Barriers and Facilitators to Antimicrobial Stewardship Implementation Across Healthcare Settings in Bangladesh: A Systematic Review

Background Antimicrobial resistance (AMR) causes 1.27 million deaths annually and is projected to kill 1.91 million people per year by 2050. Bangladesh recorded 26,200 AMR-attributable deaths in 2019, yet a persistent gap exists between its national policy frameworks and frontline antimicrobial stewardship (AMS) practice. This systematic review synthesises evidence on barriers, facilitators, and strategies relating to AMS implementation across healthcare settings in Bangladesh. Methods A systematic search of MEDLINE (PubMed), CINAHL, Scopus, Cochrane Library, and Google Scholar was conducted in August 2025 following PRISMA 2020 guidelines. The PEO (Population, Exposure, Outcome) framework guided eligibility criteria. Study quality was assessed using Critical Appraisal Skills Programme (CASP) checklists. Quantitative descriptive analysis and qualitative thematic analysis were applied for data synthesis. Results Fourteen studies encompassing 34,097 participants (33,538 patients and 559 healthcare professionals) were included. Major barriers identified included absence or weak enforcement of hospital AMS policies (n = 6 studies), entrenched empirical prescribing culture (n = 5), limited diagnostic and laboratory capacity (n = 4), and lack of dedicated AMS teams (n = 3). Key facilitators comprised antimicrobial surveillance systems (n = 6), training and education programmes (n = 5), and leadership commitment and governance (n = 3). Only 31% of prescriptions were culture-guided, and broad-spectrum antibiotic exposure exceeded 70% among hospitalised patients. No study reported a fully functioning, institutionalised AMS programme. Conclusions AMS implementation in Bangladesh remains fragmented, undermined by systemic infrastructure deficits and a persistent policy–practice gap. Training and education offer pragmatic entry points but cannot sustain change without concurrent institutionalisation of core stewardship strategies—audit and feedback, multidisciplinary teams, and formulary controls. Urgent investment in diagnostic capacity, surveillance infrastructure, and regulatory enforcement is needed to translate Bangladesh’s National Action Plan into sustainable clinical impact.