Antibiotic prescription practices in primary care in low- and middle-income countries: A systematic review and meta-analysis

Giorgia Sulis, Pierrick Adam, Vaidehi Nafade, Genevieve Gore, Benjamin Daniels, Amrita Daftary, Jishnu Das, Sumanth Gandra , Madhukar Pai



The widespread use of antibiotics plays a major role in the development and spread of antimicrobial resistance. However, important knowledge gaps still exist regarding the extent of their use in low- and middle-income countries (LMICs), particularly at the primary care level. We performed a systematic review and meta-analysis of studies conducted in primary care in LMICs to estimate the prevalence of antibiotic prescriptions as well as the proportion of such prescriptions that are inappropriate.


Antimicrobial resistance (AMR) is a major health threat globally [1]. Growing morbidity and mortality rates due to resistant infections in humans are expected worldwide, along with a substantial economic impact in terms of productivity losses and healthcare expenditures [2,3].
Several factors are known to play a role in the development and spread of AMR, with inappropriate use of antibiotics being one of its most important drivers [4]. Gathering data about resistance as well as antibiotic use is 1 of the top 5 priorities of the Global Action Plan on Antimicrobial Resistance by the World Health Organization (WHO) [5].


The protocol for this systematic review was registered in the International Prospective Register of Systematic Reviews (PROSPERO) (identifier: CRD42019123269) and followed the PRISMA guidelines [13]. The PRISMA checklist and PROSPERO protocol are provided as S1 PRISMA Checklist and S1 PROSPERO Protocol.


To our knowledge, this is the first comprehensive analysis of antibiotic prescriptions in primary care in LMICs. We found that the proportion of patients seeking care for any reason who were prescribed antibiotics in this context often exceeded 50%. Although the interpretation of our pooled estimates is limited by the considerable between-study heterogeneity, values were quite consistent across settings. Available studies from LMICs often suffer from several methodological issues and report scanty details concerning patients’ clinical features that would help accurately judge the appropriateness of prescription. The number of health facilities involved in individual studies is often very small, particularly in low-income countries (a total of 13 facilities across 4 studies that reported this information), indicating major discrepancies in the quality of information among geographic areas. Although all included studies examined prescription data in primary care facilities, we recognize that primary care entails a wide range of facility types, each with its own peculiarities and challenges. This variegated scenario prevented us from conducting specific subgroup analyses that could inform targeted antibiotic stewardship strategies. Two studies, both conducted in an Iranian province, had a very large sample size because prescription details were captured through an electronic data collection system that is available nationwide. However, clinical information on patients receiving each prescription is much more challenging to obtain from this system, thus hindering a thorough assessment of inappropriate drug use.

Citation: Sulis G, Adam P, Nafade V, Gore G, Daniels B, Daftary A, et al. (2020) Antibiotic prescription practices in primary care in low- and middle-income countries: A systematic review and meta-analysis. PLoS Med 17(6): e1003139.

Academic Editor: Margaret E. Kruk, Harvard University, UNITED STATES

Received: January 28, 2020; Accepted: May 8, 2020; Published: June 16, 2020

Copyright: © 2020 Sulis et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the manuscript and its Supporting Information files.

Funding: The authors received no specific funding for this work.

Competing interests: I have read the journal's policy and the authors of this manuscript have the following competing interests: MP is a member of the Editorial Board of PLOS Medicine, and he co-edits the PLOS Tuberculosis Channel.

Abbreviations: AMR, antimicrobial resistance; AWaRe, Access, Watch, and Reserve; HIC, high-income country; LMICs, low- and middle-income countries; WHO, World Health Organization