Point Prevalence Surveys of Antibiotic Prescribing in Children at a Tertiary Hospital in a resource constraint, low- income sub-Saharan African country.

doi:10.21203/rs.3.rs-2246440/v1

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Research Article

Point Prevalence Surveys of Antibiotic Prescribing in Children at a Tertiary Hospital in a resource constraint, low- income sub-Saharan African country.

https://doi.org/10.21203/rs.3.rs-2246440/v1

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Background

Antibiotic resistance has been widely described in children by various pathogens to multiple antibiotics, these have become a global health crisis and an emergency. Factors associated with antibiotic use are both community and hospital based as studies have reported increased use of antibiotics by parents and caregivers as well as health care providers This study aimed to describe prevalence rates of antibiotic prescribing and evaluate antibiotic prescribing practices as well as targets for improving the quality of antimicrobial prescribing in children over time.

Method

Point prevalence survey of antimicrobial use was performed yearly for 4 years to monitor trends in antimicrobial prescribing., Data from all patients admitted before 8 am on the day of the PPS were included. A web-based application designed by the University of Antwerp was used for data-entry, validation and analysis (http://www.global-pps.com).

Results

A total of 260 children including 90 (34.6%) neonates and 170 (65.4%) older children were admitted during the four surveys. Overall, 179 (68.8%) patients received at least one antibiotic. In neonates, the prevalence of antibiotic use increased from 78.9–89.5% but reduced from 100–58.8% in older children. There was a reduction in the use of antibiotics for prophylaxis from 45.7–24.6%. The most frequently prescribed antibiotic groups were third generation cephalosporins and aminoglycosides. The most common indication for antibiotic prescribing was sepsis in neonates and central nervous system infection in older children. The documentation of reason in notes increased from 33–100% while stop review date also increased from 19.4–82.1%.

Conclusion

The prevalence of antibiotic use was high with cephalosporins being the most prescribed antibiotic.

Antibiotic misuse and abuse have been a source of concern globally. While in the pre antibiotic era there was more emphasis on infection prevention, increased globalization, poor control and regulation and increased use have been associated with the advent of antibiotics, (1–4) An increase in defined daily dose (DDD) of antibiotics by 65% and increase antibiotic use by 39% with increased use of last resort antibiotics(5) was recorded globally between 2000 and 2005. The abuse of antibiotics has led to antibiotic resistance in almost all groups of antibiotics and new antibiotics to treat diseases are not rapidly being discovered compared to the rate of development of resistance.(6) The burden of antimicrobial resistance threat e (AMR) is now a global and should be considered as an re-emerging epidemic. It results in an overwhelming increase in economic cost for patients, hospitals and countries as well as increased mortality especially in low- and medium-income countries.(7, 8) Antimicrobial resistance (AMR) may not be totally eliminated; however, it can be reduced. (9)

Antibiotic resistance has been widely described in children with documented resistance by various organisms to multiple antibiotics including carbapenems.(10–18) These drug resistant strains have become global health crises and an emergency. Factors associated with antibiotic use are both community and hospitals based as studies have reported increased use of antibiotics by parents and caregivers as well as health care providers ((19–25). It is therefore imperative to monitor and control antibiotic prescribing to ensure judicious use, prevent resistance and reduce cost of healthcare. Strategies to achieve this would include development of national antibiotic policies, formation of antibiotic stewardship committees in hospitals and departmental levels and adherence to national antibiotic guidelines.

Point Prevalence Surveys (PPS) have been used to monitor antibiotic use and help evaluate, monitor and improve AMS program.((26, 27) Global PPS conducted in 41 countries, showed high rates of antibiotic prophylaxis use with two-third being for medical prophylaxis while a 15 year PPS in a paediatric hospital in Sweden showed a four-fold increase in total antibiotic prescriptions for prophylaxis without an increase in number of patients. In the United States of America, one of three children were on subnormal antibiotics with 50% not captured in stewardship programs (28–30)

Point prevalence surveys of antibiotic use in Nigeria has shown a high rate of antimicrobial prescribing (> 80%) in children, with more than 90% of antibiotics given by the intravenous route (31–33). There is an urgent need to implement antimicrobial stewardship program which has been shown to be very effective at reducing unnecessary antibiotic use, reducing morbidity and mortality and limiting the development of multidrug-resistant organisms (MDROs). (34, 35) This study aimed to describe the patterns of antibiotic use among children in Lagos Nigeria. The objectives wer

To describe prevalence rates and indications for of antibiotic prescribing for paediatric patients

