Donkor et al. Antimicrobial Resistance & Infection Control (2025) 14:5 https://doi.org/10.1186/s13756-024-01504-3 REVIEW Open Access © The Author(s) 2025. Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://​creat​iveco​mmons.​org/​licen​ses/​by-​nc-​nd/4.​0/. Antimicrobial Resistance and Infection Control Improving antibiotic utilization in West Africa: enhancing interventions through systematic review and evidence synthesis Eric S. Donkor1*, Abdul‑Halim Osman1, Bill Clinton Aglomasa1, Aaron Awere‑Duodu1, Alex Odoom1, Bismark Opoku‑Asare2 and Gilbert Lazarus3,4  Abstract  Background  Bacterial infection has been estimated to become the leading cause of death by 2050, causing 10 million deaths across the globe due to the surge in antibiotic resistance. Despite western sub-Saharan Africa being identified as one of the major hotspots of antimicrobial resistance (AMR) with the highest mortality, a comprehensive regional analysis of the magnitude and key drivers of AMR due to human antibiotic use has not been conducted. Method  We carried out a systematic review by conducting a comprehensive search in various databases includ- ing PubMed and Scopus for eligible articles published in the English Language between 1 January 2000 and 14 February 2024. Five key domains of antibiotic use were focused on: (1) antibiotic consumption; (2) appropriate antibiotic prescription; (3) indicators or key drivers of antibiotic use; (4) antimicrobial stewardship (AMS) interventions; (5) knowledge, attitudes and perceptions of antibiotic consumers and providers. Data were extracted from eligible papers for all the five domains under consideration and random-effects model meta-analysis was carried out for anti- biotic consumption. Results  Out of the 2613 records obtained, 64 articles which were unevenly distributed in the region were eligible for inclusion in our study. These articles reported on antibiotic consumption (5), appropriate antibiotic prescription (10), indicators or key drivers of antibiotic use (10), AMS interventions (10), and 31 studies reported on knowledge, attitudes and perceptions. Antibiotic consumption for inpatients has a pooled estimate of 620.03 defined daily dose (DDD) per 100 bed-days (confidence interval [CI] 0.00–1286.67; I2 = 100%) after accounting for outliers while pre- scribing appropriateness ranged from 2.5% to 93.0% with a pooled estimate of 50.09 ([CI: 22.21–77.92%], I2 = 99.4%). Amoxicillin, gentamicin, amoxicillin-clavulanate, metronidazole, and ceftriaxone were the commonly consumed antibiotics. Community-acquired infection, hospital-acquired infection, and prophylaxis were the major indicators of antibiotic use. AMS was effective to varying degrees with bundled interventions and gamified antimicrobial stew- ardship decision support application being the most effective. Healthcare workers demonstrated acceptable antibi- otic knowledge but individuals from formal and informal settings self-medicate with antibiotics and had moderate to low knowledge of antibiotic use and resistance. Conclusion  This review identified gaps in knowledge and highlighted areas where prompt actions are required, it further guides future research endeavors and policy development. The findings underscore the need for further *Correspondence: Eric S. Donkor esampane-donkor@ug.edu.gh Full list of author information is available at the end of the article http://creativecommons.org/licenses/by-nc-nd/4.0/ http://crossmark.crossref.org/dialog/?doi=10.1186/s13756-024-01504-3&domain=pdf Page 2 of 29Donkor et al. Antimicrobial Resistance & Infection Control (2025) 14:5 implementation of AMS programs across the West African region to enhance understanding of antibiotic use pat- terns, prescribing practices, and the factors influencing them in the region. Keywords  West Africa, Antibiotics, Consumption, Appropriateness, Stewardship, Indicators, Antibiotic resistance Introduction Bacterial infections have emerged as a phenomenon that mankind must come to acknowledge and coexist with, albeit accompanied by significant consequences— namely, the burden of morbidity and mortality. To man- kind rescue is antibiotic, which first discovery began with penicillin by Alexander Fleming. This initial discover- ies led to the subsequent discovery and development of many other antibiotics, saving millions of lives annually [1]. The global rise of bacterial resistance to these antibi- otics which is attributed to many factors such as inappro- priate antibiotic consumption and multifaceted evolution of bacterial genome [2–4], is one of the greatest public health threats, exerting a disproportionately profound impact on low- and middle-income countries (LMICs) [5–7]. A recent global analysis based on predictive statistical models estimated that bacterial antimicrobial resistance (AMR) directly caused 1·27 million deaths and contrib- uted to about 4·95 million (3·62–6·57) deaths worldwide. Disturbingly, findings reveal that the estimated all-age death rate directly linked to antimicrobial resistance was highest in the western sub-Saharan Africa region, with a staggering 27·3 deaths per 100 000 (20·9–35·3) [8]. In the context of the western sub-Saharan African region, among many factors that promote antibiotic resistance are antibiotic use; inappropriate administration, overuse and misuse [9–13]. The inherent challenges posed by the low-resource context of this region manifest in inade- quate access to quality healthcare, safe water, vaccination, and poor sanitation. Consequently, a vulnerable popula- tion finds themselves exposed to infections, necessitating reliance on antibiotics for treatment, all while operating within a framework where the regulation of their usage remains largely deficient [14–19]. West Africa is a region comprising sixteen countries with an overall population of about 446,273,282 peo- ple, making up 5.47% of the total world population [20]. Each nation within this region falls under the classifi- cation of lower-middle-income countries, character- ized by a diverse range of socio-economic conditions and particularly, variation of health indicators. Factors contributing to antibiotic resistance are widespread in West Africa, ranging from the high persistent burden of infectious diseases to the variability in accessing qual- ity healthcare, the inadequate enforcement of antibiotic policies, and the mass administration of some antibiotics [21–27], rendering West Africa particularly vulnerable to AMR. Coupled with these aforementioned factors that contribute to the high antibiotic resistance in this part of the world, there has been mass administration of azithro- mycin and other antibiotics to minimize childhood mor- tality and yaws in many West African countries. The pronounced presence of AMR in West Africa is sub- stantiated by the escalating number of scientific reports published on AMR in recent years. Despite western sub- Saharan Africa recording the highest AMR mortality, to the best of our knowledge, a comprehensive regional analysis of the magnitude and key drivers of AMR and antibiotic use in West Africa has not been conducted to date. Such an analysis is crucial as it would generate essential evidence and shed light on existing gaps. This information would play a pivotal role in guiding the implementation of policies in the region, to minimize the ever-growing threat of AMR. Major stakeholders and previous studies assessing antimicrobial stewardship (AMS) interventions, despite being limited and diverse in nature, have highlighted the significance of closely monitoring key elements such as antibiotic consumption, prescribing appropriateness, guideline compliance, indicators of use, and patient out- comes. However, the evidence base for these key ele- ments in West Africa is uneven. Tertiary and secondary hospitals constitute a moderate representation of this evidence, while consumers and other informal and for- mal private health providers, who significantly contribute to antibiotic distribution, are highly underrepresented. To bring these key concepts to light in West Africa, this systematic review focuses on antibiotic use for human health (J01 antibiotics) in West Africa from 2000 to 2024. This review focuses on five key antibiotic domains: (1) antibiotic consumption; (2) appropriate antibiotic pre- scription; (3) indicators or key drivers of antibiotic use; (4) AMS interventions; (5) knowledge, attitudes and per- ceptions of antibiotic consumers and providers. Method Search strategy This systematic review adhered to the guidelines out- lined by the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) [28]. On Febru- ary 14, 2024, a comprehensive search was conducted by two authors in PubMed, Scopus and other databases to Page 3 of 29Donkor et al. Antimicrobial Resistance & Infection Control (2025) 14:5 identify peer-reviewed original articles from West Africa. The search was limited to articles published in English between 1 January 2000 and 14 February 2024, utilizing the search terms listed in Table  S1. Additionally, a ref- erence screening process was employed to identify any additional relevant papers. The scope of this review was specifically focused on antibiotics for systematic human use, as classified under the J01 ATC category by WHO. Inclusion and exclusion criteria Based on the research keywords, we incorporated various types of studies including cross-sectional, prospective, and longitudinal studies. We included studies that met one or more of the following five categorized domains; 1 Antibiotic consumption; expressed as defined daily dose (DDD) per 100 bed days. All included articles are those from hospital antibiotic use. Articles that did not report antibiotic consumption in DDD and cannot be converted to DDD were excluded. We reported on antibiotics that were used in three or more of the studies. By doing so, we grouped the antibiotics into Access, Watch, and Reserve classifi- cations according to the 2021 WHO AWaRe classifi- cation [29]. 2 Examining of appropriate antibiotic prescription for the treatment of prophylaxis. This was examined based on the Gyssens method [30] or compliance with other reference guideline. 3 Indicators and key drivers of human antibiotic use. Studies that quantified the key drivers of antibiotic use were included. 4 Antimicrobial stewardship intervention evalua- tion studies. Included studies are those that clearly described the results of before and after the imple- mentation of the intervention. Studies on antimicro- bial stewardship implementation procedures were excluded. 