Community Antimicrobial Stewardship: What Actually Works? (Education, Audit-Feedback, Dispensing Interventions) — A Systematic Review Focused on UK and Low- and Middle-Income Country (LMIC) Settings

Antimicrobial resistance (AMR) represents a paramount global health threat, responsible for millions of deaths annually and jeopardizing the foundations of modern medicine. Antimicrobial stewardship (AMS) programs are a critical strategy to combat this crisis, particularly in community settings where the majority of antimicrobials are consumed. This systematic review aims to critically evaluate and compare the evidence for the effectiveness of three core community AMS interventions—educational, audit-and-feedback, and dispensing-related—in two distinct contexts: The United Kingdom (UK) as a high-income country model, and Low- and Middle-Income Countries (LMICs). A systematic search of PubMed, Cochrane CENTRAL, and Embase was conducted for studies evaluating these interventions. The synthesis reveals that intervention effectiveness is profoundly context-dependent. In the UK, systematic, data-driven audit-and-feedback has proven highly effective in reducing antibiotic prescribing in primary care, complemented by structured, pharmacist-led dispensing interventions incentivized through national schemes. Conversely, broad educational campaigns have shown limited impact. In LMICs, multifaceted educational interventions that build foundational knowledge among a wide range of formal and informal healthcare providers are the most impactful strategy. Pharmacist-led audit-and-feedback shows promise but faces significant sustainability challenges. The community pharmacist emerges as a pivotal figure in both settings, though their role shifts from an optimizer within a regulated system in the UK to a primary point of care and de facto prescriber in many LMICs. The evidence base is limited by methodological heterogeneity and a lack of studies reporting on clinical and microbiological outcomes. Effective community AMS requires context-specific strategies that align with existing health system infrastructure, regulatory capacity, and human resources. Future research must prioritize rigorous, long-term studies evaluating the sustainability and clinical impact of AMS interventions to guide global policy.