To evaluate antibiotic prescriptions and

identify targets for improving the quality of antimicrobial prescribing

This was a cross sectional study conducted over a 4- year period in the Paediatrics department of the Lagos University Teaching Hospital located Lagos, Southwest Nigeria. The state is estimated to have a population of over 20 million with more than 50% within the paediatric age group and close to 5 million under-fives(36). The department has a bed capacity of 120, made up of two neonatal wards, three paediatric medical wards, and an emergency room. The neonatal unit has both the inborn (for the neonates delivered in the hospital) and out-born (neonates brought from outside the hospital) wards. The hospital participated global PPS in 2015 and in subsequent years 2017, 2018, 2019 with the paediatrics department involved.

The department of paediatrics has an antibiotic stewardship team (AST), formed in 2017. The team developed and updated its antibiotic guidelines which were circulated to all members of the department for review and the final document adopted after a presentation to the department. All prescribers were expected to adhere strictly to this guideline. Subsequent PPS was done to monitor trends in antimicrobial prescribing, and in all the surveys, data for all patients admitted before 8 am on the day of the PPS were included. Data obtained from the case notes were age, gender, weight, antimicrobial agent, indication for antibiotic type and duration of the antibiotics given, clinical diagnosis and microbiological data. Antibiotic quality indicators such as compliance with antibiotic guideline, documentations of reasons for antimicrobial prescription, as well as route of administration, stop and review date of prescription were also collected.

A web-based application was used for data-entry, validation and analysis as designed by the University of Antwerp (http://www.global-pps.com).

Data was entered into Microsoft excel sheets and analysed. Data was presented as percentages or proportions. Antibiotics prescribed were classified as ‘Access’, ‘Watch’, ‘Reserve’ or ‘Not recommended’ using the 2019 WHO AWaRe classification list(37) .

The chi square test for trend was used to assess differences in the prevalence of antibiotic prescription and differences in quality indicators over the three PPS. The level of statistical significance was set at p < 0.05.

Two hundred and sixty children including 90 (34.6%) neonates and 170 (65.4%) older children were admitted during the four surveys in 2015, 2017, 2018 and 2019. Overall, 179 (68.8%) patients received at least one antimicrobial on the day of the survey. These were 72.2% (65/90) of neonates and 67.1% (114/170) of older children. Table 1 provides the general patient characteristics, antimicrobial use for the survey periods. Prevalence of antimicrobial use generally decreased from 89.7% in 2015 to 65.5% in 2019 (p = 0.01). A total of 340 antimicrobials were prescribed during the four survey periods.

Neonates

As shown on Table 2, The prevalence of antibiotic use reduced from 78.9% in 2015 and then started to increase till 2019 (p = 0.001). Neonates treated with antibiotics were mostly admitted to the out born neonatal ward (63.2% − 84.2%). Figure 1 provides the antimicrobial prescribing rates for inborn and out born neonatal wards. In the inborn ward, prevalence of antimicrobial use was unstable but still lower compared with where rates were between 9.7 and 100% during the survey periods (p < 0.0001).

The three most administered antimicrobials were third generation cephalosporins, aminoglycosides and fluoroquinolones.

Figure 2 provides the proportion of total antibiotic in neonate according to the AWaRe classification. The overall Access/Watch ratio was 0.99 in 2015, 0.2 in 2017, 0.97 in 2018 and 0.72 in 2019

Antimicrobial Prophylaxis In Neonates

Table 2 provides the main reasons for antibiotic prophylaxis in neonates and children. The main diagnosis to prescribe antimicrobial prophylaxis neonates was medical prophylaxis for new-born risk

factors (decreased from 46.7% in 2015 to 21% in 2019) followed by medical prophylaxis for maternal risk factors (increased from 0 to 15.8%).

Combination antibiotics was prescribed for all neonates for the other years apart from 2017 (Table 2).

Most of the antibiotic combination was third generation cephalosporin and aminoglycoside (Fig. 3a).

Antimicrobial Therapy/treatment In Neonates

The common diagnoses for which therapeutic antimicrobials were given are shown in Table 3. The most common diagnosis was neonatal sepsis. Combination antibiotics was prescribed in 100% of neonates in 2015 and reduced to 80% in 2019 (Table 2). Most of the antibiotic combination was third generation cephalosporin and aminoglycoside. Figure 3b shows the common antibiotics prescribed for therapy in neonates.

