Economic Barriers to Antimicrobial Susceptibility Testing as a Structural Contributor to Antimicrobial Resistance in Low- and Middle-Income Countries: A Narrative Review.
- 1Department of Public Health, Faculty of Medicine and Health Sciences, Hormuud University, Mogadishu, Somalia.
- 2Department of Public Health, Ministry of Health and Human Services, Mogadishu, Somalia.
Abstract
Background
Bacterial antimicrobial resistance (AMR) was directly responsible for an estimated 1.27 million deaths in 2019, with the burden. Antimicrobial susceptibility testing (AST) is essential for guiding targeted therapy and stewardship, yet the specific economic mechanisms that prevent its scale-up in low-resource settings remain poorly understood and inadequately addressed in policy.Methods
A narrative review was conducted following SANRA guidelines and PRISMA transparency principles. PubMed/MEDLINE, Scopus, and Google Scholar were searched (01 January 2026-30 April 2026) using Boolean combinations of terms across three domains: AST and diagnostics; economic and health-system barriers; and AMR and stewardship. Studies published 2019-2026 addressing economic barriers to AST, prescribing behaviour, resistance patterns, or financing strategies in LMICs were eligible. Evidence was synthesized thematically.Findings
Economic barriers to AST operate at three levels: patient-level out-of-pocket costs and transport; laboratory-level infrastructure deficits, reagent shortages, and workforce gaps; and health-system-level underinvestment and donor dependency. These barriers sustain broad-spectrum empirical prescribing, amplify selection pressure, and drive the emergence of methicillin-resistant Staphylococcus aureus (MRSA), extended-spectrum β-lactamase (ESBL)-producing Enterobacterales, and carbapenem-resistant organisms. Consequences include treatment failure, catastrophic household expenditure, and threats to universal health coverage. Effective responses require subsidized diagnostics, insurance coverage for microbiology services, tiered laboratory strengthening, and integration of diagnostic stewardship with antimicrobial stewardship.Conclusion
Economic barriers to AST are a structural, multi-level contributor to AMR in LMICs. Sustainable AMR control requires financed national action plans that explicitly fund accessible, quality-assured AST alongside prescribing reform.
Related
- The Fleming Fund: Key Features of Design and Approach to Strengthening Antimicrobial Resistance Surveillance in Low- and Middle-Income Countries.
- Artificial Intelligence in the Fight Against Antimicrobial Resistance: Applications in Diagnosis, Susceptibility Prediction, Precision Dosing, and Antibiotic Discovery.
- Surveillance Data Use Through the Fleming Fund: Informing Action on Antimicrobial Resistance in Low- and Middle-Income Countries.
- High tetracycline and azithromycin resistance of Neisseria gonorrhoeae impacting treatment and doxyPEP use - antimicrobial susceptibility patterns of isolates from a prospective cohort of men who have sex with men in Wroclaw, Lower Silesia, Poland 2022-2024 - final report.
- Methicillin resistance and antimicrobial non-susceptibility trends among Staphylococcus aureus clinical isolates in Aseer, Saudi Arabia (2013–2024): A retrospective laboratory-based surveillance study
BibTeX
@article{abdi2026economic,
title = {{Economic Barriers to Antimicrobial Susceptibility Testing as a Structural Contributor to Antimicrobial Resistance in Low- and Middle-Income Countries: A Narrative Review.}},
author = {Yusuf Hared Abdi and Sharmake Gaiye Bashir and Shadia Mohamed Ali},
journal = {Infection and drug resistance},
year = {2026},
month = oct,
doi = {10.2147/idr.s639809},
url = {https://europepmc.org/article/MED/42909939},
note = {CC BY-NC},
}
RIS
TY - JOUR
TI - Economic Barriers to Antimicrobial Susceptibility Testing as a Structural Contributor to Antimicrobial Resistance in Low- and Middle-Income Countries: A Narrative Review.
AU - Yusuf Hared Abdi
AU - Sharmake Gaiye Bashir
AU - Shadia Mohamed Ali
PY - 2026
DA - 2026/10/17
JO - Infection and drug resistance
DO - 10.2147/idr.s639809
UR - https://europepmc.org/article/MED/42909939
AB - Background Bacterial antimicrobial resistance (AMR) was directly responsible for an estimated 1.27 million deaths in 2019, with the burden. Antimicrobial susceptibility testing (AST) is essential for guiding targeted therapy and stewardship, yet the specific economic mechanisms that prevent its scale-up in low-resource settings remain poorly understood and inadequately addressed in policy.Methods A narrative review was conducted following SANRA guidelines and PRISMA transparency principles. PubMed/MEDLINE, Scopus, and Google Scholar were searched (01 January 2026-30 April 2026) using Boolean combinations of terms across three domains: AST and diagnostics; economic and health-system barriers; and AMR and stewardship. Studies published 2019-2026 addressing economic barriers to AST, prescribing behaviour, resistance patterns, or financing strategies in LMICs were eligible. Evidence was synthesized thematically.Findings Economic barriers to AST operate at three levels: patient-level out-of-pocket costs and transport; laboratory-level infrastructure deficits, reagent shortages, and workforce gaps; and health-system-level underinvestment and donor dependency. These barriers sustain broad-spectrum empirical prescribing, amplify selection pressure, and drive the emergence of methicillin-resistant Staphylococcus aureus (MRSA), extended-spectrum β-lactamase (ESBL)-producing Enterobacterales, and carbapenem-resistant organisms. Consequences include treatment failure, catastrophic household expenditure, and threats to universal health coverage. Effective responses require subsidized diagnostics, insurance coverage for microbiology services, tiered laboratory strengthening, and integration of diagnostic stewardship with antimicrobial stewardship.Conclusion Economic barriers to AST are a structural, multi-level contributor to AMR in LMICs. Sustainable AMR control requires financed national action plans that explicitly fund accessible, quality-assured AST alongside prescribing reform.
SN - 1178-6973
ER -