Community antibiotic access, use, and reported impacts in sub-Saharan Africa: a systematic review.

OBJECTIVES: Antibiotic access is crucial for reducing infectious diseases, but in sub-Saharan Africa, poor regulation leads to inappropriate use and increased antimicrobial resistance. This review aimed to synthesise evidence on community-level antibiotic access, use, and the reported impacts associated with these practices across sub-Saharan Africa. METHODS: The review adhered to PRISMA guidelines. Searches were conducted in PubMed, Embase, and CINAHL for studies published between 1 January 2000 and 30 June 2025. Eligible studies examined antibiotic access, utilisation, or related impacts in community settings in sub-Saharan Africa. Data were extracted and thematically analysed across five dimensions of access, and related use outcomes were identified. Risk of bias was assessed using the quality assessment for diverse studies tool. KEY FINDINGS: Forty studies were included. Antibiotics are accessed through formal channels, healthcare facilities, and licensed pharmacies, and through informal sources, drug shops, and unauthorised vendors. Access was common in rural settings due to affordability and convenience. Contributing factors included limited enforcement of prescribing regulations, restricted availability of diagnostic tools, and market vulnerabilities. Stewardship interventions, audit and feedback, improved prescribing quality. Outcomes varied: access supported by diagnostic testing and supervised dosing improved treatment outcomes, childhood pneumonia, and maternal infections. In contrast, unregulated access was associated with treatment failure and increased risk of resistance, although evidence on community care pathways remained limited. CONCLUSIONS: Antibiotic access in sub-Saharan Africa is essential yet problematic. Sustained progress should integrate strategies that combine regulation, diagnostic support, stewardship, affordability measures, and surveillance. Additionally, research is needed to understand the link between community antibiotic use and trends in resistance.