Antibiotic Use Among Hospitalized Patients in Africa: A Systematic Review of Point Prevalence Studies

Antibiotic use and adherence to the WHO AWaRe guidelines across 16 hospitals in Zambia: a point prevalence survey

Background

The inappropriate use of antibiotics in hospitals contributes to the development and spread of antimicrobial resistance (AMR). This study evaluated the prevalence of antibiotic use and adherence to the World Health Organization (WHO) Access, Watch and Reserve (AWaRe) classification of antibiotics across 16 hospitals in Zambia.

Methods

A descriptive, cross-sectional study employing the WHO Point Prevalence Survey (PPS) methodology and WHO AWaRe classification of antibiotics was conducted among inpatients across 16 hospitals in December 2023, Zambia. Data analysis was performed using STATA version 17.0.

Results

Of the 1296 inpatients surveyed in the 16 hospitals, 56% were female, and 54% were aged between 16 and 50 years. The overall prevalence of antibiotic use was 70%. Additionally, 52% of the inpatients received Watch group antibiotics, with ceftriaxone being the most prescribed antibiotic. Slightly below half (48%) of the inpatients received Access group antibiotics. Compliance with the local treatment guidelines was 53%.

Conclusions

This study found a high prevalence of prescribing and use of antibiotics in hospitalized patients across the surveyed hospitals in Zambia. The high use of Watch group antibiotics was above the recommended threshold indicating non-adherence to the WHO AWaRe guidelines for antibiotic use. Hence, there is a need to establish and strengthen antimicrobial stewardship programmes that promote the rational use of antibiotics in hospitals in Zambia.

Surveillance of antimicrobial utilization in Africa: a systematic review and meta-analysis of prescription rates, indications, and quality of use from point prevalence surveys

BACKGROUND

Antimicrobial resistance (AMR) is a global public health concern that is fueled by the overuse of antimicrobial agents. Low- and middle-income countries, including those in Africa,. Point prevalence surveys (PPS) have been recognized as valuable tools for assessing antimicrobial utilization and guiding quality improvement initiatives. This systematic review and meta-analysis aimed to evaluate the prescription rates, indications, and quality of antimicrobial use in African health facilities.

METHODS

A comprehensive search was conducted in multiple databases, including PubMed, Scopus, Embase, Hinari (Research4Life) and Google Scholar. Studies reporting the point prevalence of antimicrobial prescription or use in healthcare settings using validated PPS tools were included. The quality of the studies was assessed using the Joanna Briggs Institute (JBI) critical appraisal checklist. A random-effects meta-analysis was conducted to combine the estimates. Heterogeneity was evaluated using Q statistics, I² statistics, meta-regression, and sensitivity analysis. Publication bias was assessed using a funnel plot and Egger's regression test, with a p-value of < 0.05 indicating the presence of bias.

RESULTS

Out of 1790 potential studies identified, 32 articles were included in the meta-analysis. The pooled prescription rate in acute care hospitals was 60%, with significant heterogeneity (I2 = 99%, p < 0.001). Therapeutic prescriptions constituted 62% of all the prescribed antimicrobials. Prescription quality varied: documentation of reasons in notes was 64%, targeted therapy was 10%, and parenteral prescriptions were 65%, with guideline compliance at 48%. Hospital-acquired infections comprised 20% of all prescriptions. Subgroup analyses revealed regional disparities in antimicrobial prescription prevalence, with Western Africa showing a prevalence of 65% and 44% in Southern Africa. Publication bias adjustment estimated the prescription rate at 54.8%, with sensitivity analysis confirming minor variances among studies.

CONCLUSION

This systematic review and meta-analysis provide valuable insights into antimicrobial utilization in African health facilities. The findings highlight the need for improved antimicrobial stewardship and infection control programs to address the high prevalence of irrational antimicrobial prescribing. The study emphasizes the importance of conducting regular surveillance through PPS to gather reliable data on antimicrobial usage, inform policy development, and monitor the effectiveness of interventions aimed at mitigating AMR.

