Antimicrobial resistance (AMR) is a pressing global health and development crisis. Low- and middle-income countries (LMICs), like Bangladesh, are disproportionately affected due to the weak enforcement of antibiotic regulations, pluralistic healthcare systems, and limited access to healthcare facilities in a predominantly rural population. Contemporary studies highlight the limited judicious use of antibiotics, despite a higher density of pharmacies in rural areas of Bangladesh.

This study investigates the field-level dynamics of antibiotic regulation in Bangladesh and its role in fostering sustainable stewardship practices, emphasizing a bottom-up approach to regulation to complement traditional top-down mechanisms.

Employing a qualitative, case-oriented design, this study relies on both primary and secondary data. Primary data were collected through key informant interviews, focus group discussions, and semi-structured interviews with district drug inspectors, community members, and local pharmacists, supplemented by official reports.

The findings reveal a gap between policy and practice, driven by institutional inefficiencies, power dynamics, limited stakeholder engagement, and inadequate public awareness at the field level. Among community respondents, 47.06% reported using antibiotics in the last six months, with almost half engaging in self-medication, and 52% were unaware of the legal restrictions on antibiotic sales.

This study advocates for an integrated regulatory approach that fosters stakeholder participation, strengthens district-level regulatory capacity, and aligns antibiotic regulation with broader public health goals. Strengthening field-level regulation and bridging the gap between policy and practice is crucial to promoting sustainable and effective antibiotic stewardship in Bangladesh.