Older Children

As shown on Table 4, the prevalence of antibiotic use decreased from 100% in 2015 to 58.8%% in 2019 (p = 0.004). The prevalence of antibiotic use decreased from 100–67.4% in the paediatric medical wards and from 100–44% in the paediatric surgical ward (p = 0.01) (Fig. 4). In 2015, 40% received antibiotics for prophylaxis and this decreased to 17.5% in 2019 while for antibiotic treatment, it increased from 50%% to 82.5% (Table 4). The three most administered antimicrobials during the four time periods were third generation cephalosporins, aminoglycosides and imidazole derivatives.

Figure 5 provides the proportion of total antibiotic use according to the AWaRe classification. The overall Access/Watch ratio was 0.48 in 2015, 0.67 in 2017, 0.67 in 2018 and 0.39 in 2019

Antimicrobial Prophylaxis In Older Children

Most of the older children received antibiotics for surgical prophylaxis (50% in 2015, 100% in 2017, 76.9% in 2018 and 85.7% in 2019). Third generation cephalosporins were the most used for monotherapy and third generation cephalosporin with metronidazole for combination therapy see Fig. 6a)

Antibiotic Treatment In Older Children

The common diagnoses for which therapeutic antimicrobials were given are shown in Table 5. The most common diagnosis was infection of the central nervous system followed by sepsis. Most of them received antibiotics for community acquired infections (80% in 2015, 54.5% in 2017, 88.9% in 2018 and 87.9% in 2019). The most prescribed antibiotics for treatment were third generation cephalosporins (Fig. 6b).

Use Of Quinolones

Table 6 shows the characteristics of patients prescribed fluroquinolones. Most of them were neonates. The commonest Indication in neonates was healthcare associated infection but for older children, it was community acquired infections. The rates of prescribing quinolones were 2.9% in 2015, 20.7% in 2017, 10.3% in 2018 and 21.1% in 2019. The most common diagnosis for prescribing it was sepsis in neonates. In 2018 and 2019, it was mostly as targeted therapy.

Table 1

General characteristics of the patients, antimicrobial use and healthcare associated infection (HAI) prevalence
Characteristic	2015(%)	2017 (%)	2018 (%)	2019 (%)
Number of inpatients	39	49	85	87
• Neonates	19(48.7)	19(38.8)	33(38.8)	19(21.8)
• Children > 1month	20 (51.3)	30(61.2)	52(61.2)	68(78.2)
Prevalence of antimicrobial use (	35(89.7)	29(59.2)	58(68.2)	57(65.5)
Gender
• Male	23	17	36	32
• Female	12	12	22	25
Number of prescribed antimicrobials	72	54	114	100
• Neonates	36 (50.0)	13 (24.1)	53 (46.5)	35 (35.0)
• Children > 1month	36 (50.0)	41 (75.9)	61 (53.5)	65 (65.0)
Parenteral therapy (per patient)	30 (85.7)	29 (100.0)	52 (89.7)	53 (93.0)
Multiple antimicrobial use (per patient)	25(71.4)	19 (65.5)	47 (81.0)	36 (63.2)
Antimicrobial prophylaxis	16/35 (45.7)	12/29 (41.4)	22/58 (37.9)	14/57 (24.6)
Patients treated with at least one HAI	5 (12.8)	9 (18.4)	15 (17.6)	10 (11.5)
Reason in notes	24(33%)	21(38.9%)	113(99.1%)	35(100%)
Stop/review date	14(19.4%)	2(3.7%)	105(82.1%)	70(70%)
Guideline missing	35 (100%)	29 (100%)	0	11 (19.3%)
Guideline compliance	0	0	56(96.5%)	36 (63.2%)
* Defined for patients treated with at least one antimicrobial

Table 2

General characteristics of the neonates, antimicrobial use and healthcare associated infection (HAI) prevalence
Characteristics	2015	2017	2018	2019
Number admitted	19	19	33	19
Prevalence of antibiotic use	15 (78.9%)	7 (36.8%)	26 (78.8%)	17 (89.5%)
Those treated with at least one HAI	3 (15.8%)	4 (21.1%)	12 (36.4%)	5 (26.3%)
Number of prescribed antimicrobials	36	13	53	35
Parenteral therapy (per child) *	15 (100%)	7 (100%)	26 (100%)	17 (100%)
Combination therapy (per child) *	15 (100%)	4 (57.1%)	22 (84.6%)	15 (88.2%)
Antibiotic prophylaxis	8 (53.3%)	1 (14.3%)	9 (34.6%)	7 (41.2%)
Monotherapy	0	1 (100%)	0	0
Combination therapy	8 (100%)	0	9 (100%)	7 (100%)
Antibiotic therapy	7 (46.7%)	6 (85.7%)	17 (65.4%)	10 (58.8%)
Monotherapy	0	2 (33.3%)	4 (23.5%)	2 (20%)
Combination therapy	7 (100%)	4 (66.7%)	13 (76.5%)	8 (80%)
SAP > 24hrs (per patient) *	0	0	0	0
Reason in notes	20 (55.6%)	2 (15.4%)	53 (100%)	35(100%)
Stop/review date	11 (30.6%)	0	47 (88.7%)	29(82.9%)
Guideline missing	15 (100%)	7 (100%)	0	0
Guideline compliance	0	0	26 (100%)	16 (94.1%)
* Analyses at patient level

