u003e\\n\\u003cp\\u003eTheme 3: Healthcare setting-specific challenges. Implementation barriers and feasible stewardship interventions differed meaningfully by clinical setting. In intensive care units, very high multidrug-resistance burdens coexisted with minimal stewardship infrastructure (Farzana et al., 2023; Mia et al., 2017). In paediatric settings, three studies demonstrated high antibiotic exposure and systematic non-adherence to WHO paediatric prescribing guidelines (Ahmed et al., 2018; Boone et al., 2021; Rashid et al., 2017). At the community level, unregulated OTC antibiotic access driven by caregiver demand represented a distinct barrier requiring community-specific interventions (Ahmed et al., 2018).\\u003c/p\\u003e\\n\\u003cp\\u003eTheme 4: Enabling factors for AMS implementation. Despite the identified constraints, pragmatic facilitators were identified across the dataset. Clinician receptivity to training and structured stewardship support was high (Sumon et al., 2024a), and surveillance capacity\\u0026mdash;while fragmented\\u0026mdash;provided a foundation upon which expanded monitoring systems could be built (Rashid et al., 2022; Roy et al., 2025). Leadership commitment at both hospital and policy levels (Haque \\u0026amp; Godman, 2021; Harun et al., 2022; Zujbe et al., 2025), combined with international collaboration and genomic surveillance capacity (Farzana et al., 2023), represented additional leverage points for systemic change.\\u003c/p\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003eThis systematic review provides the first comprehensive synthesis of barriers, facilitators, and strategies related to AMS implementation across all healthcare settings in Bangladesh. The review synthesised evidence from 14 studies encompassing 34,097 participants and employed both quantitative descriptive analysis and qualitative thematic synthesis, revealing a consistent and concerning picture: despite the existence of a national AMR action plan and growing policy commitment, Bangladesh has not yet institutionalised the core infrastructure required for effective, sustainable antimicrobial stewardship.\\u003c/p\\u003e\\n\\u003ch2\\u003ePrincipal Findings in Global Context\\u003c/h2\\u003e\\n\\u003cp\\u003eThe documented antibiotic prescribing rates, exceeding 70% among hospitalised patients, and the near-universal reliance on empirical broad-spectrum therapy are broadly consistent with patterns observed across LMIC healthcare systems (Sulis et al., 2022; WHO, 2019). However, what distinguishes Bangladesh\\u0026rsquo;s situation is the explicit coexistence of a sophisticated national policy framework with an almost complete absence of operational AMS structures at the institutional level. No included study reported a functioning AMS committee, routine audit and feedback cycle, or prescribing formulary with active restriction mechanisms. This represents a deeper structural failure than resource scarcity alone: it reflects insufficient translation machinery between policy design and clinical implementation.\\u003c/p\\u003e\\n\\u003cp\\u003eBy contrast, high-income countries such as the United Kingdom have demonstrated that sustained investment in surveillance systems (ESPAUR), evidence-based toolkits (\\u0026lsquo;Start Smart Then Focus\\u0026rsquo;), and nationally coordinated audit mechanisms can generate measurable improvements in antimicrobial prescribing, even against a backdrop of rising absolute resistance burden (UKHSA, 2024). The critical difference is not the existence of policies but the availability of the organisational infrastructure, such as staffing, data systems, clinical governance, to enact them at the bedside (Elshenawy et al., 2023).