An assessment of the index of rational drug prescribing for severe acute respiratory infections among hospitalised children in Northern Nigeria: a retrospective study

BACKGROUND

This study evaluated drug use pattern among hospitalized children with severe acute respiratory infection (SARI) in Nigeria.

RESEARCH DESIGN AND METHODS

A retrospective assessment of prescribed medicines for children aged 13 years and below who were admitted and treated for SARI from 1 January 2016 to 31 December 2018 was conducted. The WHO prescribing indicators and the Index of Rational Drug Prescribing were used to evaluate prescriptions.

RESULTS

A total of 259 patients were included, mostly diagnosed with bronchopneumonia (56%). A summary of WHO-core prescribing indicators showed the average number of drugs per encounter was 3.9, medicines prescribed by generic name was 82.1%, and an encounter with at least an antibiotic was 99.7%. The percentage of drugs prescribed from the Essential Medicine List for children was 79%. The most frequently prescribed pharmacological class of medicines was antibiotics (41.4%). Cephalosporins (40.0%), aminoglycosides (34.1%), and penicillins (21.5%) were the most commonly prescribed antibiotic classes. Gentamicin (34.1%) and cefuroxime (21.5%) were the most commonly prescribed antibiotics.

CONCLUSIONS

Drug prescribing for hospitalized children with SARI was suboptimal, especially with regard to polypharmacy, antibiotics, and injection use. Interventions to promote rational use of medicines including antimicrobial stewardship interventions are recommended.

Surgical Antibiotic Prophylaxis: A Proposal for a Global Evidence-Based Bundle

In the multimodal strategy context, to implement healthcare-associated infection prevention, bundles are one of the most commonly used methods to adapt guidelines in the local context and transfer best practices into routine clinical care. One of the most important measures to prevent surgical site infections is surgical antibiotic prophylaxis (SAP). This narrative review aims to present a bundle for the correct SAP administration and evaluate the evidence supporting it. Surgical site infection (SSI) prevention guidelines published by the WHO, CDC, NICE, and SHEA/IDSA/APIC/AHA, and the clinical practice guidelines for SAP by ASHP/IDSA/SIS/SHEA, were reviewed. Subsequently, comprehensive searches were also conducted using the PubMed®/MEDLINE and Google Scholar databases, in order to identify further supporting evidence-based documentation. The bundle includes five different measures that may affect proper SAP administration. The measures included may be easily implemented in all hospitals worldwide and are based on minimal drug pharmacokinetics and pharmacodynamics knowledge, which all surgeons should know. Antibiotics for SAP should be prescribed for surgical procedures at high risk for SSIs, such as clean-contaminated and contaminated surgical procedures or for clean surgical procedures where SSIs, even if unlikely, may have devastating consequences, such as in procedures with prosthetic implants. SAP should generally be administered within 60 min before the surgical incision for most antibiotics (including cefazolin). SAP redosing is indicated for surgical procedures exceeding two antibiotic half-lives or for procedures significantly associated with blood loss. In principle, SAP should be discontinued after the surgical procedure. Hospital-based antimicrobial stewardship programmes can optimise the treatment of infections and reduce adverse events associated with antibiotics. In the context of a collaborative and interdisciplinary approach, it is essential to encourage an institutional safety culture in which surgeons are persuaded, rather than compelled, to respect antibiotic prescribing practices. In that context, the proposed bundle contains a set of evidence-based interventions for SAP administration. It is easy to apply, promotes collaboration, and includes measures that can be adequately followed and evaluated in all hospitals worldwide.

Antibiotic use among hospitalised patients in Sierra Leone: a national point prevalence survey using the WHO survey methodology

OBJECTIVE

Inappropriate use of antibiotics is a major driver of antibiotic resistance. A few studies conducted in Africa have documented that about half of hospitalised patients who receive antibiotics should not have received them. A few hospital-based studies that have been conducted in Sierra Leone have documented a high usage of antibiotics in hospitals. Therefore, we conducted a nationwide point prevalence survey on antibiotic use among hospitalised patients in Sierra Leone.

DESIGN

We conducted a hospital-based, cross-sectional survey on the use of antibiotics using the WHO point prevalence survey methodology.