5 Survey or studies assessing knowledge, attitude, and or perceptions on antibiotic use. Papers that reported the qualitative or quantitative data on this category were included. Our selection was limited to articles that were acces- sible to us, available in full text, and published in the Eng- lish language. The general publications excluded from our review were reviews, reports, news, views, case–control studies, preprints, commentaries, and letters to editors. In vitro studies, studies assessing cost-effectiveness, and studies on veterinary, evaluating antibacterial therapeu- tics activities and pharmacokinetics were all excluded. Studies with data from West African countries that were inseparable from non-West African countries were also excluded. Quality assessment This study was built upon previously published research articles that provided observational evidence. Rigor- ous measures were taken to ensure the review’s quality, including careful inspection and elimination of any dupli- cate articles. The abstracts/full texts of the identified arti- cles were meticulously screened and verified to ensure that only high-quality and relevant information from the literature was included in the review process. The assess- ment of article quality was conducted independently by the authors involved in this manuscript. We included studies that provided a set of essential items from the STROBE checklist [31] and also reported on additional themes specific to our study as shown in Table  S2. In cases where conflicting decisions arose, E.S-D provided guidance and expertise to resolve any discrepancies. Data analysis Data was extracted from individual studies using forms developed for this review in the Microsoft Excel 2013 software. All the forms captured data such as author names, year of publication, country, type of study partici- pants, sample size, and study period. Data on antibiotic consumption, appropriate antibiotic prescription, indi- cators of antibiotic use, AMS intervention, and Knowl- edge attitude and perception of individuals were entered separately. In performing a meta-analysis, we used the data on antibiotic consumption and appropriate antibiotic pre- scription. Using R version 4.4.0, the meta package v 4.20-2 and the random-effects model, pooled estimates for antibiotic consumption for inpatients were done using the metagen function. The rate, sample size and method used were respectively DDD/100, inverse of sample size and inverse variance. Having pooled the esti- mates, we went ahead to do the sensitivity analysis and a further Grubbs test to check and remove outliers. Hav- ing removed the outlier, we went ahead to do a subgroup analysis based on the durations of studies, the location of studies and the healthcare level in which the studies in the subgroups were undertaken. For outpatients, no meta-analysis was done as the two studies reported in DDD/1000 and Days of Antibiotic Therapy/1000 Patient- Days respectively. For the data on appropriate antibiotic prescription, we calculated the pooled estimate using the metaprop func- tion and went ahead to do sensitivity analysis. Further- more, subgroup analysis was done to understand how the pooled estimate varied by the year of study (before 2020 and after 2020), health level (either the study was done Page 4 of 29Donkor et al. Antimicrobial Resistance & Infection Control (2025) 14:5 in a secondary, tertiary or mixed health facilities), loca- tion and finally reference guideline compared to oth- ers in terms of appropriateness. As many of the studies were from Ghana, the subgroup analysis on location was done based on studies from Ghana and others (from other West African countries aside from Ghana). For the reference guideline group analysis, studies in Ghana were grouped into those that used the STG guidelines or other guidelines (STG and GNDP and unspecified guide- lines). Using the I2 statistic, heterogeneity was assessed as low < 25%, moderate 25–49%, substantial 50–74%, or high 75–100%. Bias analysis was not done on the data- set for antibiotic consumption and appropriate antibiotic prescription as the number of studies was < 10. Results Study selection Initially, A-H.O. and E.S-D searched and downloaded all the 2613 articles in the search results on Scopus (1345) and PubMed (1268). Subsequently, A-H.O. and E.S-D manually excluded retracted papers and eliminated 716 duplicates with the aid of Rayyan [32] and the Zotero referencing tool (version 6.0.30 made by Corporate for Digital Scholarship). In the case of duplicate articles, we included only the version with the most comprehensive dataset and excluded any others to ensure non-redun- dancy in the analysis. The resulting 1887 articles were examined and screened by A-H.O. and E.S-D. based on their titles and abstracts in relation to our inclusion criteria. Afterward, 1739 articles were excluded based on article title/abstract, and articles without abstracts. In total, 148 articles were subjected to full-text detailed paper screening and only 64 articles were taken into con- sideration for this manuscript (Fig. 1). Only 1 study was obtained from the reference list of included papers after reading its full-text screening. Overview and DESCRIPTION OF PAPERS In accordance with the inclusion and exclusion criteria, and the PRISMA checklist [33], we included 64 reports investigating the five outlined categories of antibiotic use in West Africa as shown in Tables 1, 2, 3, 4 and ST3. The studies were distributed across nine of the sixteen West African countries; Burkina Faso, Côte D’Ivoire, Gambia, Ghana, Liberia, Mali, Nigeria, Sierra Leone, and Togo. The countries with the most studied antibiotic use in descending order are Ghana (n = 33), Nigeria (n = 23), Sierra Leone (n = 4), and Liberia (n = 2), with Burkina Faso, Côte D’Ivoire, Gambia, Mali, and Togo contributing one study each. The study design of the included articles ranged from clinical trials to longitudinal and cross- sectional studies, with the latter being the most used study design. Generally, the population types ranged from patients, health care providers, and community Fig. 1  A flow diagram of our systematic review process (PRISMA guide) Page 5 of 29Donkor et al. Antimicrobial Resistance & Infection Control (2025) 14:5 Ta bl e  1  Su m m ar y of s tu di es o n an tib io tic c on su m pt io n Th e ta bl e su m m ar iz es s tu di es o n an tib io tic c on su m pt io n in in pa tie nt s, ex pr es se d as D efi ne d D ai ly D os e (D D D ) p er 1 00 b ed -d ay s, ov er al l a nd /o r f or in di vi du al a nt ib io tic s, an d di vi de d by p rim ar y ve rs us s ec on da ry /t er tia ry ca re s et tin gs . A w as a n ou tli er a nd w as n ot a dd ed w he n co m pu tin g th e po ol ed a nt ib io tic c on su m pt io n fo r i np at ie nt s. H ow ev er , i t w as a dd ed a s pa rt o f t he s ub gr ou p an al ys is o f i np at ie nt s to u nd er st an d th e he te ro ge ne ity th at e xi st b et w ee n st ud ie s th at to ok m or e th an a y ea r a nd th os e th at to ok le ss th an a y ea r A M X, A m ox ac ill in ; G EN , G en ta m ic in ; A M P  =  A m pi ci lli n; A M C  =  A m ox ic ill in -c la vu la na te ; S XT  =  S ul fa m et ho xa zo le tr im et ho pr im ; M ET  =  M et ro ni da zo le ; A ZM  =  A zi th ro m yc in ; C A M  =  C la rit hr om yc in ; C TX  =  C ef ot ax im e; CA Z  =  C ef ta zi di m e; C RO  =  C ef tr ia xo ne ; C IP  =  C ip ro flo xa ci n; L VX  =  Le vo flo xa ci n; M EM  =  M er op en em ; C XM  =  C ef ur ox im e; C FP -S U L =  C ef op er az on e- Su lb ac ta m Pu bl ic at io n D ur at io n of s tu dy Lo ca tio n H ea lth Ca re Le ve l Ty pe o f s tu dy po pu la tio n To ta l N o. o f pa tie nt s To ta l an tib io tic s A cc es s A nt ib io tic s W at ch A nt ib io tic s N ot re co m m en de d A M X G EN A M P A M C SX T M ET A ZM CA M CT X CA Z CR O CI P LV X M EM CX M CF P- SU L A bu ba ka r et  a l. [9 3] M ay –J ul y 20 16 N ig er ia Te rt ia ry W om en w ho ha d ob st et ric s an d  gy na ec ol - og y su rg er ie s 24 8 16 75 .3 D D D pe r 1 00 b ed da ys – 5. 6 - 75 4. 6 – 61 5. 1 – – – – 44 .4 11 .6 - - 22 7. 4 – La ko h et  a l. [6 4] Fe br ua ry an d  O ct o- be r 2 02 1 Si er ra Le on e Se co nd - ar y- an d  te r- tia ry - ca re he al th fa ci li- tie s Su rg ic al pr op hy la xi s in di vi du al s 75 3 11 7. 9 D D D pe r 1 00 b ed da ys 1. 1 2. 2 15 .0 14 .5 – 30 .8 0. 1 0. 1 - - 41 .6 1. 0 1. 9 – 0. 1 – A La bi e t a l. [6 1] Ja nu ar y 20 16 – N ov em be r 20 21 G ha na Se co nd - ar y he al th - ca re In - a nd  o ut - pa tie nt s w ho at te nd ed th e  ho sp ita l 1 02 8 01 6 2 62 9 78 6. 0 (m ea n; 25 6. 7  ±  3 3 D D D /1 00 pa tie nt s pe r y ea r) 74 .8 7 12 .7 0. 3 37 2. 6 14 5. 8 12 7. 8 88 .4 ) 39 .9 0. 1 0. 00 4 41 .9 82 .9 5. 9 0. 5 28 7. 4 – La ko h, W il- lia m s et  a l. [6 6] M ar ch – O ct ob er 20 21 Si er ra Le on e Te rt ia ry Pa tie nt s ad m it- te d to  m ed ic al or  in te ns iv e ca re u ni t 46 8 66 .9 D D D pe r 1 00 b ed da ys 0. 1 1. 7 – 3. 9 - 12 .4 2. 5 – – – 23 .9 3. 5 18 .0 – – – Be lo w a re A nt ib io tic c on su m pt io n in P ed ia tr ic w ar d an d O ut pa tie nt s e xp re ss ed in D ay s o f A nt ib io tic T he ra py /1 00 0 Pa tie nt -D ay s a nd D D D p er 1 00 0 ou tp at ie nt -d ay s r es pe ct iv el y C ha w e t a l. [5 0] Ja nu ar y– D ec em be r 20 15 G am bi a Te rt ia ry A ll pa tie nt s (a ge d  >  2 8  da ys to  1 5  ye ar s) w ho re ce iv ed an tib io tic th er ap y 91 7 67 0. 7 D ay s of  A nt ib i- ot ic T he r- ap y/ 10 00 Pa tie nt - D ay s 37 .1 16 4. 2 10 3. 0 4. 0 1. 4 18 .0 – – – – 12 1. 1 8. 7 – – – – La ko h, J oh n- Co le e t a l. [6 5] A pr il 20 22 Si er ra Le on e Te rt ia ry Pr eg na nt w om en an d  la ct at in g m ot he rs , c hi l- dr en a nd  re gu - la r p at ie nt s in  th e  ou tp a- tie nt c lin ic s 91 3 55 .3 D D D pe r 1 00 0 ou tp at ie nt - da ys 21 .9 0. 01 0. 04 4. 67 - 7. 94 0. 87 4. 09 – – 0. 00 4. 70 1. 51 – 3. 