## 3 Discussion  
We report our experience in establishing and operationalizing an AMS program in Sierra Leone to add to the evidence base in the global literature. The implementation and operationalization of an AMS program in hospitals of low-income countries is important because AMS activities are critical to the achievement of the United Nations Sustainable Development Goals (Targets 3.1 to 3.3 and 3.8, and Goal 6), especially those focused on reducing AMR [15]. This report of the activities, for the only existing hospital AMS program in Sierra Leone at the moment, showed that it is feasible to establish and implement an AMS program in low-income countries when there is support from the local human resources. An AMS program was previously set up in a rural hospital in Sierra Leone but it ceased to exist after the departure of the foreign experts who carried out its activities, demonstrating that a sustainable AMS program is the one that receives support from the local hospital structures [16]. \begin{table}
\begin{tabular}{c c c c c c} \hline \hline \multirow{2}{*}{**Variable**} & \multirow{2}{*}{**ATC Code**} & \multirow{2}{*}{
\begin{tabular}{c} **AWaRe** \\ **Category** \\ \end{tabular} } & \multicolumn{4}{c}{**Drug Administration**} \\ \cline{3-6}  & & & **Total** & **MW** & **SW** & **ICU** \\  & & & **_n_ (\%)_** & **_n_ (\%)_** & **_n_ (\%)_** & **_N_ (\%)_** \\ \hline Erythromycin & J01 FA01 & Watch & 2 (1.1) & - & 2 (1.8) & - \\ Flucloxacinillin & J01 CF05 & Access & 2 (1.1) & 2 (3.3) & - & - \\ Fluconazole & - & 2 (1.1) & 1 (1.7) & - & - \\ Gentamycin & J01 GB03 & Access & 2 (1.1) & - & 2 (1.8) & - \\ Levofloxacin & J01 MA12 & Watch & 4 (2.3) & 2 (3.3) & 2 (1.8) & - \\ Metronidazolezole & P01 AB01 & Access & 53 (30.3) & 9(15.5) & 43 (38.4) & 1 (33.3) \\ Ofloxacin & J01 MA01 & Watch & 1 (0.6) & - & 1 (1.7) & - \\ Piperacillin-tazobactam & J01 CR05 & Watch & 1 (0.6) & - & 1 (0.9) & - \\ TDF+3 TC+DTG & - & Watch & 1 (0.6) & 1 (1.7) & - & - \\ Tinidazole & P01 AB02 & Access & 22 (2.2) & 22 (7.3) & 1 (0.9) & - \\ Tinifloxacin & J01 RA13 & Access & 2 (0.2) & 2 (0.7) & - & - \\ Vanomycin & J01 XA01 & Watch & 1 (0.6) & - & 1 (0.9) & \\ \hline \hline \end{tabular}
\end{table} 
Table 2: _Cont._ \begin{table}
\begin{tabular}{c c c c c} \hline \hline \multirow{2}{*}{**Parameter**} & \multicolumn{2}{c}{**Indication for Antibiotic Prescription**} & \multirow{2}{*}{**aOR (95\% CI)**} & \multirow{2}{*}{**_p_**} \\ \cline{2-3} \cline{5-5}  & & **Yes (\%)** & **No (\%)** & \\ \hline Age \({}^{*}\) & 32 (20) & 38 (16) & 0.98 (0.96–1.01) & 0.221 \\ Sex & & & & \\ Male & 111 (73.5) & 13 (52) & 1 & - \\ Female & 40 (26.5) & 12 (48) & 0.28 (0.09–0.83) & 0.022 \\ Ward & & & & \\ Medical & 52 (34.4) & 8 (32) & 1 & - \\ Surgical & 96 (63.6) & 16 (64) & 0.47 (0.15–1.45) & 0.188 \\ ICU & 3 (2.0) & 1 (4) & 0.76 (0.06–9.47) & 0.829 \\ Reason in notes & & & \\ No & 43 (28.5) & 14 (56) & 1 & - \\ Yes & 108 (71.5) & 11 (44) & 3.78 (1.47–9.77) & 0.006 \\ Prescription based on lab. results & & & \\ No & 137 (90.7) & 20 (80) & & \\ Yes & 14 (9.3) & 5 (20) & 0.25 (0.07–0.91) & 0.035 \\ AWARe & & & & \\ Access & 73 (44.3) & 12 (48) & 1 & \\ Watch & 74 (49.0) & 9 (36) & 1.25 (0.46–3.38) & 0.658 \\ Not classified & 4 (2.7) & 4 (16) & 0.16 (0.03–0.84) & 0.031 \\ \hline \hline \end{tabular}  
* Reported as mean (standard deviation); ICU = intensive care unit.  
\end{table} 
Table 3: Multivariable regression of presence of prescription indication. Research from hospitals across Sierra Leone, including Connaught Hospital, found deep-rooted challenges not only in antimicrobial prescribing and antibiotic resistance, but also in IPC [17; 18; 19; 20; 21; 22]. This reinforces the fact that an AMS program should constitute a broad-based membership that includes IPC practitioners [23]. Furthermore, we reflect on the call in 2022 by the WHO Director-General to prioritize IPC as a key to health system strengthening and universal health coverage instrument and the idea that 'every infection prevented is an antibiotic resistance avoided' [24].