Dear Editor

Easy access to antibiotics without prescription is quietly undermining antimicrobial stewardship (AMS) in Somalia, accelerating antimicrobial resistance (AMR) before effective systems to monitor and contain it are fully established. AMR has become one of the greatest global public health threats, with an estimated 4.95 million deaths linked to bacterial AMR worldwide in 2019 and 1.27 million directly attributable to it.^{Reference Orisile, Lim, Naqvi and Amlogu1} Appropriate antibiotic use is fundamental to effective AMS, which the World Health Organization (WHO) recommends to optimize antimicrobial use through appropriate drug choice, dosage, and duration.^{Reference Orisile, Lim, Naqvi and Amlogu1} In Somalia, antibiotics are frequently available over the counter without a valid prescription, as pharmacies and informal drug vendors operate with minimal oversight.^{Reference Hassan, Mohamed Dirie, Ahmed and Omar2} Weak pharmaceutical regulation, limited access to qualified healthcare providers, and widespread self-medication contribute to inappropriate antibiotic use.^{Reference Hassan, Mohamed Dirie, Ahmed and Omar2,Reference Mohamed and Bashir3} Addressing over-the-counter antibiotic access is essential for protecting the effectiveness of existing antibiotics and strengthening Somalia’s health system, because antimicrobial stewardship cannot succeed while antibiotics remain easily accessible without adequate regulatory oversight.^{Reference Hassan, Osman and Mohamed4}

Over-the-counter antibiotic access represents a major public health and AMS challenge in Somalia because widespread self-medication, inappropriate antibiotic selection, incorrect dosing, and incomplete treatment courses are pervasive.^{Reference Mohamed and Bashir3} Community misconceptions regarding antibiotics are common, with many people not understanding that antibiotics are ineffective against viral infections or the importance of completing a full course of treatment.^{Reference Hassan, Mohamed Dirie, Ahmed and Omar2} Self-medication prevalence among Somali university students reaches 67%, with antibiotics used in 38% of cases.^{Reference Moalim, Dirie, Mohamoud, Hashi, Ali and Abubakar5} Diagnostic capacity is severely limited, forcing clinicians to rely on empirical treatment that is often inappropriate.^{Reference Hassan, Osman and Mohamed4} Weak enforcement of pharmaceutical regulations, informal medicine vendors, and ashortage of trained pharmacists compound these challenges.^{Reference Hassan, Mohamed Dirie, Ahmed and Omar2,Reference Hassan, Osman and Mohamed4} Somalia’s fragile health system, shaped by over three decades of civil conflict and political instability, together with humanitarian settings and internally displaced populations, creates a “perfect storm” for the emergence and spread of AMR.^{Reference Hassan, Osman and Mohamed4,Reference Jimale, Osman, Abdi, Adam and Moallim6} These factors contribute to treatment failure, prolonged illness, and the emergence of multidrug-resistant organisms.^{Reference Ndaki, Mwanga and Mushi7} Somalia ranks among the top 10 countries with the highest AMR-associated mortality rates globally, with near-total prevalence of methicillin-resistant Staphylococcus aureus at 97.4% and Acinetobacter baumannii exhibiting 100% resistance to carbapenems.^{Reference Hassan, Osman and Mohamed4} This increases healthcare costs, drives higher morbidity and mortality, reduces the effectiveness of essential antibiotics, and places a growing burden on Somalia’s healthcare system.^{Reference Orisile, Lim, Naqvi and Amlogu1,Reference Jimale, Osman, Abdi, Adam and Moallim6}

Practical and realistic recommendations begin with enforcing prescription-only antibiotic regulations and strengthening AMS programs, which Somalia must establish as no formally documented AMS programs exist to date.^{Reference Hassan, Osman and Mohamed4,Reference Jimale, Osman, Abdi, Adam and Moallim6} Improving pharmacy regulation and licensing, alongside pharmacist training and continuing professional education, is critical, as context-specific, economically viable, and enforceable AMS strategies are needed to empower all dispensers to serve as stewards of responsible antibiotic use.^{Reference Orisile, Lim, Naqvi and Amlogu1} Expanding diagnostic and microbiology laboratory capacity and establishing AMR surveillance are essential to create evidence-based local treatment guidelines.^{Reference Hassan, Osman and Mohamed4,Reference Jimale, Osman, Abdi, Adam and Moallim6} Public awareness campaigns on responsible antibiotic use are urgently needed to address community misconceptions and reduce harmful practices.^{Reference Hassan, Mohamed Dirie, Ahmed and Omar2,Reference Moalim, Dirie, Mohamoud, Hashi, Ali and Abubakar5} Integrating stewardship into primary healthcare and adopting a One Health collaboration involving human, animal, and environmental sectors are necessary, as Somalia requires a clearly articulated One Health approach.^{Reference Jimale, Osman, Abdi, Adam and Moallim6} Partnerships between the Ministry of Health, professional pharmacy associations, universities, WHO, and international partners can support these efforts.^{Reference Hassan, Mohamed Dirie, Ahmed and Omar2,Reference Jimale, Osman, Abdi, Adam and Moallim6} These interventions remain feasible, scalable, and cost-effective for fragile health systems such as Somalia, because context-adapted stewardship models that emphasize task shifting and hub-and-spoke approaches can maximize scarce resources.^{Reference Cohn, Mendelson, Kanj, Shafiq, Boszczowski and Laxminarayan8}

AMS begins with responsible antibiotic access, and preserving antibiotic effectiveness requires immediate regulatory action. Over-the-counter antibiotic sales threaten progress against AMR, and Somalia has an opportunity to strengthen stewardship before AMR becomes even more difficult to control.^{Reference Jimale, Osman, Abdi, Adam and Moallim6} Protecting antibiotics today safeguards future generations. Somalia’s fight against antimicrobial resistance will depend not only on expanding access to antibiotics when they are needed, but also on ensuring that every antibiotic is used responsibly, appropriately, and under effective stewardship.