04 – Page 6 of 29Donkor et al. Antimicrobial Resistance & Infection Control (2025) 14:5 members. About forty-five reports [10, 34–76] were con- ducted during the last ten years (2014–2024). Five studies [47, 77–80], were conducted between 2000 and 2014 but information on study periods were missing in five stud- ies [81–92]. Out of the 64 reports, six were on antibiotic consumption and were conducted in the most recent ten years (2014–2024) [50, 61, 64–66, 93] as shown in Table  1. Ten studies [34, 41, 42, 46, 56–58, 75, 76, 80] were on antibiotic prescription appropriateness, and ten studies [34, 35, 41, 46, 53, 55, 58, 62, 63, 68] reported on indicators or key drivers of antibiotic use as Shown in Table 2 and Table 3 respectively. Ten articles [36, 37, 44, 45, 55, 59, 67, 71, 91, 92] reported on antimicrobial stew- ardship intervention evaluation. Thirty-one studies [10, 38–40, 43, 47–49, 51, 52, 54, 60, 69, 70, 72–74, 77–79, 81–90, 94] reported on Knowledge, attitude and percep- tion as shown in ST3. Antibiotic consumption There were six reported data [50, 61, 64–66, 93] on anti- biotic consumption, distributed across only four West African countries. The studies were mainly conducted in tertiary and secondary hospitals amassing a total popula- tion of 1,029,485 inpatients, 913 outpatients, 917 pediat- ric infants and were conducted between 2015 and 2022 as shown in Table 1. The pooled estimate of overall anti- biotic consumption for in-patients was 620.03 DDD per 100 bed-days (95% confidence interval [CI] 0.00–1286.67; I2 = 100%) after removing one study for being an outlier and taking a longer duration as compared to the other studies (Fig.  2). Eliminating the outlier when comput- ing for the overall pooled antibiotic consumption was not significant (p-value = 0.0683) although it was lower when it was removed (620.03 DDD per 100 bed-days) as compared to adding it (657,911.5250 DDD per 100 bed- days, CI [0.0000; 2,480,075.7271]) (SF1). The study by (Labi et al.) took a longer duration and the result of the high DDD as compared to the other studies could be due to the need for a higher dose for patients either due to development of tolerance, occurrence of adverse events, changes in disease severity of patients or possibly the different methods used in the study. To understand this further, a subgroup analysis was performed. The studies that took less than a year had a lower pooled estimate (1469.00 DDD/100 bed days [CI: 1468.99–1469.00]) as compared to the one that took longer (2,629,786.00 [CI: 2,629,786.00–2,629,786.00]). Also, studies that took place in Nigeria had a lower (248.00 [CI: 247.99–248.00]) DDD/100 bed-days as compared to those undertaken in Sierra Leone (1221.00 [CI: 1220.98–1221.01). In terms of healthcare level, we found no difference between the DDD in either the tertiary (716.00 [CI: 715.99–716.001) and mixed levels (753.00 [CI: 752.98–753.01]). Amoxicillin, metronidazole, gentamicin, amoxicillin- clavulanate, sulfamethoxazole-trimethoprim and cefuro- xime were the commonly consumed antibiotics across all four studies. Only two studies assessed antibiotic con- sumption in outpatients and pediatrics. In this regard, the antibiotic consumption reported for those studies were respectively 55.3 DDD per 1000 outpatient-days and 670.7 Days of Antibiotic Therapy/1000 Patient-Days among pediatrics. The percentage of access antibiotics consumed out of the total antibiotics consumed among inpatients is 64% and watch antibiotics consumption is 27% while 9% is unknown to us. It is worth mentioning that no study reported on the use of cefoperazone-sul- bactam which is a non-recommended antibiotic. Examining appropriateness of antibiotic prescriptions Of all the 64 studies, ten articles [34, 41, 42, 46, 56–58, 75, 76, 80] explicitly stated the appropriateness of the antibi- otics by indicating compliance with a guideline. Among the ten studies, seven studies followed local guidelines, one followed an international guideline, and two did not specify the guidelines followed but none of the articles followed Gyssens method. The ten articles were distrib- uted across four West African countries, with Ghana being the major contributor with seven studies and one study each from Nigeria, Liberia, and Sierra Leone. All the studies were conducted in a tertiary or secondary hospital except two studies [41, 56] that did not specify the healthcare level of the hospitals. The overall appro- priateness of antibiotic prescribing ranged from 2.5% to 93.0% as seen in Table 2 with a pooled estimate of 50.09 ([CI: 22.21–77.92], I2 = 99.4%) (Fig. 3). Upon performing the sensitivity analysis, we found no study that signifi- cantly affected the pooled appropriateness of antibiotic prescribing as the studies ranged between 42.18 and 54.39% (SF2). The appropriateness of prescriptions across various subgroups, categorized by the year of study, healthcare setting, country, and guideline adherence revealed sub- stantial heterogeneity in the results ranging from 99.2 to 99.8% (ST1). For the year of study, the combined over- all effect was 62.02% (CI: 46.67–75.29%, I2 = 99.5%), with studies before 2020 recording a higher overall appro- priateness of 71.94% (CI: 69.78–74.03%) as compared to studies after 2020 (51.05% [CI: 49.20–52.90%]). The overall pooled appropriateness estimate was 62.74% (CI: 39.16–81.50%, I2 = 99.6%) for healthcare setting with the secondary level recording the highest 87.47% (CI: 85.52– 89.24%) while the mixed category recorded the lowest (31.73% [CI: 29.10–34.44%]). For the subgroup analysis on location, we found 50.77% (CI: 24.02–77.09%) to the Page 7 of 29Donkor et al. Antimicrobial Resistance & Infection Control (2025) 14:5 Ta bl e  2  Su m m ar y of s tu di es o n ap pr op ria te ne ss o f a nt ib io tic p re sc rib in g (a cc or di ng to re fe re nc e gu id el in es ) Pu bl ic at io n D ur at io n/ pe ri od o f st ud y Lo ca tio n H ea lth ca re le ve l St ud y po pu la tio n N o. o f pr es cr ip tio ns A pp ro pr ia te (% ) Re fe re nc e gu id el in es N o co nt ra - in di ca tio n/ al le rg y la be l In di ca tio n D ru g ch oi ce D os e D os in g fr eq ue nc y D ur at io n A dm in is tr at io n ro ut e O ve ra ll ap pr op ri at e us e En riq ue z et  a l. [5 6] N ov em be r to  D ec em - be r 2 01 7 Li be ria – Pa tie nt s un de rg oi ng a  su rg ic al pr oc ed ur e 14 3 – – – – – – – 20 .3 % C D C w ou nd gu id el in es B Su m ai la an d  Ta bo ng . [8 0] 1s t of  Ja nu - ar y, 2 00 9 an d  31 st D ec em - be r, 20 14 G ha na Se co nd - ar y O ut pa tie nt ch ild re n w ith  U RT Is on  a nt ib io tic s 23 7 – – – 93 .0 % 95 .6 % 96 .7 – – ST G a nd  G N D P A nk ra h et  a l. [4 6] 19 –2 1 Ju ne 2 01 9 G ha na Te rt ia ry Pa tie nt s on  a ny a nt ib i- ot ic s ad m itt ed be fo re  8 am in  a ll w ar ds on  th e  su rv ey da y 96 7 – – – – – – – 89 .0 % G N D P an d  KB TH - D O G Se fa h, S ne d- do n et  a l. [7 6] Ja nu ar y to  D ec em - be r 2 02 0 G ha na Se co nd - ar y D en ta l c ar e pa tie nt s 12 69 – – – – – – – 87 .5 % ST G Se fa h, D en oo et  a l. [7 5] Ja nu ar y to  M ay 20 21 G ha na Te rt ia ry pa tie nt s un de rg o- in g su rg er y; Su rg ic al an tim ic ro bi al pr op hy la xi s 59 7 – – 67 .0 % – – 8. 7% – 2. 5% ST G H op e et  a l. [5 7] 1 Ja nu ar y to  3 1 D ec em be r 20 21 G ha na Pa tie nt s w ith  a cu te co nj un ct iv iti s 11 1 – – – – – – – 71 .2 % ST G A bo de rin et  a l. [3 4] 10 –2 7 Ju ne 2 01 9 N ig er ia M ix ed ; Te rt ia ry an d  se c- on da ry in -p at ie nt s in cl ud in g  ne o- na te s 32 1 – – – – – – – 39 .4 % U ns pe ci fie d gu id lin e A gy ar e et  a l. [4 2] 10 th an d  17 th of  D ec em - be r 2 01 9 G ha na Te rt ia ry in -p at ie nt s 82 – – – – – – – 25 % U ns pe ci fie d gu id lin e Ka m ar a et  a l. [5 8] Ju ly -A ug us t 20 21 Si er ra le on e M ix ed ; Te rt ia ry , se co nd - ar y A cu te h ea lth - ca re h os pi ta ls an d  in pa tie nt 88 3 – – – – – – – 29 % N at io na l t re at - m en t g ui de lin e Page 8 of 29Donkor et al. Antimicrobial Resistance & Infection Control (2025) 14:5 Ta bl e  2  (c on tin ue d) Pu bl ic at io n D ur at io n/ pe ri od o f st ud y Lo ca tio n H ea lth ca re le ve l St ud y po pu la tio n N o. o f pr es cr ip tio ns A pp ro pr ia te (% ) Re fe re nc e gu id el in es N o co nt ra - in di ca tio n/ al le rg y la be l In di ca tio n D ru g ch oi ce D os e D os in g fr eq ue nc y D ur at io n A dm in is tr at io n ro ut e O ve ra ll ap pr op ri at e us e A fri yi e et  a l. [4 1] Ja nu ar y to  Ju ne 20 15 G ha na – O ut - a nd  in - pa tie nt w ith  p re - sc rib ed ce ft ria xo ne in je ct io ns 25 1 10 0% 86 .9 % - 10 0% 10 0% 85 .7 % – 93 .0 ST G ST G s, Th e st an da rd tr ea tm en t g ui de lin es o f G ha na ; G N D P, G ha na n at io na l d ug p ro gr am g ui de lin e; K BT H D O G , K or le B u Te ac hi ng H os pi ta l D ep ar tm en t o f O bs te tr ic s an d G yn ae co lo gy G ui de lin e B W as n ot a dd ed in c om pu tin g th e po ol ed a pp ro pr ia te ne ss o f a nt ib io tic p re sc rib in g as it s ov er al l a pp ro pr ia te ne ss w as u na va ila bl e. T he e ve nt s us ed fo r t he m et a- an al ys is w er e de riv ed fr om c om pu tin g it us in g th e ov er al l ap pr op ria te u se a nd n o of p re sc rip tio ns Page 9 of 29Donkor et al. Antimicrobial Resistance & Infection Control (2025) 14:5 Ta bl e  3  In di ca to rs a nd k ey d riv er s of a nt ib io tic u se Pu bl ic at io n D ur at io n/ pe ri od o f s tu dy Lo ca tio n Po pu la tio n ty pe Po pu la tio n Si ze Su m m ar y of fi nd in gs Fi na l i nd ic at or s an d ke y dr iv er s id en tifi ed A nk ra h et  a l. [4 6] 19 –2 1 Ju ne 2 01 9 G ha na Pa tie nt s on  a ny a nt ib io tic s ad m itt ed b ef or e  8a m in  a ll w ar ds on  th e  su rv ey d ay 96 7 Th e ke y in di ca to rs o f a nt ib io tic us e ex pr es se d in  p er ce nt ag es a re ; Pn eu m on ia 1 8. 4% , S ki n an d  so ft tis su e 11 .4 % , S ep si s 11 .1 % , U pp er re sp ira to ry tr ac t i nf ec tio n 7. 9% , M al ar ia 7 .6 % , I nf ec tio n of  c en tr al ne rv ou s sy st em 7 .0 % , O bs te t- ric s/ gy ne co lo gy in fe ct io n 7. 0% , Bo ne a nd  jo in t i nf ec tio n 4. 8% , G as tr o- in te st in al in fe ct io n 4. 4% , In tr a- ab do m in al s ep si s 3. 2% Pn eu m on ia , S ki n an d  so ft ti ss ue , Se ps is , U pp er re sp ira to ry tr ac t in fe ct io n, M al ar ia , a nd  In fe ct io n of  c en tr al n er vo us s ys te m En im il et  a l. [5 5] Se pt em be r 2 01 5 an d  20 19 G ha na In -p at ie nt s 38 6 an d  63 0 in  2 01 5 an d  20 19 re sp ec - tiv el y Th e ke y in di ca to rs o f a nt ib io tic us e ex pr es se d in  p er ce nt ag es in  2 01 5 an d  20 19 re sp ec tiv el y, ar e; P ne um on ia 1 6. 9% a nd  2 3% , Sk in a nd  s of t t is su e 15 .2 % an d  15 .7 % , O bs te tr ic /g yn ae co - lo gi ca l i nf ec tio ns 1 0. 