Table 3.

Challenges in implementing an antibiotic stewardship program in four countries or regions. AMR: antimicrobial resistance, ASP: antibiotic stewardship program, TrACSS: Tracking AMR Country Self-Assessment Survey, IPC: infection prevention and control, EML: essential medicine list, NA: not available. TrACSS Country Report grading: A: none, B: limited, C: developed, D: demonstrated, E: sustained

Country/Region	AMR burden	TrACSS 2022 Country reports [51]	Established antimicrobial stewardship program	Success	Challenges
Thailand	Estimated to cause 88,000 infections, 3.24 additional hospitalizations, and 38,000 deaths in 2010 (21)	Training and Education on AMR in human healthcare sector: C Monitoring antimicrobial consumption in human health C National surveillance system for AMR in human health: D IPC in human health: D Adoption of AWaRe classification into national EML: D [52]	National AMR Surveillance Centre founded in 1998 Additional antibiotics smart use program added in 2007 Antibiotic awareness day introduced 2013	80% of hospitals have an established ASP	Evaluation of effectiveness of ASP is ongoing
Japan	Disability-adjusted life years due to bloodstream infections caused by nine major antimicrobial-resistant bacteria: 195.2/100,000 population (2021) [53]	Training and Education on AMR in human healthcare sector: E Monitoring antimicrobial consumption in human health E National surveillance system for AMR in human health: E IPC in human health: E Adoption of AWaRe classification into national EML: NA [54]	Action plan on antimicrobial resistance introduced in 2016 Updated national action plan on antimicrobial resistance in 2023	Immediate effect seen on use of antimicrobials	No sustainable effect, despite ongoing downward trend in use of antimicrobials
South Africa	According to the Global Burden of Disease study, sub-Saharan Africa had the highest mortality (23.7 deaths per 100,000) attributable to AMR (5).	Training and Education on AMR in human healthcare sector: C Monitoring antimicrobial consumption in human health B National surveillance system for AMR in human health: D IPC in human health: B Adoption of AWaRe classification into national EML: B [55]	Antimicrobial resistance National Strategy Framework introduced in 2014 (2014–2024) Guidelines on Implementation of the Antimicrobial Strategy in South Africa: One Health Approach & Governance (February 2017) South African Antimicrobial Resistance National Strategy Framework; a one Heath approach (2018–2024): Guidelines for the Prevention and Containment of AMR in South African Hospitals: One Health Approach and Governance 2018	Ministerial Advisory Board for Antimicrobial Resistance has been appointed by the Minister of Health, in 2015. A nationwide surveillance of antimicrobial use by a web-based application.	South Africa’s national action plan against antibiotic resistant bacterial infections remains unfunded. The prevalence of infections caused by difficult-to-treat resistant Gram-negative bacteria (DTR-GNB) is rapidly increasing.
Latin America	Estimated to cause 338,000 deaths associated with and 84,300 deaths attributable to AMR in Latin America and the Caribbean (5).	NA	In 22 out of 33 countries in Latin America, 50% have not implemented an ASP yet, whereas in the other half, an ASP is currently being implemented.	Cost-effectiveness of ASP in Latin America are proven	Limited support by federal governments and local healthcare facility administrators to establish resources for ASP