Barriers, facilitators, and opportunities for hospital antimicrobial stewardship in low and lower middle - income countries in the Eastern Mediterranean region: results from a mixed methods study.

BACKGROUND: Antimicrobial stewardship programmes (ASP) are crucial for mitigating antimicrobial resistance (AMR), a growing threat in the Eastern Mediterranean region (EMR) where conflict, instability, and economic challenges hinder health systems. EMR specific barriers of antimicrobial stewardship (AMS) remain under documented. METHODS: A mixed methods study was conducted to explore barriers and opportunities for ASP implementation in EMR focusing on low (LIC) and lower middle-income countries (LMIC) with relatively stable policy environments and demonstrated interest, capacity, and infrastructure for stewardship. We used literature review, semi-structured interviews of experts, and a stakeholder consultation. RESULTS: Seven key themes emerged: One, AMS implementation capacity varies across the region, necessitating tailored approaches. Two, the limited availability of expertise requires urgent upscaling of knowledge and capacity. Three, mentorship and the development of centres of excellence is needed. Four, existing AMS tools should be enhanced, disseminated, and occasionally, adjusted to local needs. Five, the lack of a sustainable platform for networking impedes collaboration. Six, accreditation and national level mandates for hospital AMS can support scale-up. Seven, expanding research is critical to inform local evidence-based action. CONCLUSIONS: Several components of ASPs are achievable in the EMR using existing resources with targeted support from local and identified regional and global partners.