7% a nd  3 .7 % , In fe ct io n of  th e  ce nt ra l n er vo us sy st em 5 .1 % a nd  5 .2 % , S ep si s 7. 3% a nd  6 .8 % , T ub er cu lo si s 6. 2% an d  8. 9% , a nd  B on e/ jo in t i nf ec - tio ns 7 .9 % o nl y  in  2 01 5 Pn eu m on ia , S ki n an d  so ft ti ss ue , an d  O bs te tr ic /g yn ae co lo gi ca l in fe ct io ns D ar kw ah e t a l. [5 3] D ec em be r 2 01 9 an d  M ar ch 2 02 0 G ha na O ut pa tie nt s an d  in -p at ie nt s 18 4 Th e ke y in di ca to rs o f a nt ib io tic us e ex pr es se d in  p ro po rt io ns ar e; D en ta l a nd  re la te d in fe ct io ns 20 .7 % . P os t- de liv er y pr op hy la xi s 18 .1 % , R es pi ra to ry tr ac t i nf ec - tio ns 1 3. 8% , G as tr oi nt es tin al tr ac t in fe ct io ns 1 2. 3% , U rin ar y tr ac t in fe ct io ns 9 .0 % , S ki n an d  so ft tis su e in fe ct io ns 6 .4 % , S ex ua lly tr an sm itt ed in fe ct io ns 4 .8 % , Ca es ar ea n Se ct . " O ve rv ie w an d  D es cr ip tio n of  P ap er s" % , an d  En te ric fe ve r 3 .2 Th e to p dr iv er s id en tifi ed a re ; D en ta l a nd  re la te d in fe ct io ns , P os t- de liv er y pr op hy la xi s, Re sp ira to ry tr ac t i nf ec tio ns , G as tr oi nt es tin al an d  ur in ar y tr ac t i nf ec tio ns Page 10 of 29Donkor et al. Antimicrobial Resistance & Infection Control (2025) 14:5 Ta bl e  3  (c on tin ue d) Pu bl ic at io n D ur at io n/ pe ri od o f s tu dy Lo ca tio n Po pu la tio n ty pe Po pu la tio n Si ze Su m m ar y of fi nd in gs Fi na l i nd ic at or s an d ke y dr iv er s id en tifi ed A fri yi e et  a l. [9 7] Ja nu ar y- Ju ne , 2 01 5 G ha na O ut pa tie nt s an d  in pa tie nt s 25 1 Th e ke y in di ca to rs o f a pp ro pr i- at e ce ft ria xo ne u se e xp re ss ed in  p ro po rt io ns a re ; C o- m or bi di ty (M al ar ia  +  o th er b ac te ria l in fe ct io ns ) ( 78 % ), U rin ar y tr ac t in fe ct io n (1 00 % ), Se ps is (1 00 % ), G as tr oe nt er iti s (1 00 % ), U pp er re sp ira to ry tr ac t i nf ec tio n (1 00 % ), A pp en di ci tis (1 00 % ), G as tr iti s (1 00 % ), Fo od p oi so ni ng (1 00 % ), Fr ac tu re (B on e in fe ct io n) (1 00 % ), Ce llu lit is (1 00 % ), an d  En te ric fe ve r (1 00 % ). Ce ft ria xo ne w as  a ls o  us ed in ap pr op ria te ly in  2 2% o f C o- m or bi di ty (M al ar ia  +  o th er b ac te - ria l i nf ec tio ns ) c as es Th e to p dr iv er s id en tifi ed a re ; C o- m or bi di ty (M al ar ia  +  o th er b ac te ria l in fe ct io ns ), U rin ar y tr ac t i nf ec tio n, Se ps is , G as tr oe nt er iti s, U pp er re sp ira to ry tr ac t i nf ec tio n, A pp en - di ci tis , G as tr iti s, Fo od p oi so ni ng , Fr ac tu re (B on e in fe ct io n) , C el lu lit is , an d  En te ric fe ve r Ka m ar a et  a l. [9 6] Ju ly –A ug us t, 20 21 Si er ra L eo ne Pa tie nt s 11 98 Th e ke y in di ca to rs o f a nt ib io tic us e ex pr es se d in  p ro po rt io ns a re ; Co m m un ity a cq ui re d in fe ct io ns (5 1. 9% ), an d  Su rg ic al p ro ph yl ax is (2 3. 8% ) Th e to p dr iv er s id en tifi ed a re ; Co m m un ity a cq ui re d in fe ct io ns , an d  Su rg ic al p ro ph yl ax is A bo de rin e t a l. [9 5] 10 –2 7 Ju ne , 2 01 9 N ig er ia Pa tie nt s 32 1 Th e ke y in di ca to rs o f a nt ib io tic us e ex pr es se d in  p ro po rt io ns a re ; Co m m un ity -a cq ui re d in fe ct io n (2 9. 2% ), H os pi ta l-a cq ui re d in fe c- tio n (8 .8 % ), Su rg ic al p ro ph yl ax is (3 6. 9% ), an d  M ed ic al p ro ph yl ax is (1 1. 2% ) Th e to p dr iv er s id en tifi ed a re ; Co m m un ity -a cq ui re d in fe ct io n, Su rg ic al p ro ph yl ax is , a nd  M ed ic al pr op hy la xi s La bi e t a l. [6 3] Se pt em be r- D ec em be r, 20 16 G ha na Pa ed ia tr ic in pa tie nt s 71 6 Th e ke y in di ca to rs o f a nt ib io tic us e ex pr es se d in  p ro po rt io ns a re ; Co m m un ity -a cq ui re d in fe ct io ns (6 1% ), H os pi ta l-a cq ui re d in fe c- tio ns (1 0. 3% ), pr op hy la xi s (2 3. 7% ), an d  U nk no w n re as on (4 .8 % ) Th e to p dr iv er s id en tifi ed a re ; Co m m un ity -a cq ui re d in fe ct io ns , H os pi ta l-a cq ui re d in fe ct io ns , an d  pr op hy la xi s A bu ba ka r e t a l. [3 5] A pr il– M ay , 2 01 9 N ig er ia H os pi ta liz ed p at ie nt s 32 1 Th e ke y in di ca to rs o f a nt ib io tic us e ex pr es se d in  p ro po rt io ns a re ; Co m m un ity -a cq ui re d in fe c- tio n (3 8. 7% ), Su rg ic al a nt ib io tic pr op hy la xi s (2 2. 5% ), H os pi ta l- ac qu ire d in fe ct io n (1 6. 3% ), M ed ic al p ro ph yl ax is (1 4. 9% ), an d  U nk no w n in di ca tio n (7 .6 % ) Th e to p dr iv er s id en tifi ed a re ; Co m m un ity -a cq ui re d in fe ct io n, Su rg ic al a nt ib io tic p ro ph yl ax is , H os pi ta l-a cq ui re d in fe ct io n, an d  M ed ic al p ro ph yl ax is Page 11 of 29Donkor et al. Antimicrobial Resistance & Infection Control (2025) 14:5 Ta bl e  3  (c on tin ue d) Pu bl ic at io n D ur at io n/ pe ri od o f s tu dy Lo ca tio n Po pu la tio n ty pe Po pu la tio n Si ze Su m m ar y of fi nd in gs Fi na l i nd ic at or s an d ke y dr iv er s id en tifi ed N na do zi e et  a l. [6 8] M ay , 2 01 9 N ig er ia In pa tie nt s 82 Th e ke y in di ca to rs o f a nt ib io tic us e ex pr es se d in  p ro po rt io ns a re ; Co m m un ity -a cq ui re d in fe ct io n (3 4. 1% ), H os pi ta l-a ss oc ia te d in fe ct io n (9 % ), an d  Su rg ic al pr op hy la xi s (5 6. 95 % ) Th e to p dr iv er s id en tifi ed a re ; Co m m un ity -a cq ui re d in fe ct io n, an d  Su rg ic al p ro ph yl ax is La bi e t a l. [6 2] Fe br ua ry –M ar ch , 2 01 6 G ha na In pa tie nt s 67 7 Th e ke y in di ca to rs o f a nt ib io tic us e ex pr es se d in  p ro po rt io ns a re ; Co m m un ity -a cq ui re d in fe c- tio ns (4 0. 1% ), H os pi ta l-a cq ui re d in fe ct io ns (2 1. 0% ), Su rg ic al pr op hy la xi s (3 3. 6% ), an d  M ed ic al pr op hy la xi s  (5 .4 % ) Th e to p dr iv er s id en tifi ed a re ; Co m m un ity -a cq ui re d in fe ct io ns , H os pi ta l-a cq ui re d in fe ct io ns , an d  Su rg ic al p ro ph yl ax is Page 12 of 29Donkor et al. Antimicrobial Resistance & Infection Control (2025) 14:5 estimate with Ghana recording a higher appropriateness (70.74% [CI: 69.14–72.29%]) than those of other coun- tries (30.51% [CI: 28.06–33.05%]). In terms of the guide- lines being used in Ghana, the STG guideline had a lower appropriate percentage (64.50, [CI: 62.47–66.49%]) than other guidelines (83.98% [CI: 81.62–86.15%]). Among the ten studies, there was limited information on the individual indicators of prescribing appropriate- ness with respect to the guideline used. This therefore makes it difficult to specifically state the indicators of prescribing appropriateness that are less followed. Indicators and key drivers of antibiotic use About ten articles [34, 35, 41, 46, 53, 55, 58, 62, 63, 68] reported the indicators and drivers of antibiotic use as shown in Table  3. All these studies were conducted among inpatients and outpatients with sample sizes ranging from 82 to 1198 patients of varying health con- ditions. All the studies identified numerous indicators of antibiotic use, of which five studies expressed the preva- lence of the indicators in percentage while seven studies expressed the prevalence of the indicators in proportions. The majority of the studies [35, 62, 63, 68, 95, 96] gen- eralized the indicators as community-acquired infection (6), hospital-acquired infection (5), and prophylaxis (5); medical and surgical. As a result, these three were the major key drivers of antibiotic use on patients (in terms of frequencies), followed by pneumonia, skin and soft tis- sue, sepsis, malaria, tuberculosis, respiratory, and urinary tract infections. Antimicrobial stewardship intervention evaluation Ten studies [36, 37, 44, 45, 55, 59, 67, 71, 91, 92] reported data on the effect of antimicrobial stewardship interven- tion of which all were in the hospital setting. The study’s population sizes ranged from 60 to 1718 people. The interventions focused on various themes, such as knowl- edge and guideline compliance, antimicrobial guideline adherence, quality of antimicrobial use, antibiotic pre- scriptions, antibiotic utilization, compliance with surgical antibiotic prophylaxis, prescription behavior, and guide- line compliance as shown in Table  4. A variety of AMS interventions were used across the studies including the utilization of the SAPG triad approach, implementa- tion of a bundle of interventions, incorporation of rapid diagnostic tests into diagnostic algorithms, educational training and meetings, and the adoption of gamified anti- microbial stewardship decision support app (GADSA). The diverse interventions demonstrate the effectiveness of antimicrobial stewardship in each setting where it was implemented, as varying degrees of improvements were observed across the different themes of antibiotic use that were assessed. Despite the improvement of the theme of focus of AMS in each study, the most significant was observed in the study by Sneddon et al. [92] in a hospital where the SAPG triad approach of developing and implementing AMS using information, education and quality improvement was applied to enhance the knowledge and guideline compliance of the healthcare professionals on antibiotic use and prescription. The study by Alabi et  al. [44] also resulted in a significant improvement in the quality of antimicrobial use among healthcare workers in Liberia by doubling the initial utilization of suitable antimicrobi- als in accordance with the guideline or laboratory reports from 34.5% to 61.0%, when a bundle of three interven- tions (local treatment guideline, training, and regular AMS ward rounds) on the quality of antimicrobial use was implemented. The authors further observed a con- siderable decrease in the use of antibiotics such as ceftri- axone 51.3% to 14.2% after the implementation of (AMS) [44]. Similarly, the implementation of a bundle of inter- ventions for Antibiotic Stewardship in Nigeria also led to a notable increase in compliance with the timing of sur- gical antibiotic prophylaxis, rising from 14.2% to 43.3% [36]. These findings underscore the significant impact of AMS training among healthcare workers and the effec- tiveness of bundled interventions in West Africa. Knowledge, attitudes, and perceptions on antibiotic use There were 31 reports [10, 38–40, 43, 47–49, 51, 52, 54, 60, 69, 70, 72–74, 77–79, 81–90, 94] on knowledge, attitudes and practice. These studies were conducted across different