Antibiotics Use Patterns in Low- and Middle-Income Countries: A Systematic Review Analysis

Antibiotics are vital for treating infections, but their inappropriate use has driven widespread resistance, now a major global health threat. This systematic review examines antibiotic use patterns in low- and middle-income countries using WHO's prescribing indicator, aiming to guide interventions that promote rational antibiotic use, reduce resistance, and improve public health outcomes. The review followed PRISMA guidelines, searching databases such as Scopus, Embase (Ovid), and Medline (Ovid) for publications from January 2010 to November 2025. Titles and abstracts were initially screened by the first reviewer and discussed with a second reviewer to assess eligibility. Full texts of eligible articles were then independently reviewed by the reviewers, with final inclusion determined through consensus. The methodological quality of selected studies was evaluated using the Kmet Critical Appraisal Checklist. Studies were categorized into 3 groups-public and private sector, public sector only, and private sector only-to examine antibiotic use patterns relative to WHO standards, alongside demographic and institutional data. Electronic searches identified 2912 studies, of which 20 cross-sectional studies were from 11 countries considered eligible for inclusion. Their methodological quality scores ranged from 0.50 to 0.78. Across all studies, the average "percentage of prescriptions with antibiotics" was 51.4%, with 52.7% in the private sector, 49.3% in the public sector, and 61.8% in studies covering both sectors. Amoxicillin, an "Access" antibiotic under the WHO AWaRe framework, was most frequently prescribed, while "Watch" antibiotics such as ceftriaxone and cefixime were also widely used. Some studies reported high Watch antibiotic use (47.4%-74.0%), exceeding WHO recommendation and raising significant concern. The types of antibiotics prescribed also varied across age groups. The percentage of prescriptions with antibiotics and prescribing Watch group antibiotics was found to be higher than the WHO recommendation across studies. Implementing effective antibiotic stewardship programs is recommended.