\\u003c/p\\u003e\\n\\u003ch2\\u003eCore and Supplemental AMS Strategies\\u003c/h2\\u003e\\n\\u003cp\\u003eThe distinction between core and supplemental AMS strategies is analytically important. Core strategies, such as prospective audit and feedback, multidisciplinary AMS committees, formulary restriction, and microbiology-guided prescribing, represent the structural backbone of effective stewardship and are associated with the most robust evidence for sustained prescribing improvement (Barlam et al., 2016; Davey et al., 2017). In Bangladesh, these strategies existed only as policy recommendations; none was found to be systematically implemented across the included studies.\\u0026nbsp;\\u003cstrong\\u003eSupplemental strategies\\u003c/strong\\u003e\\u003cstrong\\u003e,\\u003c/strong\\u003e such as training, education, awareness campaigns, and guideline dissemination, were more frequently cited and are undoubtedly valuable, particularly given the documented receptivity of clinicians to AMS engagement (Sumon et al., 2024a). However, global evidence consistently demonstrates that education and awareness alone cannot produce durable changes in prescribing behaviour without the concurrent institutionalisation of structural governance mechanisms (Charani \\u0026amp; Holmes, 2019; Limato et al., 2022). The risk in Bangladesh is that supplemental interventions come to substitute for, rather than complement, the core infrastructure that sustains stewardship.\\u003c/p\\u003e\\n\\u003ch2\\u003eDiagnostic and Surveillance Capacity\\u003c/h2\\u003e\\n\\u003cp\\u003eThe finding that only 31% of antibiotic prescriptions were informed by microbiological culture is a particularly stark indicator of the diagnostic-prescribing gap in Bangladesh (Sumon et al., 2024b). Without reliable, timely culture and susceptibility results, prescribers cannot de-escalate therapy, prescribing audits cannot identify appropriate targets for intervention, and AWaRe benchmarking cannot be meaningfully acted upon. Strengthening diagnostic laboratory capacity is therefore not merely a technical upgrade but a prerequisite for any culture-change stewardship programme. Similarly, the fragmentation of antimicrobial surveillance across fewer than a dozen GLASS-reporting hospitals limits the national evidence base for resistance monitoring and policy development (GLASS, 2023). Bangladesh\\u0026rsquo;s National Action Plan identifies surveillance strengthening as a priority; this review\\u0026rsquo;s findings underline the urgency and centrality of that commitment.\\u003c/p\\u003e\\n\\u003ch2\\u003e\\u003cstrong\\u003eRegulatory Environment and Community Stewardship\\u003c/strong\\u003e\\u003c/h2\\u003e\\n\\u003cp\\u003eThe documented availability of antibiotics without prescription, affecting an estimated 56.6% of antibiotic dispensing transactions in community pharmacies (Al Masud et al., 2024), represents a dimension of AMS that hospital-focused stewardship programmes cannot address in isolation. Effective regulatory enforcement, community pharmacist engagement, and public education about antimicrobial use are essential complements to facility-based stewardship, particularly given the high rates of caregiver-driven antibiotic demand documented in paediatric community settings (Ahmed et al., 2018; Rashid et al., 2017). A One Health approach\\u0026mdash;integrating human, animal, and environmental stewardship\\u0026mdash;as outlined in Bangladesh\\u0026rsquo;s 2023\\u0026ndash;2028 National Action Plan, is the appropriate strategic framework, provided it is accompanied by the resourcing and enforcement mechanisms necessary to operationalise it across sectors.\\u003c/p\\u003e\\n\\u003ch2\\u003eStrengths and Limitations\\u003c/h2\\u003e\\n\\u003cp\\u003eThis review provides the most comprehensive synthesis of AMS implementation evidence specific to Bangladesh undertaken to date, spanning empirical hospital-based studies, laboratory and genomic surveillance, healthcare professional surveys, and narrative policy analyses. The dual quantitative-qualitative synthesis method enabled both descriptive characterisation of prescribing metrics and deeper interpretive analysis of implementation processes.