populations and the number of studies Fig. 2  Forest plot of antibiotic consumption Page 13 of 29Donkor et al. Antimicrobial Resistance & Infection Control (2025) 14:5 varied across each population; surveys among commu- nity members (8), health providers (9), health provid- ers and community members (3), patients (2), university staff (1), and tertiary students (8) as shown in ST3. There were challenges in the interpretation of the study find- ings due to considerable differences in study populations and methodologies (specifically, questionnaires). The main themes that emerged were knowledge of antibiot- ics (including antibiotic use and antibiotic resistance) in the community reports, knowledge of AMR, and antibi- otic prescription practices in reports on health providers, and knowledge of AMR, self-medication, and sources of antibiotics used in reports on tertiary students. Among the community respondents, there were wide variations in the knowledge of antibiotics (8 reports); overall 8.3– 53.6% had good knowledge of antibiotic use [51, 94] and 33–57.4% had poor knowledge of antibiotic resistance [51, 81, 88]. High cost of antibiotics and low socioeco- nomic status were found to be associated with inappro- priate use of antibiotics [38, 40, 60]. There was high use of antibiotics ranging from 44.1 to 72.5% among commu- nity respondents [77, 81, 94]. Among healthcare providers, the percentage of those who had good knowledge of AMR ranged from 49.2 to 88% [48, 49, 52, 69]. Prescription of antibiotics was found to be at a high rate of 98.2% in a study among 442 pri- mary health workers [84]. Interestingly, laboratory inves- tigations were less frequently requested and used in the prescription of antibiotics by health providers [69, 85, 98]. Tertiary students who had good knowledge of AMR were 57.5–73% [43, 70, 74, 89]. Self-medication was high among tertiary students and ranged from 47.7% to 80.1% [78, 86, 87, 99]. The major reasons for self-medication among tertiary students were cost saving (23.1–40.5%) [74, 78, 87], and convenience (40.5–55.2%) [74, 78, 87]. The main sources of antibiotics were pharmacies (29.1– 85.6%) [43, 74, 86, 87], and doctor’s prescriptions (68.3%) [79]. The study by Ogunleye et  al. [85] in a hospital in Nigeria reveals that clinical judgment made without laboratory results among physicians was 93.9%. This observation is similar to the study by Opoku et  al. [72] in Ghana where 70.11% of the participating febrile patients were prescribed antibiotics, and amongst these, 74.6% of those for whom no laboratory investigation was requested were prescribed antibiotics. Even though there was an encouraging antibiotic knowledge among health- care workers across the studies, it is alarming to observe that, antibiotics were prescribed for common viral infec- tions such as sore throats (75.7%), measles (37.7%), com- mon cold and flu (21.2%) by health workers [52]. This is strikingly similar to the knowledge of community mem- bers claiming antibiotics could cure all types of infections and therefore using antibiotics in treating malaria [81] in addition to confusing antibiotics as painkillers [100]. Discussion Though West Africa has been established as the greatest global hotspot of antibiotic resistance, culminating in the rising number of scientific reports focusing on AMR in the region, a single study unifying human antibiotic use in the region is lacking. Nonetheless, evidence-based information and data are uneven with tertiary and sec- ondary hospitals moderately represented while other sectors such as the private healthcare providers, infor- mal, and community members who play a major role in antibiotic distribution and consumption are highly Fig. 3  Forest plot of appropriate antibiotic prescription Page 14 of 29Donkor et al. Antimicrobial Resistance & Infection Control (2025) 14:5 Ta bl e  4  A nt im ic ro bi al s te w ar ds hi p In te rv en tio n Ev al ua tio n St ud ie s Pu bl ic at io n D ur at io n/ pe ri od o f st ud y Lo ca tio n Po pu la tio n ty pe Po pu la tio n Si ze Th em e of St ew ar ds hi p in te rv en tio n In te rv en tio n de sc ri pt io n Su m m ar y of fin di ng s O ut co m e Sn ed do n, C oo pe r et  a l. [9 2] – G ha na he al th ca re p ro fe s- si on al s; N ur se s, Ph ar - m ac is t, an d  M ed ic al D oc to rs 60 Kn ow le dg e an d  gu id el in es co m pl ia nc e SA PG tr ia d ap pr oa ch in  d ev el op in g an d  im pl em en tin g A M S us in g in fo rm a- tio n, e du ca tio n an d  qu al ity im pr ov e- m en t t o  op tim iz e th e  us e of  a nt im ic ro - bi al s w as  a do pt ed to  te ac hi ng h ea lth - ca re p ro fe ss io na ls in  th e  ho sp ita ls . A  k no w le dg e qu iz an d  an  a tt itu de an d  be ha vi or s su rv ey w er e th en us ed to  g at he r d at a be fo re  a nd  a ft er th e  tr ai ni ng s es si on . To a sc er ta in th e  in flu - en ce o f t he  tr ai ni ng on  th e  kn ow le dg e an d  gu id el in es co m pl ia nc e Th er e w as  a  s ig - ni fic an t i nc re as e in  k no w le dg e to w ar ds  a nt im i- cr ob ia l r es is ta nc e an d  ap pr op ria te us e of  a nt ib io tic s fro m  9 .4 in  K et a M un ic ip al H os pi ta l, 9. 2 in  G ha na P ol ic e H os pi ta l t o  10 .9 11 .1 in  th e  re sp ec - tiv e ho sp ita ls . A  c om pa ris on of  s ur ve y re sp on se s be fo re  a nd  a ft er th e  ed uc at io n se s- si on s re ve al ed th at , it po si tiv el y aff ec te d th ei r p er ce pt io n of  th ei r r ol e in  A nt i- bi ot ic S te w ar ds hi p (A M S) a nd  b oo st ed th ei r c on fid en ce in  u til iz in g th e  G ha na St an da rd T re at m en t G ui de lin es Im pr ov ed k no w le dg e an d  gu id el in e co m pl i- an ce Page 15 of 29Donkor et al. Antimicrobial Resistance & Infection Control (2025) 14:5 Ta bl e  4  (c on tin ue d) Pu bl ic at io n D ur at io n/ pe ri od o f st ud y Lo ca tio n Po pu la tio n ty pe Po pu la tio n Si ze Th em e of St ew ar ds hi p in te rv en tio n In te rv en tio n de sc ri pt io n Su m m ar y of fin di ng s O ut co m e O la -B el lo e t a l. [7 1] A pr il— Se pt em be r 20 19 N ig er ia A ll ch ild re n w ith in  th e  ag e gr ou p of  0 –1 6  ye ar s on  a nt i- bi ot ic s. Bu t t he  ta rg et au di en ce w er e he al th c ar e w or ke rs ; an tib io tic P re sc rib er s 58 2 Co m pl ia nc e w ith  a nt im ic ro bi al gu id el in es , A tt en di ng c lin ic ia ns co nd uc te d da ily re vi ew s of  a nt ib io tic s pr es cr ib ed , c on si de r- in g va rio us fa ct or s su ch a s  cl in ic al d ia g- no si s, ch oi ce o f a nt i- bi ot ic s, do sa ge , du ra tio n of  th er ap y, cl in ic al in di ca tio ns , an d  re le va nt m ic ro bi - ol og y or  b io m ar ke r- ba se d in ve st ig at io ns . Th es e re vi ew s in vo lv ed d oc to rs , cl in ic al p ha rm ac ol o- gi st s, an d  in fe ct io us di se as e ph ys ic ia ns . I n ca se s w he re  th e  in i- tia l p re sc rip tio n w as  d ee m ed in ap pr op ria te , th e  re vi ew er s pr o- vi de d re co m m en da - tio ns fo r o pt im iz in g an tim ic ro bi al th er ap y in  a cc or da nc e w ith  th e  ho sp ita l’s an tib io tic p ol ic y, a im - in g fo r t he  a pp ro pr i- at e us e of  a nt ib io tic s. Th e in te rv en tio ns w er e th en a ss es se d ba se d on  th e  co m pl i- an ce w ith  th e  re co m - m en da tio ns Pr io r t o  th e  im pl e- m en ta tio n of  th e  po in t pr ev al en ce s ur ve y (P PS ), th e  pr ev a- le nc e of  a nt ib i- ot ic p re sc rib in g w as  h ig h, w ith  7 9. 9% of  p at ie nt s (1 39 pa tie nt s on  a dm is - si on ) r ec ei vi ng a nt i- bi ot ic th er ap y. O ut of  th es e pa tie nt s, a  to ta l o f 2 02 a nt ib i- ot ic th er ap ie s w er e ad m in is te re d to  1 11 in di vi du al s, ac co un t- in g fo r t he  h ig h pr ev al en ce o f a nt i- bi ot ic u se . H ow ev er , af te r t he  p pp w as  im pl em en te d, A  to ta l o f 1 14 6 an tim ic ro bi al s w er e au di te d fo r 5 82 pa tie nt s, of  w hi ch 58 .1 % w er e ap pr op ri- at e th er ap ie s, 59 .8 % ap pr op ria te p re sc rip - tio n in  a cc or da nc e to  th e  de pa rt - m en ta l g ui de lin es , an d  40 .2 % w er e in ap pr op ria te pr es cr ip tio ns . T he re w as  a ls o  a si gn ifi ca nt de cr ea se o f t ot al an tib io tic p re sc rib ed fo r a  p er so n, a s  it re du ce d to  a n  av er - ag e pr es cr ip tio n of  1 .9 7 dr ug s Im pr ov ed c om pl i- an ce w ith  a nt im i- cr ob ia l g ui de lin es w as  o bs er ve d Page 16 of 29Donkor et al. Antimicrobial Resistance & Infection Control (2025) 14:5 Ta bl e  4  (c on tin ue d) Pu bl ic at io n D ur at io n/ pe ri od o f st ud y Lo ca tio n Po pu la tio n ty pe Po pu la tio n Si ze Th em e of St ew ar ds hi p in te rv en tio n In te rv en tio n de sc ri pt io n Su m m ar y of fin di ng s O ut co m e A la bi e t a l. [4 4] 20 19 Li be ria H ea lth ca re w or ke rs 31 0 qu al ity o f a nt im ic ro - bi al u se To e va lu at e th e  im pa ct of  a  b un dl e of  th re e in te rv en tio ns (l oc al tr ea tm en t g ui de lin e, tr ai ni ng , a nd  re gu la r A M S w ar d ro un ds ) on  th e  qu al ity o f a nt i- m ic ro bi al u se , a  c as e se rie s w as  c on - du ct ed . T he s tu dy as se ss ed th e  ad he r- en ce to  th e  lo ca l tr ea tm en t g ui de lin e, co m pl et en es s of  m ic ro bi ol og i- ca l d ia gn os tic s (a s pe r t he  tr ea tm en t gu id el in e) , a nd  c lin i- ca l o ut co m es a s  pr i- m ar y en dp oi nt s. Th e as se ss m en ts w er e co nd uc te d be fo re  a nd  a ft er th e  im pl em en ta tio n of  A M S w ar d ro un ds Th er e w as  im pr ov ed ad he re nc e to  lo ca l gu id el in es . T he ut ili za tio n of  s ui t- ab le a nt im ic ro bi - al s, in  a cc or da nc e w ith  th e  gu id el in e or  la bo ra to ry re po rt s, w itn es se d a  no ta bl e en ha nc em en t fo llo w in g  th e  A M S w ar d ro un d, w ith  th e  pe rc en t- ag e in cr ea si ng fro m  3 4. 5% to  6 1. 0% . T he u se of  c ef tr ia xo ne s ig - ni fic an tly d ec re as ed fro m  5 1. 3% to  1 4. 2% af te r t he  im pl em en - ta tio n of  A nt ib io tic St ew ar ds hi p (A M S) w ar d ro un ds . A pp ro xi m at el y 79 .7 % o f p at ie nt s ha d th ei r s am pl es se nt fo r m ic ro bi o- lo gi ca l a na ly si s. O n D ay 3 , a  s ig ni fic an t im pr ov em en t w as  o bs er ve d in  9 2. 