## 3 Discussion
Consequently, we adopted a multidisciplinary approach in the selection of the AMS subcommittee members and in the implementation of the AMS activities, similar to the recommendations made by [PERSON] et al. [25]. Our AMS program is unique in that it operates within the remit of a broader IPC, WASH and AMS committee that interweaves IPC, WASH and AMS activities within an integrated framework at the hospital. Through this broader committee, the three subcommittees can share experiences, gain a better understanding of the operations of the different subcommittees, and generally improve the outcomes of their interventions. We developed policies, updated guidelines and trained healthcare workers to support the implementation of our AMS program. In his guide on how to start a hospital AMS program, [PERSON] recommends training and resource mobilization as part of the preparation for implementing AMS activities [23]. Our AMS program conducted a GPPS, which was critical in the external validation of our AMS experience, because it was easy to complete and the data collection software automatically generated a report which enabled comparison of antimicrobial prescribing at Connaught Hospital with other hospitals in the African continent and worldwide. In this hospital-wide GPPS, 56% of hospitalized patients were prescribed antibiotics, compared with 82% reported in 2017 [12]. The difference in the prevalence between the two studies could be attributed to the differences in the methods applied (point prevalence vs. period prevalence) and ongoing AMS activities or perhaps it could be due to the availability of more medical specialists to oversee antibiotic prescribing. Likewise, the departure of low-level medical staff known as community health officers (CHOs) who historically prescribed large quantities of antibiotics in the emergency department of Connaught Hospital could explain the difference in prevalence between the two studies. Yet, this prevalence of 56% is still higher than the African average of 42% [26]. In addition, antibiotic use remained higher among inpatients in adult surgical wards (69.6%) compared with adult medical wards (51.9%). This discrepancy may be related to the surgical team's concern about poor IPC and environmental conditions in the wards or operating theatres leading to unnecessary and prolonged use of prophylactic antibiotics. We join the call to reshape the global health architecture to reduce reliance on the use of antibiotics for patient care and encourage non-medicinal care, such as providing supports to patients and addressing their concerns [27]. Combined with the results of a previous study, this point prevalence survey showed an ongoing high rate of antibiotic use among surgical patients and provided the stimulus for reviewing and updating guidelines for antibiotic prophylaxis in surgery [13]. We believe that the inappropriate use of antibiotics in the surgical wards will reduce with the implementation of targeted AMS activities. Although no Reserve antibiotics were prescribed in this study, which may reflect unavailability, the prescription of non-antibacterial agents such artesunate and acyclovir without documented indication calls for expanded stewardship activities. Our AMS program is not without challenges or limitations. One of the main challenges in the implementation of the AMS program is the unavailability of financial support from local sources as the Government of Sierra Leone does not provide specific budgetary support for AMS activities. As shown by GPPS, less than 11% of antibiotic prescriptions were supported by microbiology or other laboratory tests, showing the hospital's limited laboratory capacity to support AMS activities. Owing to the funder's requirements, focused primarily on pharmacists, we could not directly fulfil the multidisciplinary principles of AMS in our AMS champion training program.