Table 3

Diagnoses for the antimicrobials prescribed for the neonates
Diagnoses	2015 (N = 15)	2017 (N = 7)	2018 (N = 28)	2019 (N = 19)
Sepsis	5 (33.3%)	5 (71.4%)	12 (42.8%)	12 (63.2%)
CNS	0	0	3 (10.7%)	0
Pneu	1 (6.7%)	1 (14.3%)	1 (3.6%)	0
Intra-abdominal	1 (6.7%)	0	1 (3.6%)	0
SST	0	0	1 (3.6%)	0
Cardiovascular inf	0	0	1 (3.6%)	0
Neonatal – MP	7 (46.7%)	1 (14.3%)	8 (28.5%)	4 (21%)
MP – MAT	0	0	1 (3.6%)	3 (15.8%)
Proph CNS	1 (6,7%)	0	0	0

Neonates recorded with more than one diagnoses were counted by number of diagnosis. Patients not treated with antibiotics for systemic use, but who were treated with other antimicrobials (eg antimalarials) were not included.

CNS = Infection of central nervous system; Pneumonia = Pneumonia or lower respiratory tract infection; SST = Skin & Soft Tissue: Cellulitis, wound including surgical site infection, deep soft tissue not involving bone e.g., infected pressure or diabetic ulcer, abscess; Intra-abdominal = Intraabdominal sepsis including hepatobiliary, intra-abdominal abscess etc; Sepsis = sepsis, sepsis syndrome or septic shock with no clear anatomic site; Cardiovascular inf = Cardiovascular system infections: endocarditis, endovascular prosthesis or device e.g pacemaker, vascular graft; Neonatal – MP = Drug is used as Medical Prophylaxis for new-born risk factors e.g. VLBW (Very Low Birth Weight) and IUGR (Intrauterine Growth Restriction); MAT – MP = Drug is used as Medical Prophylaxis for maternal risk factors e.g. maternal prolonged rupture of membranes, Proph CNS = Prophylaxis for Central nervous system (neurosurgery, meningococcal);

Table 4 General characteristics of the older children, antimicrobial use and healthcare associated infection (HAI) prevalence

Characteristics	2015	2017	2018	2019
Number admitted	20	30	52	68
Prevalence of antibiotic use	20 (100%)	22(73.3%)	32(61.5%)	40(58.8%)
Those treated with at least one HAI	2 (10%)	5 (16.7%)	3 (5.8%)	5 (7.4%)
Number of prescribed antimicrobials	36	41	61	65
Parenteral therapy (per child)*	15 (75%)	22 (100%)	26 (81.3%)	36 (90%)
Combination therapy (per child)*	10 (50%))	15 (68.2%)	25 (78.1%)	21 (52.5%)
Antibiotic prophylaxis	8 (40%)	11 (50%)	13 (40.6%)	7 (17.5%)
Mono-therapy	4 (50%)	6 (54.5%)	4 (30.8%)	3 (42.9%)
Combination therapy	4 (50%)	5 (45.5%)	9 (69.2%)	4 (57.1%)
Antibiotic therapy	10 (50%)	11 (50%)	18 (56.3%)	33 (82.5%)
Monotherapy	5 (50%)	1 (9.1%)	3 (16.7%)	16 (48.5%)
Combination therapy	5 (50%)	10 (90.9%)	15 (83.3%)	17 (51.5%)
SAP > 24hrs (per patient)*	4 (100%)	11 (100%)	4 (40%)	6 (100%)
Reason in notes	4(11.2%)	19(46.3%)	60(98.4%)	65(100%)
Stop/review date	3(8.3%)	2(4.9%)	58(95.1%)	41(63.1%)
Guideline missing	20 (100%)	22 (100%)	0	9 (22.5%)
Guideline compliance	0	0	30 (93.8%)	20 (50%)
* Analyses at patient level