3% of  th e  pa tie nt s Q ua lit y of  a nt i- m ic ro bi al u se w as  a nd  g ui de lin e co m pl ia nc e im pr ov ed Page 17 of 29Donkor et al. Antimicrobial Resistance & Infection Control (2025) 14:5 Ta bl e  4  (c on tin ue d) Pu bl ic at io n D ur at io n/ pe ri od o f st ud y Lo ca tio n Po pu la tio n ty pe Po pu la tio n Si ze Th em e of St ew ar ds hi p in te rv en tio n In te rv en tio n de sc ri pt io n Su m m ar y of fin di ng s O ut co m e A dj ei e t a l. [3 7] Se pt em be r 2 02 0 to  S ep te m be r 2 02 1 G ha na In di vi du al s ag ed 6  m on th s to  <  1 8  ye ar s of  b ot h  se xe s w ith  a cu te fe br ile ill ne ss 15 12 p at ie nt s w er e ra nd om iz ed to  e ith er  th e in te r- ve nt io n (n  =  7 61 ) or  c on tr ol (n  =  7 51 ) gr ou p an tib io tic p re sc rip - tio ns Ex am in in g th e  eff ec ts o f i nc or - po ra tin g ra pi d di ag no st ic te st s in to  d ia gn os tic al go rit hm s on  c lin ic al ou tc om es a nd  a nt i- bi ot ic p re sc rip tio ns in  c om pa ris on to  s ta nd ar d- of -c ar e pr ac tic es Th e in te rv en tio n gr ou p ex pe rie nc ed an  1 1% re la tiv e ris k re du ct io n in  a nt i- bi ot ic p re sc rip - tio n co m pa re d to  th e  co nt ro l gr ou p. S pe ci fic al ly , am on g  ch ild re n ag ed u nd er  5  y ea rs , th er e w as  a  1 4% re du ct io n, w hi le  a m on g  no n- m al ar ia p at ie nt s an d  th os e w ith  re s- pi ra to ry s ym p- to m s, th er e w er e re du ct io ns o f 1 5% an d  16 % re sp ec tiv el y in  a nt ib io tic p re sc rip - tio n ra te s. Th es e fin d- in gs d em on st ra te th e  eff ec tiv en es s of  th e  in te rv en tio ns in  re du ci ng u nn ec es - sa ry a nt ib io tic p re - sc rib in g ac ro ss  v ar i- ou s pa tie nt su bg ro up s Th e in te rv en tio n ha d si gn ifi ca nt im pa ct o n  re du ci ng un ne ce ss ar y an tib io tic pr es cr ip tio ns Page 18 of 29Donkor et al. Antimicrobial Resistance & Infection Control (2025) 14:5 Ta bl e  4  (c on tin ue d) Pu bl ic at io n D ur at io n/ pe ri od o f st ud y Lo ca tio n Po pu la tio n ty pe Po pu la tio n Si ze Th em e of St ew ar ds hi p in te rv en tio n In te rv en tio n de sc ri pt io n Su m m ar y of fin di ng s O ut co m e A bu ba ka r e t a l. [3 6] M ay a nd  D ec em be r 20 16 N ig er ia A ll ad ul t p at ie nt s w er e el ig ib le to  p ar - tic ip at e in  th e  st ud y ex ce pt  H IV a nd  c an - ce r p at ie nt s 22 6 an d  23 8 su rg ic al p ro ce du re s in  th e  pr e- a nd  p os t- in te rv en tio n pe rio ds re sp ec tiv el y A nt ib io tic u til iz at io n an d  co m pl ia nc e w ith  s ur gi ca l a nt ib i- ot ic p ro ph yl ax is A b un dl e of  in te r- ve nt io ns fo r A nt i- bi ot ic S te w ar ds hi p w as  im pl em en te d, w hi ch in cl ud ed ed uc at io na l m ee t- in gs , t he  d ev el op - m en t o f a  p ro to co l, an d  re gu la r a ud it an d  fe ed ba ck p ro - ce ss es Fo llo w in g th e  in te r- ve nt io ns , t he re w as  a  n ot ab le in cr ea se in  c om pl i- an ce w ith  th e  tim in g of  s ur gi ca l a nt ib io tic pr op hy la xi s, ris in g fro m  1 4. 2% to  4 3. 3% . Si m ila rly , c om pl i- an ce w ith  th e  du ra - tio n of  p ro ph yl ax is im pr ov ed fr om  0 % to  2 1. 8% . T he in te rv en tio ns al so  h ad a  s ig ni fic an t im pa ct o n  re du c- in g th e  pr es cr ip tio n of  th ird -g en er at io n ce ph al os po rin by  8 .6 % , r ed un - da nt a nt ib io tic u se by  1 9. 1% , a nd  o ve ra ll an tib io tic u til iz at io n by  3 .8 d efi ne d da ily do se s (D D D ) p er  p ro - ce du re Th e in te rv en tio n ha d a  si gn ifi ca nt p os iti ve im pa ct a s  co m pl ia nc e w ith  s ur gi ca l a nt ib io tic pr op hy la xi s an d  an ti- bi ot ic u til iz at io n w er e im pr ov ed Page 19 of 29Donkor et al. Antimicrobial Resistance & Infection Control (2025) 14:5 Ta bl e  4  (c on tin ue d) Pu bl ic at io n D ur at io n/ pe ri od o f st ud y Lo ca tio n Po pu la tio n ty pe Po pu la tio n Si ze Th em e of St ew ar ds hi p in te rv en tio n In te rv en tio n de sc ri pt io n Su m m ar y of fin di ng s O ut co m e Lu ed tk e et  a l. [6 7] Ju ne 1 st to  D ec em - be r 3 1s t 2 01 9 N ig er ia H ea lth c ar e w or ke rs : su rg eo ns a nd  p ha r- m ac is ts w ho w or ke d cl os el y w ith  s ur gi ca l te am s – Pr es cr ip tio n be ha vi or o f s ur - ge on s an d  gu id el in e co m pl ia nc e A s m ar tp ho ne ap pl ic at io n, G am i- fie d A nt im ic ro bi al St ew ar ds hi p D ec i- si on S up po rt A pp (G A D SA ), pr ed e- si gn ed w ith  fe at ur es su ch a s  be ha vi or ch an ge s up po rt sy st em , d ec is io n su pp or t s ys te m an d  pe rs ua si ve g am e te ch ni qu es . I t a id s its us er s on  a nt ib io tic pr es cr ip tio n ba se d on  s ta nd ar d gu id e- lin es . T hi s is  b as ed on  d at a th e  us er en te rs in to  it Fo llo w in g th e  fe ed - ba ck p ro vi de d by  th e  ap p, 1 2% of  s ur ge on s ad ju st ed th ei r de ci si on s to  a lig n w ith  th e  gu id el in es . Sp ec ifi ca lly , 1 0% of  s ur ge on s ch an ge d th ei r d ec is io n re ga rd - in g  th e  ne ce ss ity of  S ur gi ca l A nt ib io tic Pr op hy la xi s (S A P) to  b e in  li ne w ith  th e  gu id el in es . th er e w as  a  s im ila r pa tt er n of  c ha ng e ob se rv ed in  d ec i- si on -m ak in g re la te d to  th e  "t yp e" an d  "d ur at io n" of  S A P, w ith  6 % an d  5% o f s ur ge on s re sp ec tiv el y m ak in g ad ju st m en ts to  c om - pl y w ith  th e  gu id e- lin es G A D SA a pp ha s  th e  po te nt ia l to  b rin g ab ou t s ub - st an tia l c ha ng es in  p re sc rib in g be ha v- io r a t t he  p oi nt o f c ar e w ith in  a n  A fri ca n co nt ex t Page 20 of 29Donkor et al. Antimicrobial Resistance & Infection Control (2025) 14:5 Ta bl e  4  (c on tin ue d) Pu bl ic at io n D ur at io n/ pe ri od o f st ud y Lo ca tio n Po pu la tio n ty pe Po pu la tio n Si ze Th em e of St ew ar ds hi p in te rv en tio n In te rv en tio n de sc ri pt io n Su m m ar y of fin di ng s O ut co m e Sn ed do n, A fri yi e et  a l. [9 1] – G ha na H os pi ta l s ta ff (m ed ic al , p ha rm ac y, nu rs in g an d  la bo ra - to ry s ta ff ) O ve r 1 00 – Tr ai ni ng o f h os pi ta l st aff a nd  e st ab lis hi ng A M S te am s Th e as se ss m en t of  th e  tr ai ni ng ’s im pa ct re ve al ed a  su bs ta nt ia l p os iti ve sh ift in  p ar tic ip an ts ’ un de rs ta nd in g of  a nt im ic ro bi al re si st an ce (A M R) an d  ap pr op ria te an tib io tic u til iz a- tio n. It a ls o  re su lte d in  im pr ov ed at tit ud es a nd  b eh av - io ur s to w ar ds  A M R, a  be tt er c om pr eh en - si on o f t he ir ro le in  A nt im ic ro bi al St ew ar ds hi p (A M S) , an d  in cr ea se d co n- fid en ce in  u til iz in g th e  G ha na S ta nd ar d Tr ea tm en t G ui de - lin es Tr ai ni ng H os pi ta l st aff o n  A M S is  a  k ey in te rv en tio n En im il et  a l. [5 5] Se pt em be r 2 01 5 an d  20 19 G ha na In -p at ie nt s oc cu py - in g be ds in  S ep - te m be r 38 6 an d  63 0 in  2 01 5 an d  20 19 re sp ec - tiv el y A nt ib io tic U sa ge an d  th e  us e of  m ar k- er s fo r a pp ro pr ia te an tib io tic p re sc rip - tio n in  th e  ho sp ita l G lo ba l-P PS p ro to co l on  a ll in pa tie nt s; al l a du lts , c hi ld re n an d  ne on at es Th e in ci de nc e of  h os pi ta l-a cq ui re d in fe ct io ns d ec re as ed fro m  6 .2 % (2 4/ 38 6) in  2 01 5 to  4 .8 % (3 0/ 63 0) in  2 01 9. Th e ut ili za tio n of  b io m ar ke rs th at  a id in  d ia gn os is in cr ea se d fro m  4 .9 % (1 2/ 24 7) to  7 .6 % (2 8/ 36 8) Pa ra m et er s or  m ar k- er s fo r a pp ro pr ia te an tib io tic p re sc rip tio n im pr ov ed Page 21 of 29Donkor et al. Antimicrobial Resistance & Infection Control (2025) 14:5 Ta bl e  4  (c on tin ue d) Pu bl ic at io n D ur at io n/ pe ri od o f st ud y Lo ca tio n Po pu la tio n ty pe Po pu la tio n Si ze Th em e of St ew ar ds hi p in te rv en tio n In te rv en tio n de sc ri pt io n Su m m ar y of fin di ng s O ut co m e A m po ns ah e t a l. [4 5] N ov em be r 2 02 1 to  M ay 2 02 2 G ha na H ea lth c ar e st aff in  th e  ho sp ita l – A nt ib io tic u se an d  in fe ct io ns m an - ag em en t A M S bu nd le d st ew - ar ds hi p pr og ra m m e in te rv en tio n w as  ra n on  a ll th e  he al th - ca re w or ke rs th ro ug h  se m in ar s an d  hy br id tr ai n- in g. G lo ba l-P oi nt Pr ev al en ce S ur ve y (P PS ) p ro to co l w as  e m pl oy ed in  a ss es si ng a nt ib io t- ic s us e at  h os pi ta l at  b as el in e, m id po in t an d  en d of  th e  pr o- je ct Th e ut ili za tio n of  a nt ib io tic s de cr ea se d fro m  6 5% in iti al ly to  5 9. 7% up on  c om pl et io n of  th e  pr oj ec t. Si m ila rly , t he  p re va - le nc e of  h ea lth - ca re -a ss oc ia te d in fe ct io ns d ec re as ed fro m  1 7. 5% at  th e  be gi nn in g to  6 .5 % a t t he  c on - cl us io n. T he a do p- tio n of  a nt ib io tic s fro m  th e  W H O A cc es s gr ou p st ar te d at  4 0% b ut  s aw an  in cr ea se to  5 0% by  th e  en d. F ur th er - m or e, th e  us ag e of  w at ch a nt ib io tic s de cr ea se d fro m  6 0 to  5 0% c om pa re d to  th e  in iti al a ss es s- m en t. In te rm s of  c ul tu re a nd  s us - ce pt ib ili ty te st in g, th er e w as  a  n ot ab le in cr ea se fr om  1 11 to ta l r eq ue st s at  th e  ou ts et to  3 30 re qu es ts d ur - in g  th e  in te rv en tio n pe rio d, w hi ch p la ye d a  cr uc ia l r ol e in  g ui d- in g an tim ic ro bi al th er ap y de ci si on s Th er e w as  a  n ot ic e- ab le im pr ov em en t in  a nt ib io tic u se an d  th e  ov er al l q ua lit y of  a nt im ic ro bi al th er - ap y du rin g  th e  st ud y pe rio d Page 22 of 29Donkor et al. Antimicrobial Resistance & Infection Control (2025) 14:5 Ta bl e  4  (c on tin ue d) Pu bl ic at io n D ur at io n/ pe ri od o f st ud y Lo ca tio n Po pu la tio n ty pe Po pu la tio n Si ze Th em e of St ew ar ds hi p in te rv en tio n In te rv en tio n de sc ri pt io n Su m m ar y of fin di ng s O ut co m e Ki em de e t a l. [5 9] Se pt em be r 20 20 -S ep te m be r 20 21 Bu rk in a Fa so In di vi du al s p re se nt ed at  o ut pa tie nt c lin ic s w ith  a cu te fe br ile di se as e de fin ed as  fe ve r 17 18 A nt ib io tic P re sc rip - tio ns A c on tr ol a nd  in te r- ve nt io n pr oc ed ur e m ad e of  p ac ka ge co ns is tin g of  d ia g- no st ic to ol a nd  a lg o- rit hm o f a nt ib io tic pr es cr ip tio n; to  g ui de he al th w or ke rs on  w he th er  to p re - sc rib e an  a nt ib io tic or  n ot  fo r p at ie nt s w ith  fe br ile il ln es se s Th er e w as  n o  si g- ni fic an t d iff er en ce in  th e  cl in ic al ou tc om es o f p at ie nt s in  th e  co nt ro l an d  in te rv en tio n ar m s. Bu t t he  a nt i- bi ot ic p re sc rip tio n w as  s ig ni fic an tly lo w er in  th e  in te r- ve nt io n ar m : 4 0. 