\\u003c/p\\u003e\\n\\u003cp\\u003eSeveral limitations must be acknowledged. The absence of standardised AMS metrics (DDD, DOT, LOS, cost) across all included studies limits comparability and precludes economic analysis. Most included studies were conducted in tertiary urban hospitals, with limited primary care and rural representation, which may underestimate the burden of inappropriate antibiotic use in community settings where most of the population receives care. The restriction of the search to English-language publications may have excluded relevant grey literature or studies published in Bangla. Finally, with only a single reviewer conducting screening and extraction, the risk of selection bias cannot be fully excluded.\\u003c/p\\u003e\\n\\u003ch2\\u003eRecommendations\\u003c/h2\\u003e\\n\\u003cp\\u003eBased on the synthesised evidence, this review makes the following recommendations for policymakers, hospital administrators, and professional bodies:\\u003c/p\\u003e\\n\\u003cul\\u003e\\n \\u003cli\\u003eEstablish functioning multidisciplinary AMS committees in all tertiary and secondary hospitals, comprising infectious disease physicians, clinical pharmacists, microbiologists, and infection control practitioners, aligned with WHO and Infectious Diseases Society of America guidelines (Barlam et al., 2016; WHO, 2019).\\u003c/li\\u003e\\n \\u003cli\\u003eImplement routine prospective audit and feedback programmes, drawing on point prevalence survey data and linked to locally adapted antibiotic formularies informed by resistance surveillance data (Davey et al., 2017).\\u003c/li\\u003e\\n \\u003cli\\u003ePrioritise investment in diagnostic microbiology laboratory capacity to increase the proportion of culture-guided prescribing from the current 31% toward international benchmarks.\\u003c/li\\u003e\\n \\u003cli\\u003eEnforce existing regulatory frameworks for antibiotic dispensing in community pharmacies and integrate pharmacist-led AMS into primary care and community settings.\\u003c/li\\u003e\\n \\u003cli\\u003eAdopt standardised AMS outcome metrics (DDD, DOT, LOS, cost per episode) to enable national benchmarking and health-economic justification for stewardship investment.\\u003c/li\\u003e\\n \\u003cli\\u003eLeverage international collaborations and adapt successful stewardship models from high-income countries, contextualising them appropriately for Bangladesh\\u0026rsquo;s healthcare infrastructure and resource constraints.\\u003c/li\\u003e\\n\\u003c/ul\\u003e\"},{\"header\":\"Conclusion\",\"content\":\"\\u003cp\\u003eAMS implementation in Bangladesh remains at an early and fragmented stage, characterised by a critical gap between national policy ambition and institutional practice. Core stewardship strategies\\u0026mdash;audit and feedback, multidisciplinary AMS committees, culture-guided prescribing, and formulary controls\\u0026mdash;are absent from frontline settings despite their proven effectiveness. Training and education offer important and pragmatic entry points, and clinician receptivity is high, but supplemental strategies alone are insufficient to change prescribing norms sustainably. Translating Bangladesh\\u0026rsquo;s progressive National Action Plan into clinical impact will require urgent investment in diagnostic laboratory infrastructure, antimicrobial surveillance systems, AMS staffing, and regulatory enforcement. Future research should evaluate stewardship interventions across primary, secondary, and rural settings using standardised outcome metrics, and explore implementation science frameworks to understand how successful models can be adapted and scaled within Bangladesh\\u0026rsquo;s health system.\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003eAuthor Contributions\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eSMC: Conceptualisation, literature search, screening, data extraction, quality assessment, formal analysis, writing \\u0026ndash; original draft. RAE: Conceptualisation, supervision, methodology, validation, writing \\u0026ndash; review and editing, project administration. All authors approved the final manuscript.