## 4 Discussion
Nurses are competent in antibiotic drug administration and act as patient advocates to question the antibiotics being prescribed. While there were guidelines and consultations with other colleagues, the HCPs confirmed that other resources, such as improved laboratory services and an expanded workforce, would increase efficiency in the delivery of AMS roles. The HCPs recommended protocols and guidelines, more AMR training courses, improved laboratory and diagnostic services and availability of patient educational materials in order to support the delivery of AMS in the local hospital. All of these recommendations have also been identified in earlier studies as effective strategies for long-term sustenance of antibiotic stewardship programmes in LMICs [17; 18; 19]. The HCPs perceived that there is generally irrational overuse of antibiotics in Ghanaian hospitals, citing the broad-spectrum and empirical prescription of antibiotics. Factors contributing to the irrational use of antibiotics in Ghana include a lack of continuous AMR training, poor AMR knowledge, limited diagnostic services, understaffing and pressure from patients and pharmaceutical companies. This is consistent with other findings reported in Ghana [3; 20; 21]. Broad-spectrum antibiotics, including penicillin, cephalosporporins, aminoglycos and metronidazole zeolite, are commonly prescribed. Common indications for which antibiotics are prescribed include respiratory tract infections, UTIs, STIs and GIT infections. Others include typhoid and surgical prophylaxis. In the study hospital, antibiotics are prescribed in both branded and generic forms, but mostly as generics, and they are in the EML and hospital formulary. Similar indications for antibiotic use have previously been identified in Ghana [6; 9; 22; 23]. Presently, there are standard treatment guidelines in the hospital to guide antibiotic use. Most HCPs employ the use of guidelines as often as they need to when dispensing, prescribing or administering antibiotics. While patients can request antibiotics, they have no influence on the decisions on if they eventually get an antibiotic or which antibiotic should be prescribed for and dispensed to them. In addition to laboratory diagnostic reports, the following factors are considered in choosing antibiotics for a patient: the disease and its severity, the cost of the antibiotic and the availability. Our study had several limitations. First, only a small subset of HCPs from the study hospital were involved in the AMR training programme. The impact of the training would be more effective if a larger cohort had been trained. Secondly, while improvements to knowledge and awareness was assessed immediately after the training, we relied on self-reported changes in practice to assess the impact. This assessment may be subject to reporter bias [24]. However, a key strength of our approach was training those directly involved with antibiotic use within the study hospital, who could then lead a stewardship committee and champion the cause of rational antibiotic use. The findings of this work have several implications for practice and policies. Given the factors underpinning current antimicrobial use patterns, there is a need for dedicated AMS staff to promote and oversee AMS activities in the hospital. Routine training and AMR-focused workshops should be organised for healthcare providers to reinforce and sustain AMS practices. According to data from the GPPS results, local AMS policies should be developed to guide antimicrobial use in the local hospital context. National and international treatment guidelines should be adapted and tailored for relevance and use in the local settings. There is a need for further research to evaluate the impact of the AMS team on practice and to identify further parameters for long-term sustainability.