Strengthening Antimicrobial Stewardship in Nigeria: Qualitative and Quantitative Insights into Barriers, Enablers, and Implementation Strategies (2015-2025).

BACKGROUND: Antimicrobial resistance is a critical global health threat. Nigeria faces particular challenges implementing antimicrobial stewardship (AMS) programs due to structural barriers and resource constraints. This review synthesizes evidence on barriers, facilitators, and strategies influencing AMS implementation in Nigerian healthcare facilities. METHODS: A systematic search of 6 databases (PubMed, Scopus, Web of Science, the Cochrane Library, CINAHL, and Google Scholar; 1 January 2015-31 December 2025) identified English-language studies reporting AMS implementation in Nigerian healthcare settings. Quality was assessed using Critical Appraisal Skills Program and Mixed Methods Appraisal Tool. Data were synthesized using narrative and thematic analysis. Frequencies are expressed as the number (and percentage) of the 10 included studies reporting each item (denominator = 10 studies), not as proportions of pooled participants. The review was registered with PROSPERO (CRD420251165641) and followed PRISMA 2020 guidelines. RESULTS: Ten studies (1343 participants) met the inclusion criteria. The most frequently reported barriers were insufficient training/knowledge (9/10, 90%), lack of guidelines and limited resources/funding (each 8/10, 80%), and poor surveillance systems (7/10, 70%). Leading facilitators were leadership support (8/10, 80%), multidisciplinary collaboration and education/training (each 7/10, 70%), and availability of guidelines (6/10, 60%). The most frequently reported implementation strategies were education and training (9/10, 90%), antibiotic-use audits and clinical-guideline development (each 8/10, 80%), and formulary restrictions/policies (7/10, 70%). CONCLUSIONS: This first Nigeria-specific systematic review identifies critical implementation gaps. Pharmacy-led, leadership-supported, and governance-embedded AMS programs show the greatest promise. Five evidence-based recommendations centered on policy reform, capacity building, diagnostic investment, AMS-Infection Prevention and Control integration, and sustainability planning are proposed.