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eCompeting Interests\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe authors declare no competing interests. RAE is a Senior Lecturer at the University of Hertfordshire and serves as Associate Editor at JAC\\u0026ndash;Antimicrobial Resistance (Oxford University Press); these roles did not influence the conduct or reporting of this review.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eData Availability\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eAll data supporting the findings of this review are available within the article and its supplementary materials. The full search strategies and CASP quality assessment tables are available from the corresponding author upon request.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eFunding\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThis systematic review received no specific funding.\\u0026nbsp;\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\n\\u003cli\\u003eAhmed S, Korpe P, Ahmed T, Chisti MJ, Faruque ASG. Burden and Risk Factors of Antimicrobial Use in Children Less Than 5 Years of Age with Diarrheal Illness in Rural Bangladesh. Am J Trop Med Hyg. 2018;98(6):1571\\u0026ndash;1576. https://doi.org/10.4269/ajtmh.17-0988\\u003c/li\\u003e\\n\\u003cli\\u003eAfroz H, Hossain MM, Fakruddin M. A 6-year retrospective study of bloodstream Salmonella infection and antibiotic susceptibility of Salmonella enterica serovar Typhi and Paratyphi in a tertiary care hospital in Dhaka, Bangladesh. Tzu Chi Med J. 2014;26(2):73\\u0026ndash;78. https://doi.org/10.1016/j.tcmj.2014.05.006\\u003c/li\\u003e\\n\\u003cli\\u003eAl Masud A, Walpola RL, Sarker M, et al. Understanding antibiotic purchasing practices in community pharmacies: A potential driver of emerging antimicrobial resistance. Explor Res Clin Soc Pharm. 2024;15:100485. https://doi.org/10.1016/j.rcsop.2024.100485\\u003c/li\\u003e\\n\\u003cli\\u003eBarlam TF, Cosgrove SE, Abbo LM, et al. Implementing an Antibiotic Stewardship Program: Guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Clin Infect Dis. 2016;62(10):e51\\u0026ndash;e77. https://doi.org/10.1093/cid/ciw118\\u003c/li\\u003e\\n\\u003cli\\u003eBoone K, Morris SK, Doshi S, et al. Antimicrobial Prescribing during Infant Hospital Admissions in a Birth Cohort in Dhaka, Bangladesh. J Trop Pediatr. 2021;67(3):fmaa093. https://doi.org/10.1093/tropej/fmaa093\\u003c/li\\u003e\\n\\u003cli\\u003eCharani E, Holmes A. Antibiotic Stewardship\\u0026mdash;Twenty Years in the Making. Antibiotics. 2019;8(1):7. https://doi.org/10.3390/antibiotics8010007\\u003c/li\\u003e\\n\\u003cli\\u003eCritical Appraisal Skills Programme (CASP). CASP Checklists. 2022. https://casp-uk.net/casp-tools-checklists/\\u003c/li\\u003e\\n\\u003cli\\u003eDavey P, Marwick CA, Scott CL, et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev. 2017;2:CD003543. https://doi.org/10.1002/14651858.CD003543.pub4\\u003c/li\\u003e\\n\\u003cli\\u003eDyar OJ, Huttner B, Schouten J, Pulcini C. What is antimicrobial stewardship? Clin Microbiol Infect. 2017;23(11):793\\u0026ndash;798. https://doi.org/10.1016/j.cmi.2017.08.026\\u003c/li\\u003e\\n\\u003cli\\u003eElshenawy RA, Umaru N, Alharbi AB, Aslanpour Z. Antimicrobial stewardship implementation before and during the COVID-19 pandemic in the acute care settings: A systematic review. BMC Public Health. 2023;23(1):309. https://doi.org/10.1186/s12889-023-15072-5\\u003c/li\\u003e\\n\\u003cli\\u003eFarzana R, Jones LS, Rahman MA, et al. Genomic Insights Into the Mechanism of Carbapenem Resistance Dissemination in Enterobacterales From a Tertiary Public Health Setting in South Asia. Clin Infect Dis. 2023;76(1):119\\u0026ndash;133. https://doi.org/10.1093/cid/ciac287\\u003c/li\\u003e\\n\\u003cli\\u003eGLASS. WHO Global Antimicrobial Resistance and Use Surveillance System Dashboard. 