People often assume that the only issue low- and- middle income countries (LMICs) facewhen it comes to antibiotics is lack of access. Given that antibiotics improve disease outcomes, a lack of access to antibiotics means worse health outcomes and often excess deaths. When considering access to antimicrobials as more than availability but also appropriate prescribing as recommended by experts, that assumption would be true. However, although there is a distinct lack of access to new antibiotics, broad-spectrum antibiotics belonging to the Watch group of the WHO AWaRe classification are generally available in many LMICs.

These antibiotics are often not accompanied with appropriate prescribing in these settings, leading to excess usage. Patterns of antibiotic consumption in LMICs are far more complex than is often assumed, studies have reported high levels of antibiotic misuse in many LMICs with distinct differences in access and consumption between the Asian and African LMICs. These great variations in access and usage patterns across individual countries and regions highlight the necessity of not considering all LMICs as a single group.

The conflicting evidence on access to antibiotics means that tackling overconsumption or misuse of antibiotics in LMICs is tricky, especially since there are not much data available on the subject. In any case, it is now apparent that universal approaches to improve antibiotic stewardship are not appropriate. For instance, mandating the delivery of antibiotics only via prescriptions is an intervention already implemented successfully in several high-income countries (HICs). While this may be successful in some LMICs with good access to antibiotics, in others it would further worsen the health inequalities that already exist. Instead, an understanding of local healthcare systems and stakeholders is necessary to formulate the best setting-specific policy.

This is not to say that the focus should only be on improving stewardship in LMICs with good antibiotic access. It is important to remember that the prevalence of resistance and the number of infections with resistant bacteria is higher in LMICs. Consequently, most of the annual deaths which could have been prevented by antibiotics (which reportedly surpass the estimated deaths caused by antibiotic-resistant infections) occur in LMICs. Hence, it is still necessary to increase access where needed in LMICs, while promoting responsible use of antibiotics.

Antibiotics have generally been used to prop up the poor healthcare systems lacking sufficient  trained health personnel and diagnostic infrastructure in bacterial disease prevalent settings. With increasing drug resistance, it is apparent that infection prevention, rather than treatment, should be the focus.

In LMICs, antibiotic stewardship will remain largely unsuccessful without first reducing the drug pressure necessitated by the high incidence and prevalence of disease. This may happen through vaccination for endemic diseases, improved diagnostics for diseases with non-specific symptoms, improved hygiene and sanitation, access to clean water supply, more healthcare workers and better access to good healthcare facilities. Furthermore, extensive research and better surveillance systems are required for evidence-based policies. Overall, antibiotic stewardship in LMICs needs to be context-specific, and this means improving access to antibiotics while reducing inappropriate use.