6% ve rs us  5 7. 5% in  th e  co nt ro l a rm Re du ce in ap pr op ria te an tib io tic p re sc rip tio n Page 23 of 29Donkor et al. Antimicrobial Resistance & Infection Control (2025) 14:5 underrepresented. We therefore aimed to bridge this gap by bringing together the various components of J01 anti- biotic use in West Africa, encompassing antibiotic con- sumption, appropriateness, uncovering the key indicators of antibiotic use, evaluating stewardship interventions, as well as Knowledge, attitude, and perception of the peo- ple in West Africa for evidence synthesis of human anti- biotic use. To our knowledge, this is the first manuscript encompassing all the elements necessary to identify and curb the high antibiotic resistance as a whole. The findings of our review reveal that antibiotic con- sumption in West Africa exhibits high heterogeneity and ranges from 66.9 to 2,629,786 DDD per 100 bed-days. The pooled estimate of overall antibiotic consumption was 620.03 DDD per 100 bed-days (CI: 0.00–1286.67; I2 = 100%). This finding reveals a substantially high antibi- otic consumption in the region. The antibiotic consump- tion at 620.03 DDD per 100 bed-days in this study is far higher than the antibiotic consumption of 479.18 DDD per 1000 inhabitants per day reported by Zaha et al. (105) among surgical inpatients admitted in 2017 in a clini- cal emergency hospital in Romania (though the units of DDD measurement varied). Also, the high antibiotic con- sumption recorded in our present study is substantially higher than the WHO reports [101] of antibiotic con- sumption that represented 2015 data from 65 countries, which ranged from 4.4 to 27.29 DDD per 100 inhabit- ants per day in the African Region, 10.26 to 22.75 in the Region of the Americas, 7.66 to 38.18 European Region, 8.92 to 38.78 in the Eastern Mediterranean Region, and 5.92 to 64.41in the Western Pacific Region. The antibi- otic consumption in West Africa is also higher than the 164.48 DDD/100-BD increase in antibiotic consumption in the Hazhaz medical ward reported in Eritrea [102]. Our observed high antibiotic consumption aligns with the findings of Klein et al. [12], who identified low- and lower-middle-income countries as major contributors to global antibiotic consumption. The authors reported a significant increase in antibiotic consumption, from 11.4 to 24.5 billion DDDs, representing a remarkable 114% increase. The most consumed antibiotics were amoxicillin, gen- tamicin, metronidazole, amoxicillin-clavulanate (all four are access antibiotics), and ceftriaxone (watch antibiotic). This is in line with other studies in other parts of the world that also identified one or more of these antibiotics among their most consumed antibiotic but contradicts the reports of Klein et al. who identified broad-spectrum penicillin to be the most consumed global antibiotic in 2015 [12]. A study conducted in Eritrea [102] and Roma- nia [103] also identified ceftriaxone as a major consumed antibiotic. The higher utilization of access antibiot- ics compared to watch antibiotics in West Africa, as we are reporting, can be attributed to their preference as essential first or second-line empiric treatment options for infectious syndromes, as recommended by WHO. These access antibiotics encompass a group of antibiot- ics that demonstrate efficacy against a broad spectrum of commonly encountered susceptible pathogens, while maintaining a lower potential for resistance compared to other antibiotics. Our study further identified that some healthcare professionals in West Africa prescribe anti- biotics without bacteriological diagnosis as observed in other parts of the world [104, 105], therefore puts them on the edge of prescribing access antibiotics to patients, and therefore resulting in the high use of access antibiot- ics in the West African region. Our observed 64% access antibiotic consumption is above the 60% threshold set by WHO and higher than the watch antibiotic consumption (27%) in the region. The Access antibiotic consumption is consistent with the reports of Limato et al. [106] in Indo- nesia but lesser than the 69% reported in their study. The disproportionate use of Watch antibiotics we identified in this study corroborates the findings of Limato et  al. [106] in Indonesia. Our finding reaffirms previous find- ings that, the consumption of Watch antibiotics is high in LMICs compared with high-income countries [12]. The use of different varieties of antibiotics, as observed in our study, explains the high resistance to these antibiotics in West Africa as it has well been established that, exposure of bacteria to antibiotics results in resistance over time. The comprehensive assessment of antibiotic consump- tion by inpatients in our study resulted in an estimated rate of 620.03 DDD per 100 bed-days (CI: 0.00–1286.67; I2 = 100%) which surpasses the recent 134.8 per 100 bed- days antibiotic consumption reported from Indonesia [106]. This significant disparity highlights the pressing need for immediate intervention. The urgency is further underscored by projections indicating a potential 200% increase in global antibiotic consumption between 2015 and 2030 if effective policies are not implemented [12]. The considerable divergence observed in antibiotic con- sumption, both among inpatients and outpatients, can be attributed to a multitude of factors. From our study, some of the factors resulting in this divergence are as a result of disparities across countries and the duration of the study. Studies in Sierra Leone recorded a higher antibiotic consumption as compared to Nigeria. The disparity observed from subgroup analysis on the dura- tion of studies may have resulted in country-level differ- ences in antibiotic consumption. For longer studies, the reason for the higher antibiotic consumption may be due to tolerance and the need for continual increases in antibiotic consumption to augment therapy. Other fac- tors like variations in the burden of infectious diseases, different healthcare systems and sectors, discrepancies in Page 24 of 29Donkor et al. Antimicrobial Resistance & Infection Control (2025) 14:5 antibiotic accessibility, and variations in regulatory poli- cies, among numerous others [106–108]. It is noteworthy that there was no consumption of non-recommended or reserved antibiotics in all the studies. This absence may be attributed to their unavailability in the local market and their exclusion from various local guidelines, such as the Standard Treatment Guidelines of Ghana [61, 109]. It is laudable and reassuring to mention that cefoperazone- sulbactam, which is a non-recommended antibiotic was not prescribed in any of the studies in West Africa. Generally, rational use of antibiotics depends on its prescription alignment with a predetermined standard guideline. In this present study, the overall appropri- ateness of antibiotic prescribing ranged from 2.5% to 93.0% with a pooled estimate of 50.09 ([CI: 22.21–77.92], I2 = 99.4%). With the range being 2.5–93.0%, only a few of the studies had the prescribing appropriateness above 75%, resulting in the 50.09% pooled appropriateness recorded in this study. Moreover, many studies in the West African region report a high number of antibiotic prescribing inappropriateness [110–113]. Inappropriate antibiotic prescribing has been reported in many parts of the world [114, 115] with an estimation of less than 70% compliance with standards in hospitals in Latin America, West and Central Asia, and Africa [116]. Attaining a long- term goal of minimizing or curbing antibiotic resistance is highly unlikely if the standard guidelines put in place are not strictly followed. In the West African context, the inappropriate prescribing of antibiotics can be attributed to a complex interplay of multiple factors, which vary across settings and countries. In this study, we found that the level of antibiotic appropriateness dropped after 2020 (51.05 [CI: 49.20–52.90]) as compared to before 2020 (71.94 [CI: 69.78–74.03]), possibly due to the COVID-19 pandemic in which a lot of antibiotics were prescribed in the initial stages of the pandemic. Other factors may encompass limited availability or inadequate utilization of diagnostic facilities, physicians’ non-adherence to anti- biotic guidelines, financial constraints faced by patients, influence exerted by the pharmaceutical industry, and patient-related pressures [106, 116]. Higher antibiotic consumption and relatively moderate prescribing appro- priateness can lead to a higher emergence of resistance. A comprehensive systematic review and meta-analysis demonstrated a remarkable 35% relative risk reduction in mortality associated with the implementation of guide- line-adherent empirical therapy. However, the reasons behind the persistently low compliance with these guide- lines remain complex and multifactorial [117]. In West Africa, we have identified the general key indi- cators of antibiotic use among inpatients and outpatients to be dominated by community-acquired infection, fol- lowed by hospital-acquired infection and prophylaxis; medical and surgical. This finding corroborates the reports of Fentie et al. [118] who also identified commu- nity-acquired infection and hospital-acquired infection to be the major cause of antibiotic use in Ethiopia. Our findings are also in line with the key indicators of anti- biotic use in Thailand as reported by Anugulruengkitt et al. [119] who identified community-acquired infection as the main reason for antibiotic treatment initiation in Thailand after conducting a study across 41 hospitals. Similar to many other studies in other parts of the world, the predominant specific health conditions driving anti- biotic utilization among both inpatients and outpatients in West Africa encompass pneumonia, skin and soft tis- sue infections, sepsis, malaria, tuberculosis, respiratory tract infections, and urinary tract infections. Further- more, the inclusion of malaria as a condition requiring antibiotic use in some cases may be attributed to the presence of co-infections, where individuals affected by malaria also get bacterial infections. However, it is important to acknowledge that