Inventory of Survey Instruments for Monitoring Antimicrobial Use in Primary Care Settings in Low- and Middle-Income Countries: A Narrative Review

TL;DR

This paper reviews survey tools used to track antimicrobial use in primary care in low- and middle-income countries, highlighting gaps and suggesting improvements.

Contribution

The paper provides a comprehensive inventory and analysis of survey instruments for antimicrobial use monitoring in primary care in LMICs.

Findings

42 survey instruments were identified, mostly post-2000, covering multiple countries and regions.

Most surveys focused on antibiotics, used paper-based methods, and rarely included AWaRe classification.

Many tools lacked implementation protocols or analytic support, limiting their effectiveness.

Abstract

Background: Over 80–90% of antimicrobial use occurs in primary health care, underscoring the need for specific data from this sector to inform practices and interventions to improve antimicrobial use. This study aimed to identify a wide range of research instruments in primary health care and qualitatively describe their structure, scope, and content. Methods: For the narrative review, we reviewed Medline (inception–November 2023) and agency/network websites to identify surveys on antimicrobial use prevalence in LMIC primary care. We applied no language restrictions and extracted survey instruments from publications or requested them from authors when unavailable. Results: We identified 450 studies and extracted 42 survey instruments issued between 1993 and 2023, all but one post-2000. These covered both multi-country (16.7%) and country-specific implementations across all WHO regions. Sampling units included households/consumers (24/42, 57.2%), health professionals (14/42, 33.3%), drug sellers (3/42, 7.1%), and bulk sales data (1/42, 2.4%). Surveys typically captured antimicrobial type, prescription status, and reason for use; AWaRe classification was mentioned only once. We found 13 stand-alone protocols on antimicrobial use and 4 on general medicine use. Conclusions: We identified diverse tools for measuring antimicrobial use in LMICs, though many lacked protocols or analytic support. Surveys often focused solely on antibiotics, used paper-based methods, and rarely referenced the AWaRe classification. Future efforts should broaden the scope beyond antibiotics, leverage digital data systems, include implementation protocols and analytic tools, report standardized indicators, and adopt AWaRe-related variables as a core criterion to strengthen AMU monitoring in PHC.

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