SETTING

The study was conducted in 26 public and private hospitals that are providing inpatient healthcare services.

PARTICIPANTS

All patients admitted to paediatric and adult inpatient wards before or at 08:00 on the survey date were enrolled.

OUTCOME MEASURES

Prevalence of antibiotic use, antibiotics Access, Watch and Reserve (AWaRe) categorisation, indication for antibiotic use prevalence and proportion of bacteria culture done.

RESULTS

Of the 1198 patient records reviewed, 883 (73.7%, 95% CI 71.1% to 76.2%) were on antibiotics. Antibiotic use was highest in the paediatric wards (306, 85.7%), followed by medical wards (158, 71.2%), surgical wards (146, 69.5%), mixed wards (97, 68.8%) and lowest in the obstetrics and gynaecology wards (176, 65.7%). The most widely prescribed antibiotics were metronidazole (404, 22.2%), ceftriaxone (373, 20.5%), ampicillin (337, 18.5%), gentamicin (221, 12.1%) and amoxicillin (90, 5.0%). Blood culture was only done for one patient and antibiotic treatments were given empirically. The most common indication for antibiotic use was community-acquired infection (484, 51.9%) followed by surgical prophylaxis (222, 23.8%).

CONCLUSION

There was high usage of antibiotics in hospitals in Sierra Leone as the majority of patients admitted received an antibiotic. This has the potential to increase the burden of antibiotic resistance in the country. We, therefore, recommend the establishment of hospital antimicrobial stewardship programmes according to the WHO core components.

Antibiotic prescribing to inpatients in Limpopo, South Africa: a multicentre point-prevalence survey

BACKGROUND

Electronic continuous surveillance databases are ideal for monitoring antibiotic use (ABU) in hospitalised patients for antibiotic stewardship programmes (ASP). However, such databases are scarce in low-resource settings. Point prevalence surveys (PPS) are viable alternatives. This report describes ABU and identifies ASP implementation improvement areas in Limpopo Province, South Africa.

METHODS

This cross-sectional descriptive study extracted patient-level ABU data from patients' files using a modified global PPS tool. Data were collected between September and November 2021 at five regional hospitals in Limpopo Province, South Africa. All patients in the wards before 8 a.m. on study days with an antibiotic prescription were included. Antibiotic use was stratified by Anatomic Therapeutic Chemical and Access, Watch, Reserve classifications and presented as frequencies and proportions with 95% confidence intervals (CI). Associations between categorical variables were assessed using the chi-square test. Cramér's V was used to assess the strength of these associations.

RESULTS

Of 804 inpatients surveyed, 261 (32.5%) (95% CI 29.2-35.7) were prescribed 416 antibiotics, 137 were female (52.5%) and 198 adults (75.9%). One hundred and twenty-two (46.7%) patients received one antibiotic, 47.5% (124/261) received two, and 5.7% (15/261) received three or more antibiotics. The intensive care units had a higher ABU (68.6%, 35/51) compared to medical (31.3%, 120/384) and surgical (28.5%, 105/369) wards (p = 0.005, Cramér's V = 0.2). Lower respiratory tract infection (27.4%, 104/379), skin and soft tissue infections (SST) (23.5%, 89/379), and obstetrics and gynaecology prophylaxis (14.0%, 53/379) were the common diagnoses for antibiotic prescriptions. The three most prescribed antibiotic classes were imidazoles (21.9%, 91/416), third-generation cephalosporins (20.7%, 86/416) and combination penicillin (18.5%, 79/416). Access antibiotics accounted for 70.2% (292/416) of prescriptions and Watch antibiotics for 29.6% (123/416) (p = 0.110, Cramér's V = 0.1). Reasons for prescribing and treatment plans were documented in 64.9% (270/416) (95% CI 60.3-69.5) and 21.4% (89/416) (95% CI 17.3-25.3) of prescriptions, respectively.

CONCLUSIONS

The study serves as a baseline for ABU surveillance at the five regional hospitals in Limpopo Province. Lack of documentation indicates poor prescribing practices; ASP should address gaps by deploying evidence-based, multifaceted and stepwise interventions.