Assessing the impact of antimicrobial resistance policies on antibiotic use and antimicrobial resistance-associated mortality in children and adults in low and middle-income countries: a global analysis.

Introduction: Antimicrobial resistance (AMR) poses a major threat to global health security today. In recent years, many low and middle-income countries (LMICs) have implemented policies to optimise antibiotic use in both formal and informal healthcare settings. However, there is limited evidence on the effectiveness of these national efforts in LMICs. Methods: We investigated the empirical relationship between national policies aimed at restricting antibiotic use and actual antibiotic consumption in 138 LMICs. Data on national policies were obtained from the Tripartite AMR Country Self-Assessment Survey (TrACSS) as well as from the Global Survey of Experts on AMR (GSEAR). Seven independent variables relating to AMR policies were evaluated. Outcomes included the proportion of children receiving antibiotics for lower respiratory tract infections and diarrhoea (specific to paediatric populations), along with total antibiotic consumption and AMR-associated mortality in general populations. Results: Our analysis of 138 LMICs found wide variation in antibiotic use between countries and regions. We observed strong evidence of negative association (mean difference MD=-0.150, 95% CI (-0.2593 to -0.0407)) between the presence of regulatory or legislative policies that ban over-the-counter sales of antibiotics and the proportion of children receiving antibiotic drugs for lower respiratory tract infection. Furthermore, stronger AMR governance was associated with reduced total antibiotic consumption at the country level (MD=-1.259, 95% CI (-2.297 to -0.2216)). No associations were found between other policy variables and antibiotic use or mortality. Conclusion: The results presented here suggest that there is some evidence of an empirical relationship between national policies aimed at limiting over-the-counter antibiotic sales and actual antibiotic usage practices. Further policy effectiveness research will be needed to better understand the true impact of government measures. In general, a multifaceted approach will likely be needed to fight AMR and preserve antibiotics' effectiveness, including evidence-based policies, targeted education and research.