## 3 Discussion  
The Point Prevalence Surveys presented provide key insights into antibiotic prescribing in selected public or not-for-profit hospitals across Ghana, Tanzania, Uganda, and Zambia. The overall prevalence of antimicrobial use was 50% (30-57%), with most antibiotics prescribed belonging to the WHO 'Access' and 'Watch' groups. No 'Reserve' category antibiotics were prescribed across the study sites; however, there were some prescriptions of 'Not Recommended' antibiotic combinations. While this pattern of antibiotic use may partly be due to the prescriber's consideration of optimality and potential for antimicrobial \begin{table}
\begin{tabular}{c c c c c c c c c c c c c c c c c c} \hline \hline \multicolumn{11}{c}{**Hospital**} \\ \hline  
\end{table} 
Table 7: AMS interventions at 16 of the 17 hospitals in response to the PPS carried out. resistance, in line with WHO's goal of improving antibiotic use through antimicrobial watershship [19], other authors suggest alternative reasoning [20; 21]. Antibiotic prescribing patterns were significantly associated with accessibility and affordability, with broad-spectrum antibiotics in the Access category being more readily available and affordable than antibiotics in the Watch and Reserve categories and the 'Not Recommended' group [20; 21]. A recent study on antibiotic availability and use in 20 low- and middle-income countries reported that the median proportion of facilities across countries with availability of Access category antibiotics was 89.5% [22]. [PERSON] et al. (2021) reported that low-income countries had the highest percentage of use of Access category antibiotics (63%), the lowest use of Watch category antibiotics (36%) and no Reserve category prescriptions on adult wards across 69 countries [23]. A PPS conducted across six referral hospitals in Tanzania also supports data presented in the current study, reporting 62% of prescriptions for in-patients being from the Access group [24]. In addition to availability and affordability, the similarity in prescription patterns across all four countries in the current study might be associated with the circulating bacterial strains and disease burden across low- and middle-income countries [6; 7; 25]. The WHO proposes that the AWaRe classification should support monitoring of antibiotic prescribing and inform AMS programmes and has the target that by 2023 at least 60% of national antibiotic consumption should come from the Access category [15]. In data presented here, 60% of the total of ATC J01 antibiotics prescribed in Ghana (1212/2071), 52% in Uganda (309/592), 58% in Zambia (201/347) and 59% in Tanzania (170/288) were in the Access category, demonstrating the hospitals' alignment with the WHO target for national antibiotic consumption. The antibiotics most commonly prescribed across hospitals in all four countries in the current study were metronidazolezole and ceftaxone, with metronidazolezole being the most prescribed antibiotic across Ghanaian hospitals. These findings are supported by data from the [PERSON] et al. study across 69 countries, where ceftaxone was the most commonly used antibiotic for therapeutic use on adult wards worldwide. In the same study, up to 24% of prescriptions for surgical prophylaxis in sub-Saharan Africa were for metronidazolezole, followed by ceftaxone (23%) [23]. A PPS carried at the Korle-Bu Teaching Hospital in Ghana (2018) reported metronidazolezole as the most frequently prescribed antibiotic, followed by amoxicillin-clavulanic acid, cephalospororus (ceftriaxone, cefuroxime), and coloxacillin [26]. A PPS in Kenya also recorded a higher use of nitroimidazoles compared to beta-lactam antibiotics [27]. Furthermore, a PPS in three hospitals in north-eastern Tanzania reported ceftaxone, metronidazolezole, and penicillin as the most prescribed antibiotics [28]. Metronidazolezole is effective in the treatment of a broad range of anaerobic infections which may be more common in African countries [29].