in certain instances, the classification of malaria as a condition necessitating anti- biotic use could be a result of misdiagnosis, highlighting the challenges associated with accurately identifying and distinguishing between different types of infections in clinical practice. A plethora of compelling evidence has accumulated, highlighting the favorable outcomes associated with AMS intervention programs in various regions world- wide and has become a major global strategy being advanced to curb the development and spread of anti- biotic resistance [63, 120, 121]. In West Africa, AMS is still in its early stages with many of the countries having implemented AMS within the last ten years and are often limited to tertiary and secondary hospitals. Our study identified a variety of AMS intervention strategies used across the West African countries in this study. After the implementation of these interventions, varying degrees of improvements were observed across the different themes of antibiotic use that were assessed. Despite the improvement of the theme of focus of AMS in each study, the most effective strategies identified were bun- dled interventions (local treatment guidelines, training, and regular AMS ward rounds), the SAPG triad approach of developing and implementing AMS using informa- tion, education and quality improvement to enhance the knowledge and guideline compliance of healthcare professionals on antibiotic use and prescription. These findings highlight the profound influence of AMS train- ing among healthcare professionals and the implemen- tation of comprehensive bundled intervention in West Africa. This further emphasizes the effectiveness and feasibility of AMS interventions within the local context, offering substantial potential for curtailing antibiotic Page 25 of 29Donkor et al. Antimicrobial Resistance & Infection Control (2025) 14:5 consumption, enhancing prescribing appropriateness, reducing the incidence of unnecessary prescriptions, and ultimately fostering improved patient care in the West African region. A key component in addition to the key domains of antibiotic use discussed above is the knowledge, atti- tude and perception of the general population encom- passing inpatients, outpatients, health care workers, and other healthy individuals in formal and informal settings towards the use of J01 antibiotics. In this study, health care providers demonstrated good knowledge of AMR ranging from 49.2 to 88% but employed laboratory inves- tigation prior to antibiotic prescription less frequently. This high knowledge of health-care workers in this study corroborates the findings of Firouzabadi et al. [122] and Florian [123]. Despite the laudable range of knowledge demonstrated by healthcare workers, the persistently high levels of antibiotic consumption and inappropri- ate use may be attributed to the inadequate availability of appropriate antibiotic intervention structures, such as bacteriological diagnostic labs. However, it is impor- tant to recognize that other factors, originating from the patient’s perspective, also contribute to this issue. One prominent theme was the glaring lack of awareness and knowledge regarding AMR and antibiotics, particularly among individuals from lower-educated or uneducated backgrounds. Additionally, a concerning trend observed across both educated and uneducated individuals was the widespread practice of self-medication with antibi- otics, disregarding the need for a prescription. Among the community respondents who reported a high usage of antibiotics (ranging from 44.1% to 72.5%), there was a considerable disparity in their knowledge about antibiot- ics. The findings revealed a range of 8.3–53.6% of indi- viduals possessing good knowledge regarding antibiotic use, while a higher range of 33–57.4% demonstrated poor knowledge concerning antibiotic resistance. This poor knowledge of West African antibiotic consumers on anti- biotic resistance is similar to the findings of Limato et al. [106] who also observed similar trends in their systematic review of antibiotic use in Indonesia. Our study further identified that high cost of antibiot- ics, knowledge of the effectiveness of some antibiotics, convenience, and low socioeconomic status were found to be associated with self-medication and inappropriate use of antibiotics, while the common source of obtaining antibiotics were from pharmacies, chemists, and hawk- ers. These findings are concurrent with the reports in Asia [106, 124, 125] and in Egypt [126]. Our research has revealed that the primary sources of antibiotic knowl- edge in West Africa encompass doctors, pharmacies, over-the-counter (OTC) sellers, drug peddlers, family members, friends, radio, and television. Notably, these sources of information are accessible to a significant por- tion of the population, including those residing in rural areas, as radio stations and bands are widely distrib- uted throughout the region. Consequently, implement- ing comprehensive training programs on antibiotic use across various media platforms would be highly advanta- geous in enhancing antibiotic knowledge. By leveraging these accessible channels, such training initiatives can effectively reach and educate a diverse range of individu- als, contributing to improved antibiotic practices and the prevention of antibiotic resistance. Limitation This systematic review had certain limitations that should be acknowledged. Firstly, there were variations in study designs and periods among the articles analyzed, which may have introduced some heterogeneity in the findings. Additionally, the reporting patterns of antibiotic con- sumption in West Africa were uneven, with some studies providing data in percentages rather than defined daily doses (DDD), making it challenging to standardize the data for comparison. As such, studies that did not report antibiotic consumption in DDD were not included. One additional constraint of our manuscript revolves around the pooled estimate concerning antibiotic consumption, as our investigation reveals that the majority of the avail- able data stems from a single study conducted by Labi et  al. [61], as depicted in our forest plot. Furthermore, certain studies did not meet the inclusion criteria as they solely focused on reporting the inappropriate prescribing of antibiotics, rather than assessing appropriate antibiotic prescriptions according to established guidelines. This may have introduced unintended bias in the results, as some relevant studies from the region were not included. The heterogeneity in methodology, study design, and patient characteristics among the included studies can also impact the overall estimate of antibiotic consump- tion and prescribing appropriateness. Moreover, the decision to exclude non-peer-reviewed articles and infor- mation from websites may have resulted in the omission of valuable data regarding antibiotic use and effective interventions implemented by governmental or non- governmental organizations in the region. However, this exclusion was made to uphold the quality of the review, considering that non-peer-reviewed sources may not consistently adhere to recognized standards or recom- mended evaluation guidelines. Conclusion This comprehensive review serves as a valuable resource for policymakers and academics, offering a con- cise summary of the prevailing state of antibiotic use among humans in West Africa for the past 24 years. By Page 26 of 29Donkor et al. Antimicrobial Resistance & Infection Control (2025) 14:5 identifying gaps in knowledge and highlighting areas where prompt actions are required, this review guides future research endeavors and policy development. The findings underscore the need for further implementa- tion of AMS programs across the West African region to enhance our understanding of antibiotic use patterns, prescribing practices, and the factors influencing them in the region. Supplementary Information The online version contains supplementary material available at https://​doi.​ org/​10.​1186/​s13756-​024-​01504-3. Additional file1 (DOCX 699 KB) Author contributions Conceptualization, E.S.D., and A.-H.O.; design, E.S.D., and A.-H.O.; validation, E.S.D., A.-H.O., B.C.A., A.A.-D., A.O., B.O.-A., and G.L.; resources, E.S.D., A.-H.O., B.C.A., A.A.-D., A.O., and B.O.-A.; data acquisition, E.S.D., A.-H.O., A.A.-D., and A.O.; writing—original draft preparation, E.S.D., A.-H.O., B.C.A.; analysis, B.C.A., and G.L.; writing—review and editing, E.S.D., A.-H.O., B.C.A., A.A.-D., A.O., B.O.-A., and G.L.; supervision, E.S.D. and B.O.-A.; project administration, E.S.D.; funding acquisition, E.S.D. All authors have read and agreed to the published version of the manuscript. All authors have agreed to be personally accountable for the contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution docu- mented in the literature. Funding This review paper was funded by the Fogarty International Center of the National Institutes of Health through the Research and Capacity Building in Antimicrobial Resistance in West Africa (RECABAW) Training Programme hosted at the Department of Medical Microbiology, University of Ghana Medical School (Award Number: D43TW012487). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Availability of data and materials No datasets were generated or analysed during the current study. Declarations Competing interests The authors declare no competing interests. Author details 1 Department of Medical Microbiology, University of Ghana Medical School, Accra, Ghana. 2 Department of Medicine and Therapeutics, University of Ghana Medical School, Accra, Ghana. 3 Oxford University Clinical Research Unit (OUCRU) Indonesia, Jakarta, Indonesia. 4 Faculty of Medicine, Universitas Indo- nesia, Jakarta, Indonesia. Received: 22 June 2024 Accepted: 5 December 2024 References 1. Carlet J, Collignon P, Goldmann D, Goossens H, Gyssens IC, Harbarth S, et al. Society’s failure to protect a precious resource: antibiotics. Lancet. 2011;378(9788):369–71. 2. Cantón R, Horcajada JP, Oliver A, Garbajosa PR, Vila J. Inappropriate use of antibiotics in hospitals: the complex relationship between antibiotic use and antimicrobial resistance. Enferm Infecc Microbiol Clin. 2013;31:3–11. 3. Hasan CM, Dutta D, Nguyen AN. Revisiting antibiotic resistance: mecha- nistic foundations to evolutionary outlook. Antibiotics. 2021;11(1):40. 4. Saha M, Sarkar A. 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