Patterns and contextual determinants of antibiotic prescribing for febrile under-five outpatients at primary and secondary healthcare facilities in Bugisu, Eastern Uganda

Abstract

Objectives To describe patterns and contextual determinants of antibiotic prescribing for febrile under-five outpatients at primary and secondary healthcare facilities across Bugisu, Eastern Uganda. Methods We surveyed 37 public and private-not-for-profit healthcare facilities and conducted a retrospective review of antimicrobial prescribing patterns among febrile under-five outpatients (with a focus on antibiotics) in 2019–20, based on outpatient registers. Multilevel logistic regression analysis was used to identify determinants of antibiotic prescribing at patient- and healthcare facility-levels. Results Antibiotics were prescribed for 62.2% of 3471 febrile under-five outpatients. There were a total of 2478 antibiotic prescriptions of 22 antibiotic types: amoxicillin (52.2%), co-trimoxazole (14.7%), metronidazole (6.9%), gentamicin (5.7%), ceftriaxone (5.3%), ampicillin/cloxacillin (3.6%), penicillin (3.1%), and others (8.6%). Acute upper respiratory tract infection (AURTI) was the commonest single indication for antibiotic prescribing, with 76.3% of children having AURTI as their only documented diagnosis receiving antibiotic prescriptions. Only 9.2% of children aged 2–59 months with non-severe pneumonia received antibiotic prescriptions in line with national guidelines. Higher health centre levels, and private-not-for-profit ownership (adjusted OR, 4.30; 95% CI, 1.91–9.72) were significant contextual determinants of antibiotic prescribing. Conclusions We demonstrated a high antibiotic prescribing prevalence among febrile under-five outpatients in Bugisu, Eastern Uganda, including prescriptions for co-trimoxazole and ampicillin/cloxacillin (which are not indicated in the management of the common causes of under-five febrile illness in Uganda). Study findings may be linked to limited diagnostic capacity and inadequate antibiotic availability, which require prioritization in interventions aimed at improving rational antibiotic prescribing among febrile under-five outpatients.

Impact of the Introduction of a Package of Diagnostic Tools, Diagnostic Algorithm, and Training and Communication on Outpatient Acute Fever Case Management at 3 Diverse Sites in Uganda: Results of a Randomized Controlled Trial

“…More amoxicillin was prescribed for intervention-arm patients, presumably due to algorithm guidance for respiratory syndromes. Antibiotic choice for empiric prescribing varied across sites, likely due to local availability, individual health facility and clinician preferences, as was seen in control arms in this study and in other studies in similar settings [ 14 , 30 ].…”

Modeling pediatric antibiotic use in an area of declining malaria prevalence

“…In parts of Sub-Saharan Africa, inappropriate antimicrobial use and over prescription is becoming a pressing issue, especially among children 2 – 4 , 27 . An antibiotic that is incorrectly dosed or inappropriately used can result in drug toxicity, delayed treatment of the actual infection, and, most concerningly, can contribute to the development of antibiotic resistances 7 .…”

“…In areas where malaria is endemic, the significant clinical overlap of non-specific symptoms that accompany malaria and non-malarial febrile illnesses (NMFIs) can make it challenging to differentiate between the two. Especially in severe cases where delays can result in long-term sequelae or mortality, treatment is often initiated before laboratory results are available and children with malaria can be treated, sometimes empirically, with antibiotics 2 – 4 . Antibiotics are not necessary for the treatment of uncomplicated malaria and are only recommended where a bacterial co-infection has been confirmed or a severe bacterial infection such as sepsis is suspected 5 , 6 .…”

A Narrative Review of Antibiotic Prescribing Practices in Primary Care Settings in South Africa and Potential Ways Forward to Reduce Antimicrobial Resistance

“…These concerns with the prescribing of antibiotics in South Africa are similar to those of a number of other African countries. Excessive and inappropriate prescribing of antibiotics is often seen in primary care among other African countries [49,64,[108][109][110][111], with associated cost and adverse reaction implications alongside increasing AMR [56,99,[112][113][114]. Encouragingly, the majority of antibiotics prescribed across both sectors in South Africa were typically from the 'Access' list rather than the 'Watch' list, with little or no prescribing of 'Reserve' antibiotics where the nature and content of prescriptions were documented (Tables 2 and 3).…”