2023. https://worldhealthorg.shinyapps.io/glassdashboard/\\u003c/li\\u003e\\n\\u003cli\\u003eHaque M, Godman B. Potential strategies to improve antimicrobial utilisation in hospitals in Bangladesh building on experiences across developing countries. Bangladesh J Med Sci. 2021;20(3):469\\u0026ndash;477. https://doi.org/10.3329/bjms.v20i3.52787\\u003c/li\\u003e\\n\\u003cli\\u003eHarun MGD, Anwar MMU, Sumon SA, et al. Rationale and guidance for strengthening infection prevention and control measures and antimicrobial stewardship programs in Bangladesh: A study protocol. BMC Health Serv Res. 2022;22(1):1\\u0026ndash;11. https://doi.org/10.1186/s12913-022-08603-0\\u003c/li\\u003e\\n\\u003cli\\u003eHarun MGD, Sumon SA, Hasan I, et al. Barriers, facilitators, perceptions and impact of interventions in implementing antimicrobial stewardship programs in hospitals of low-middle and middle countries: A scoping review. Antimicrob Resist Infect Control. 2024;13(1):8. https://doi.org/10.1186/s13756-024-01369-6\\u003c/li\\u003e\\n\\u003cli\\u003eLewnard JA, Charani E, Gleason A, et al. Burden of bacterial antimicrobial resistance in low-income and middle-income countries avertible by existing interventions: An evidence review and modelling analysis. Lancet. 2024;403(10442):2439\\u0026ndash;2454. https://doi.org/10.1016/S0140-6736(24)00862-6\\u003c/li\\u003e\\n\\u003cli\\u003eLimato R, Broom A, Nelwan EJ, Hamers RL. A qualitative study of barriers to antimicrobial stewardship in Indonesian hospitals. Antimicrob Resist Infect Control. 2022;11(1):85. https://doi.org/10.1186/s13756-022-01126-7\\u003c/li\\u003e\\n\\u003cli\\u003eMcGowan JE, Gerding DN. Does antibiotic restriction prevent resistance? New Horiz. 1996;4(3):370\\u0026ndash;376.\\u003c/li\\u003e\\n\\u003cli\\u003eMia MF, Mia AA, Saha D, Khan AA, Chakraborty A. Antibiotic Resistance Pattern and Stewardship Programme in Critical Care Settings. Bangladesh Med Res Counc Bull. 2017;43(3):131\\u0026ndash;137. https://doi.org/10.3329/bmrcb.v43i3.36417\\u003c/li\\u003e\\n\\u003cli\\u003eMurray CJL, Ikuta KS, Sharara F, et al. Global burden of bacterial antimicrobial resistance in 2019: A systematic analysis. Lancet. 2022;399(10325):629\\u0026ndash;655. https://doi.org/10.1016/S0140-6736(21)02724-0\\u003c/li\\u003e\\n\\u003cli\\u003eNaghavi M, Vollset SE, Ikuta KS, et al. Global burden of bacterial antimicrobial resistance 1990\\u0026ndash;2021: A systematic analysis with forecasts to 2050. Lancet. 2024;404(10459):1199\\u0026ndash;1226. https://doi.org/10.1016/S0140-6736(24)01867-1\\u003c/li\\u003e\\n\\u003cli\\u003eNational Strategy and Action Plan for Antimicrobial Resistance Containment in Bangladesh 2023\\u0026ndash;2028. Directorate General of Health Services, Bangladesh. 2023.\\u003c/li\\u003e\\n\\u003cli\\u003ePage MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. BMJ. 2021;372:n71. https://doi.org/10.1136/bmj.n71\\u003c/li\\u003e\\n\\u003cli\\u003eRashid MM, Akhtar Z, Chowdhury S, et al. Pattern of Antibiotic Use among Hospitalized Patients according to WHO Access, Watch, Reserve (AWaRe) Classification: Findings from a Point Prevalence Survey in Bangladesh. Antibiotics. 2022;11(6):810. https://doi.org/10.3390/antibiotics11060810\\u003c/li\\u003e\\n\\u003cli\\u003eRashid MM, Chisti MJ, Akter D, Sarkar M, Chowdhury F. Antibiotic use for pneumonia among children under-five at a pediatric hospital in Dhaka city, Bangladesh. Patient Prefer Adherence. 2017;11:1335\\u0026ndash;1342. https://doi.org/10.2147/PPA.S140002\\u003c/li\\u003e\\n\\u003cli\\u003eRoy S, Barua HT, Sujan MJ, et al. Trends and Patterns of Antimicrobial Resistance in a Tertiary Care Hospital in Bangladesh. 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World Health Organization; 2019.\\u003c/li\\u003e\\n\\u003cli\\u003eWHO. Global Action Plan on Antimicrobial Resistance. World Health Organization; 2015.\\u003c/li\\u003e\\n\\u003cli\\u003eZujbe Z, Tabassum N, Kibria G, et al. The burden of hospital-acquired infections and antibiotic resistance in Bangladesh: Current trends and policy implications. Discov Public Health. 