Table 5

Diagnoses for the antimicrobials prescribed for the older children
Diagnoses	2015 (N = 20)	2017 (N = 23)	2018 (N = 37)	2019 (N = 45)
CNS	4 (20%)	1 (4.3%)	6 (16.2%)	9 (20%)
ENT inf	0	0	0	1 (2.2%)
Bronchitis	0	0	1 (2.7%)	0
Tuberculosis	0	0	0	1 (2.2%)
Pneumonia	0	1 (4.3%)	3 (8.1%)	2 (4.4%)
Cardiovascular inf	0	0	1 (2.7%)	1 (2.2%)
GI infection	0	0	1 (2.7%)	2 (4.4%)
Intra-abdominal	0	4 (17.4%)	1 (2.7%)	0
SST	0	2 (8.7%	1 (2.7%)	2 (4.4%)
Bone/joint infection	3 (15%)	1 (4.3%)	3 (8.1%)	3 (6.7%)
Upper UTI	1 (5%)	0	1 (2.7%)	0
Cystitis	0	0	0	1 (2.2%)
Sepsis	3 (15%)	2 (8.7%)	1 (2.7%)	8 (17.8%)

Children recorded with more than one diagnoses were counted by amount of diagnosis. Patients not treated with antibiotics for systemic use, but who were treated with other antimicrobials (eg antimalarials) were not included.

CNS = Infection of central nervous system; Pneumonia = Pneumonia or lower respiratory tract infection; SST = Skin & Soft Tissue: Cellulitis, wound including surgical site infection, deep soft tissue not involving bone e.g., infected pressure or diabetic ulcer, abscess; Intra-abdominal = Intraabdominal sepsis including hepatobiliary, intra-abdominal abscess etc; Sepsis = sepsis, sepsis syndrome or septic shock with no clear anatomic site; Cardiovascular inf = Cardiovascular system infections: endocarditis, endovascular prosthesis or device such as pacemaker, vascular graft; Proph CNS = Prophylaxis for Central nervous system (neurosurgery, meningococcal); Bone/joint infection = Bone joint Infection: Septic arthritis (including prosthetic joint), osteomyelitis; Cystitis = lower urinary tract infection; Upper UTI = upper urinary tract infection including catheter related urinary tract infection, pyelonephritis; GI inf = GI infections (salmonellosis, Campylobacter, parasitic, C.difficile, etc.); Bronchitis = Acute Bronchitis or exacerbations of chronic bronchitis; ENT inf = Therapy for Ear, Nose, Throat infections including mouth, sinuses, larynx;.

Table 6 Characteristics of patients who were prescribed quinolones.

Characteristics	2015	2017	2018	2019
Quinolones prescribed per patient*	1/35 (2.9%)	6/29 (20.7%)	6/58 (10.3%)	11/57 (19.3%)
HAI⁺	0	3 (50%)	4 (66.7%)	5 (45.5%)
CAI⁺	1 (100%)	2 (33.3%)	1 (16.7%)	6 (54.5%)
Targeted therapy ⁺	0	0	3 (50%)	7 (63.6%)
Sepsis ⁺	0	3(50%))	3 (50%)	7 (50%)
Neonate
Quinolones prescribed per neonate*	0	3/7 (42.9%)	5/26 (19.2%)	7/17 (41.2%)
HAI⁺	0	2/3 (66.7%)	4/5 (80%)	4/7 (57.1%)
Targeted therapy ⁺	0	0	3/5 (60%)	5/7 (71.4%)
Child > 1 month
Quinolones prescribed per older child*	1/20 (5%)	3/22 (13.6%)	1/32 (3.1%)	4/40 (10%)
CAI⁺	1/1 (100%)	1/3 (33.3%)	1/1 (100%)	4/4 (100%)
Targeted therapy ⁺	0	0	0	2/4 (50%)
Total	36	41	61	65

HAI = Healthcare associated infection; CAI = Community acquired infection.

* Denominator is the number of patients, neonates or children who received at least one antimicrobial.

⁺ Denominator is the number of patients, neonates or children who were prescribed at least one quinolone.

Antimicrobial resistance can be curtailed when there is judicious and effective use of antibiotics. The Global PPS can be used to monitor rates of antimicrobial prescribing in hospitalized adults, children and neonates and identify targets to improve quality of antimicrobial use/prescribing (27, 32). The Global – PPS was used in this study to determine the rates of antibiotic use, antibiotic therapy and prophylaxis and patterns of antibiotic use over a period of four years from 2015 to 2019.

