Discussion

Antimicrobial resistance (AMR) remains a pressing global challenge, exacerbated by the overuse and misuse of antibiotics in both inpatient and outpatient settings. Low- and middle-income countries (LMICs) face disproportionate challenges due to limited resources, inadequate diagnostic capacities, and unregulated access to antibiotics. ^{Reference Murray2,Reference Pasquale, Trienski and Olexia6,Reference Ouedraogo, Pierre, Bañuls, Ouédraogo and Godreuil13,Reference Da, Somé and Carine14}

This first national Global-PPS in Burkina Faso revealed an alarmingly high prevalence of AMU, with 73.3% of hospitalized patients receiving at least one antimicrobial (69.7%–79.2% across facilities). These rates are more than double the global average (34.4%) and markedly higher than those in high-income countries (23.7%–62%) ^{Reference Versporten, Zarb and Caniaux3} and neighboring Ghana (55%), ^{Reference D’Arcy, Ashiru-Oredope and Olaoye9} though similar to Nigeria (70.7%) ^{Reference Umeokonkwo, Oduyebo and Fadeyi5} and parts of Asia (up to 85.7%). ^{Reference Versporten, Zarb and Caniaux3} These high AMU rates reflect systemic pressures, i.e, empirical treatment due to limited diagnostics, insufficiently trained personnel, and weak stewardship oversight, particularly in primary and secondary hospitals. These findings underscore the urgent need to strengthen hospital governance, prescriber education, and laboratory support to promote rational antibiotic use. ^{Reference Ouedraogo, Pierre, Bañuls, Ouédraogo and Godreuil13,Reference Sana, Kaboré, Ouédraogo, Traoré, Saybou, Saybou and Semdé15,Reference Yehouenou, Nagalo, Kabore and Ouedraogo16}

Most antibiotics (95.7%) targeted CAI infections, predominantly skin/soft-tissue (12.2%), gastrointestinal (10.7%), and pneumonia (10.4%). These findings mirror trends in Egypt ^{Reference Talaat, Saied and Kandeel17} and other LMICs, where CAIs dominate due to the burden of infectious diseases linked to poor sanitation and hygiene. ^{Reference Umeokonkwo, Oduyebo and Fadeyi5,Reference Ouedraogo, Pierre, Bañuls, Ouédraogo and Godreuil13} Parenteral administration was predominant, reflecting clinical habits common in resource-limited settings. ^{Reference D’Arcy, Ashiru-Oredope and Olaoye9}

Ceftriaxone, metronidazole, and gentamicin were the most frequently prescribed antibiotics, consistent with regional studies. ^{Reference Enimil, Agbedinu and Yeboah18,Reference Haseeb, Faidah and Algethamy19} Beta-lactams were the dominant class, as reported elsewhere, ^{Reference Versporten, Zarb and Caniaux3,Reference Umeokonkwo, Oduyebo and Fadeyi5,Reference D’Arcy, Ashiru-Oredope and Olaoye9,Reference Porto, Goossens, Versporten and Costa20,Reference Panditrao, Shafiq and Chatterjee21} though over-reliance on these drugs raises concern, given the rising resistance to third-generation cephalosporins. The heavy reliance on Watch-group antibiotics, such as ceftriaxone, despite national guidance restricting its use in primary care, reveals gaps in prescriber adherence and enforcement of stewardship policies. Encouragingly, Reserve-group antibiotics were rarely used, likely due to their high cost and limited availability in the absence of national health insurance. Strengthening regulatory enforcement and promoting adherence to national guidelines remain crucial to preserve antibiotic efficacy.

Quality indicators further revealed suboptimal prescribing practices: nearly all prescriptions lacked review or stop dates, and 15% lacked documented indications. Guideline compliance averaged only 40%, varying by hospital level. Interestingly, adherence tended to be higher in lower-level facilities. Variations across hospital levels may reflect differences in clinician experience and case complexity. While general practitioners in primary and secondary hospitals often rely more strictly on standard protocols, tertiary clinicians managing complex cases may deviate due to the lack of specialized local guidance.

A key barrier identified was the limited use of microbiological diagnostics, with 98.5% of prescriptions empirically based. Despite laboratory capacity in tertiary and some secondary hospitals, utilization remained low due to test costs, lack of insurance coverage, and frequent pretreatment with antibiotics that compromise culture results. To address this, the National AMR Action Plan (2024–2027) prioritizes upgrading laboratories, piloting microbiology units in primary care, and expanding the national AMR surveillance network from 15 to 26 sentinel sites. ²² These actions aim to enhance diagnostic-guided therapy and strengthen evidence-based stewardship. ^{Reference Ouedraogo, Pierre, Bañuls, Ouédraogo and Godreuil13,Reference Sana, Kaboré, Ouédraogo, Traoré, Saybou, Saybou and Semdé15,Reference Yehouenou, Nagalo, Kabore and Ouedraogo16}

Following this initial survey, several national AMS initiatives have been rolled out. These include the National Antibiotic Prescription Guideline (first released in 2021, revised in 2023), integrating WHO AWaRe principles, and the National Action Plan for Rational Antimicrobial Use in Hospitals. ^12,23 These guidelines have been tailored to local epidemiology and informed by data from the national laboratory-based AMR surveillance network. ²⁴ Prescribers from secondary and tertiary hospitals have received training on applying the national guidelines and integrating the AWaRe classification into their decision-making processes. Additionally, since 2017, an average of 500 healthcare professionals across Francophone West and Central Africa have been trained during an Inter-University Diploma course on AMR (www.diu-antibio.org/), organized annually by national universities and partners. Approximately half of these participants have come from all healthcare levels of the Burkinabe healthcare system, ensuring broad capacity building for evidence-based prescribing decisions. In parallel, Pharmaceutical and Therapeutic Committees have been institutionalized in all tertiary and secondary hospitals, some extending to primary care, to oversee AMS implementation and individualized drug dispensation. The national pharmaceutical regulatory authority now conducts annual antimicrobial consumption surveys to monitor progress. A second round of the Global-PPS is ongoing and will evaluate progress and guide corrective actions.

Implementation of the first PPS faced expected challenges. Initial apprehension among clinicians, concerned that results might expose poor practices, was mitigated by Ministry of Health endorsement and strong engagement of hospital managers. Mobilizing young general practitioners as data collectors and using the standardized Global-PPS online platform facilitated efficient data collection and validation. However, funding constraints limited geographic coverage and individualized feedback. Key findings were instead disseminated through quarterly national AMS meetings, ensuring that results informed national interventions.

Despite limitations, ie., non-random sampling, regional concentration, and inclusion of only ∼ 12% of national hospital beds, this survey provides baseline data for Burkina Faso’s AMS strategy. It has directly influenced policy design, stewardship training, and laboratory strengthening. Repeat PPS rounds, currently underway, will assess progress in stewardship implementation and identify persistent barriers to rational antibiotic use.

Overall, this first nationwide survey revealed extensive AMU in Burkinabe hospitals, largely empirical and driven by system-level constraints. Nonetheless, it has catalyzed policy reforms, guideline development, and stewardship actions that lay a foundation for sustained improvements in antimicrobial rationalization. Repeating the PPS will be essential to measure progress and ensure continued momentum toward responsible antibiotic use essential for long-term containment of AMR in Burkina Faso.