2025;22(1):290. https://doi.org/10.1186/s12982-025-00665-9\\u003c/li\\u003e\\n\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":true,\"hideJournal\":true,\"highlight\":\"\",\"institution\":\"University of Hertfordshire\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true},\"keywords\":\"antimicrobial stewardship, antimicrobial resistance, Bangladesh, systematic review, implementation, low- and middle-income countries\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-9123957/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-9123957/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003ch2\\u003eBackground\\u003c/h2\\u003e \\u003cp\\u003eAntimicrobial resistance (AMR) causes 1.27\\u0026nbsp;million deaths annually and is projected to kill 1.91\\u0026nbsp;million people per year by 2050. Bangladesh recorded 26,200 AMR-attributable deaths in 2019, yet a persistent gap exists between its national policy frameworks and frontline antimicrobial stewardship (AMS) practice. This systematic review synthesises evidence on barriers, facilitators, and strategies relating to AMS implementation across healthcare settings in Bangladesh.\\u003c/p\\u003e\\u003ch2\\u003eMethods\\u003c/h2\\u003e \\u003cp\\u003eA systematic search of MEDLINE (PubMed), CINAHL, Scopus, Cochrane Library, and Google Scholar was conducted in August 2025 following PRISMA 2020 guidelines. The PEO (Population, Exposure, Outcome) framework guided eligibility criteria. Study quality was assessed using Critical Appraisal Skills Programme (CASP) checklists. Quantitative descriptive analysis and qualitative thematic analysis were applied for data synthesis.\\u003c/p\\u003e\\u003ch2\\u003eResults\\u003c/h2\\u003e \\u003cp\\u003eFourteen studies encompassing 34,097 participants (33,538 patients and 559 healthcare professionals) were included. Major barriers identified included absence or weak enforcement of hospital AMS policies (n\\u0026thinsp;=\\u0026thinsp;6 studies), entrenched empirical prescribing culture (n\\u0026thinsp;=\\u0026thinsp;5), limited diagnostic and laboratory capacity (n\\u0026thinsp;=\\u0026thinsp;4), and lack of dedicated AMS teams (n\\u0026thinsp;=\\u0026thinsp;3). Key facilitators comprised antimicrobial surveillance systems (n\\u0026thinsp;=\\u0026thinsp;6), training and education programmes (n\\u0026thinsp;=\\u0026thinsp;5), and leadership commitment and governance (n\\u0026thinsp;=\\u0026thinsp;3). Only 31% of prescriptions were culture-guided, and broad-spectrum antibiotic exposure exceeded 70% among hospitalised patients. No study reported a fully functioning, institutionalised AMS programme.\\u003c/p\\u003e\\u003ch2\\u003eConclusions\\u003c/h2\\u003e \\u003cp\\u003eAMS implementation in Bangladesh remains fragmented, undermined by systemic infrastructure deficits and a persistent policy\\u0026ndash;practice gap. Training and education offer pragmatic entry points but cannot sustain change without concurrent institutionalisation of core stewardship strategies\\u0026mdash;audit and feedback, multidisciplinary teams, and formulary controls. Urgent investment in diagnostic capacity, surveillance infrastructure, and regulatory enforcement is needed to translate Bangladesh\\u0026rsquo;s National Action Plan into sustainable clinical impact.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Barriers and Facilitators to Antimicrobial Stewardship Implementation Across Healthcare Settings in Bangladesh: A Systematic Review\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2026-03-18 08:43:16\",\"doi\":\"10.21203/rs.3.rs-9123957/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"f6880c25-19c9-4ebc-80bb-a152506287c9\",\"owner\":[],\"postedDate\":\"March 18th, 2026\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"posted\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2026-03-18T08:43:16+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2026-03-18 08:43:16\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-9123957\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-9123957\",\"identity\":\"rs-9123957\",\"version\":[\"v1\"]},\"buildId\":\"XKTyCvWXoU3ODBz1xrDgd\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}