Impact of a clinical engagement targeted antimicrobial stewardship program on antimicrobial use in Pakistan: a multicenter longitudinal point prevalence survey

BACKGROUND Antimicrobial resistance is driven by excessive antibiotic use in hospitals, but evidence on the long-term effectiveness of antimicrobial stewardship interventions in public-sector hospitals in Pakistan is limited. We evaluated the impact of a structured clinical engagement AMS intervention affected antibiotic prescribing and stewardship in Pakistani public hospitals.METHODS A multicenter longitudinal study was conducted using serial WHO-standardized point prevalence surveys at baseline (February – March 2021), midline (July – August 2022), and endline (September – October 2023) across tertiary care public hospitals. Outcomes included antibiotic prescribing prevalence, guideline compliance, WHO AWaRe antibiotic distribution, microbiological practices, and institutional AMS capacity.RESULTS Across three survey rounds, 2,574 inpatients were assessed, and antibiotic use remained persistently high (78–80%). Guideline-concordant prescribing improved significantly (p < 0.0001), with modest increases in Access-category and reductions in Reserve-category antibiotics, while Watch-category antibiotics remained (~56%). Microbiological culture requests increased (p < 0.0001), but targeted therapy remained uncommon, with over 95% empirical prescribing. AMS infrastructure improved substantially, including the establishment of committees and the appointment of stewardship leadership.CONCLUSION Clinical engagement – based AMS improved institutional capacity and some prescribing indicators but did not reduce overall antibiotic exposure. Ongoing empirical prescribing due to diagnostic limitations and entrenched practices underscores the need for better microbiology and diagnostic support