Evaluating Antimicrobial Stewardship Deficits and WHO AWaRe Alignment in Conflict-Affected Tertiary Hospitals: A Quantitative Study from Sana’a, Yemen

Background The rapid rise of antimicrobial resistance is a critical global public health crisis, presenting severe challenges in fragile, conflict-affected healthcare systems. While antimicrobial stewardship programs optimize antibiotic use, the capacity for implementing these initiatives in Yemen remains deeply under-researched. This study evaluated inpatient antibiotic prescribing patterns, WHO Access, Watch, and Reserve (AWaRe) alignment, and chart documentation completeness across public and private tertiary hospitals in Sana’a, Yemen. Methods Across-sectional medical record audit was conducted across acute clinical departments Intensive Care Unit, Surgery, and Internal Medicine in one public (Hospital 1) and one private (Hospital 2) tertiary hospitals in Sana’a over a 12-month period (March 2025-March 2026). Systematic random sampling yielded 379 inpatient records evaluating 775 individual antibiotic prescriptions. Prescribed antibiotics were evaluated using the WHO AWaRe classification, diagnostic stewardship indicators, and documentation completeness. Results Prescribing was heavily dominated by Watch-group antibiotics (67.1%, n = 520/775), followed by Access (26.6%, n = 206/775) and Reserve agents (6.3%, n = 49/775). Ceftriaxone was the single most prescribed drug (27.7%, n = 215/775). Prescribing was overwhelmingly empirical (98.2%, n = 761/775), with documented microbiological culture or susceptibility results present in only 0.8% (n = 3/379) of patient records. Multi-drug exposure was high, with 64.4% of patients receiving two or more concurrent antimicrobials. While the private hospital achieved significantly higher chart documentation completeness than the public facility (93.9% vs. 27.3%, p < 0.001), AWaRe distribution and Watch-category reliance did not significantly differ between facilities (p = 0.395). Conclusion Inpatient antibiotic prescribing across tertiary hospitals in Sana’a is characterized by a heavy reliance on broad-spectrum Watch-category agents and near-total empirical treatment driven by severe diagnostic stewardship deficits. While electronic records improved documentation completeness, clinical prescribing practices remained unoptimized across both public and private sectors. Implementing routine diagnostic requisitions, local antibiograms, and structured stewardship policies is urgently needed to curb AMR in conflict-affected health systems.