Discussion

This retrospective cross-sectional study explored AMS practices within the male medical wards of a major tertiary healthcare center in Nigeria. It assessed the use of process measures as an important AMS tool which plays a key role in curbing the threat of AMR.

Our findings demonstrate suboptimal adherence to AMS principles, which aligns with challenges commonly observed in LMIC settings. ^{Reference Harun, Sumon, Hasan, Akther, Islam and Anwar25} The high empirical prescribing rate (75.3%) highlights systemic and diagnostic limitations, including inadequate access to timely microbial culture testing and poor clinical documentation. This reliance on empirical therapy, coupled with the low rate of transition to definitive therapy based on culture results (24.7%), poses a substantial risk for treatment failures and the propagation of AMR. To support this finding, Alanazi et al. reported that limited adoption of antibiotic de-escalation was associated with increased antibiotic consumption, longer hospital stays, and higher costs, highlighting the importance of timely culture-guided adjustments. ^{Reference Alanazi, Almuhaya and Almohaimeed26}

In Figure 2, where diagnoses were highlighted, it is not surprising that prophylaxis emerged as the most frequent indication, as many other studies have reported similar findings. For instance, in a global pediatric survey, almost 29% of antibiotic prescriptions were for prophylaxis (primarily medical prophylaxis). ^{Reference Hufnagel, Versporten and Bielicki27} In a tertiary hospital in Malaysia, prophylactic use accounted for 11.5% of all prescriptions, more than any diagnosis-driven empiric therapy. ^{Reference Jamaluddin, Periyasamy and Lau28} PostCOVID-19 point-prevalence surveys in India and Pakistan also found prophylaxis rates ranging from 37% to 85%, especially in surgical settings. ^{Reference Sheikh, Vishwas and Aggarwal29} Prophylactic antibiotic use is a well-established practice, particularly in settings where the risk of hospital-acquired infections increases with length of stay. ^{Reference Hassan, Tuckman, Patrick, Kountz and Kohn30} However, while prophylaxis plays a valuable role in infection prevention, it must be applied judiciously and in line with clinical guidelines to avoid contributing to AMR. ^{Reference Ioannou, Karakonstantis and Schouten31}

The predominance of broad-spectrum antibiotics like ceftriaxone and metronidazole is influenced by the high rate of empirical antibiotic therapy, and as discussed, can worsen the emergence of AMR. These findings underscore the need for targeted interventions to promote narrower-spectrum agent use where appropriate, in line with international guidelines. ^32–34

Although our study showed that 77.5% of prescriptions had correct posology (dose, frequency, route), it remains essential that both prescribing and administration practices are rational and adhere strictly to established guidelines.

The observed low adherence to crucial process measures—such as poor documentation of indications for antibiotic use, infrequent conduct of 48-hour antibiotic time-outs (only 34.3%) and limited conversion from empirical to definitive therapy following microbial testing—indicates a significant gap in the implementation and monitoring of AMS activities. ^{Reference Sahota, Rajan and Comont35} These deficiencies, alongside the apparent lack of formal AMS oversight, are likely compounded by broader systemic barriers such as patients’ out-of-pocket payment models and intermittent antibiotic stock-outs, which discourage culture testing and continuity of therapy. Together, these factors contribute to irrational prescribing patterns and hinder efforts to optimize antibiotic use within the hospital. These findings are consistent with previous studies conducted in similar resource-constrained environments that highlight the widespread challenge of inappropriate antibiotic prescribing and poor adherence to stewardship guidelines. ^{Reference Kakkar, Shafiq and Singh36,Reference Guma, Godman, Campbell and Mahomed37}

While this study offers important insights, certain limitations should be considered when interpreting the findings. First, the sample size was smaller than the number estimated by the Kish formula, which may have reduced the representativeness and generalizability of the findings. Second, the study was restricted to male medical wards only. This decision reflected feasibility constraints during the COVID-19 period, when access to hospital records was already limited. While this focused approach provided valuable insights as a case study, it also limited the applicability of findings to other patient populations, such as female, pediatric, or surgical wards. Third, as a retrospective study, it relied heavily on the quality and completeness of patient medical records, which were sometimes inconsistent due to poor documentation. In addition, the data collection period (July 2019–July 2020) coincided with the early phase of the COVID-19 pandemic, which may have influenced healthcare practices and documentation due to activity restrictions. Gutema and Homa reported similar widespread disruptions to AMS and diagnostic activities during this period in African healthcare settings. ^{Reference Gutema and Homa38} Collectively, these limitations may impact the generalizability of our findings beyond the pandemic period and to other departments or hospitals without further investigation.

Despite these limitations, the study has notable strengths. First, by applying WHO-recommended process indicators, our findings can be directly compared with similar studies across LMICs, adding to the global evidence base. Second, it provides baseline institutional data for JUTH, which can inform tailored AMS interventions. To our knowledge, few Nigerian hospital studies have explicitly applied the WHO LMIC AMS process indicators; most prior work has used Global-PPS frameworks capturing related measures (eg, a multicenter PPS across northern Nigeria documented comparable process metrics). ^{Reference Abubakar39} Our study therefore adds ward-level detail and quantifies gaps in documentation, 48-hour reviews, and culture-guided therapy practices in a Nigerian tertiary hospital setting. Furthermore, the persistent challenges observed in the study reflect real systemic barriers to effective AMS implementation in LMIC hospitals and emphasize the urgent need for comprehensive AMS programs in this and other Nigerian hospitals.

Given the gaps observed in prescribing practices and stewardship processes, several critical steps are needed to foster rational antibiotic use and mitigate the rise in AMR. These include establishment of active multidisciplinary AMS committees, enhanced healthcare provider education, improved documentation standards (potentially leveraging digital solutions), and increasing the accessibility and affordability of microbial diagnostics. These measures have been found to improve patient outcomes and drive AMS, thereby contributing to curbing the spread of AMR. ^{Reference Abdel Hadi, Eltayeb, Al Balushi, Daghfal, Ahmed and Mateus40} Ultimately, the findings from this study should serve as a catalyst for institutional policy change, guiding the establishment of sustainable AMS structures, enhancing diagnostic capacity, and fostering accountability in antibiotic use across Nigerian tertiary hospitals. By addressing these gaps through structured AMS programs and stronger multidisciplinary engagement, hospitals like JUTH can not only optimize antibiotic use but also strengthen global efforts against AMR in resource-limited settings.