In this study, the overall prevalence of antibiotic use (AMU) in children (both neonates and older children) in this study was high, similar to other studies in Nigeria and Africa (32, 38), however, higher than published rates for Europe (39, 40). Therefore, if we are to gain meaningful control of antimicrobial use, we must focus on children, and neonates in particular.

The prevalence of AMU decreased significantly over the years from 89.7% in 2015 to 65.5% in 2019. This significant decrease was also observed in the older children from 100% in 2015 to 58.8%% in 2019. This must be due to the implementation of antimicrobial stewardship programme in the hospital with development of antibiotic guidelines in the department of Paediatrics. It was shown that there was compliance to the use of this guidelines which increased from 0–93% initially. However, the rate of antimicrobial use in neonates increased significantly from 78.9% in 2015 to 89.5% in 2019 and the increase was more in the inborn neonatal ward. The high rates, especially for medical prophylaxis may be attributed to the indication for use which was a diagnosis of sepsis in the newborn with a very a high likelihood of severe and life-threatening infections in neonates if not promptly and properly treated. Focussed research on the needs and outcomes of antibiotic prophylaxis in children especially neonates are needful for improved rational antibiotic prescribing. Worldwide, there is a high rate of use of antibiotics especially for prophylaxis in neonates hence the very high rates of antimicrobial use in the neonates are like other studies in Nigeria and Africa (32, 38).

The overall rate for antibiotic prophylaxis in the study significantly decreased from 2015 to 2019. This is attributed to more awareness and adherence to guideline (41, 42). All the antibiotic prophylaxes in neonates were combination therapies (except in 2017) which included a third-generation cephalosporin and an aminoglycoside, which contrasts with our local guideline recommendation of use of cephalosporin. WHO which recommends a penicillin and an aminoglycoside for sepsis prophylaxis in newborn (37, 43–45).

The most common diagnosis for treatment in neonates was neonatal sepsis. Antibiotic recommended in our guidelines for treatment of neonates was mainly combination therapy with a third-generation cephalosporin and an aminoglycoside. Our choice was based on local antibiogram. This is different from the WHO recommendation for treatment of neonatal sepsis, which is ampicillin and gentamicin, which is also the recommendation based on surveys of 56 paediatrics hospitals worldwide (44, 46). This has been the most common antibiotics prescribed for neonates in African hospitals (44, 45), and it reflects the resistance profile of relevant pathogens in our hospitals (47).

In the older children surveyed, the rate of antibiotic use for prophylaxis decreased significantly from 40–17.5% between 2015 and 2019. Most of antibiotic prophylaxis received were for surgical prophylaxis (50–100%). The use of third generation cephalosporins is at variance with both local and international guidelines. This use of ceftriaxone and other third generation of cephalosporin often in combination with metronidazole for more than 24 hours is in Nigeria and East Africa (48–50). This prolonged surgical prophylaxis with broad spectrum antibiotics can increase the risk of antibiotic resistance (48)Appropriate surgical antibiotic prophylaxis is potentially a low hanging fruit for improving quality of antimicrobial prescribing in children.

Central nervous system infection and sepsis remain very common life-threatening infections in children for which antibiotics are commonly prescribed (32, 44, 45).

The use of parenteral antimicrobial therapy was very high (> 85%) in all time periods and this was similar to rates documented studies in Nigeria East and South Asia, North America and Africa from the Global – PPS network (49, 51–53),. An AMS intervention using intravenous (IV) to oral antibiotic switch may be a low hanging fruit to consider in our hospital to reduce the high rate of parenteral therapy especially in the older children. The IV to oral switch for older children as a supplementary strategy can help to reduce length of hospital stay, cost of healthcare, staff workload and risk of catheter associated infections (26–28)

AWaRe antibiotics

The use of “Watch” antibiotics was high throughout the survey periods. This may be a reflection of high resistance rates to access antibiotics as shown by our antibiotic guidelines. Setting a target of 60% for access group antibiotics as recommended by WHO would require strengthening our AMS program to reverse the trend of irrational antibiotic use.

Noteworthy is the frequent use of quinolones in neonates in this study group. Quinolones are contraindicated in children except in shigellosis, salmonellosis, immunocompromised children with multidrug resistant organisms and where there are no other safe or effective antibiotics.(54–57) However, none of these diagnoses was made in the children in this study. Quinolone have been used extensively in other countries (55, 57–59), Use was documented in Asia and European even beyond the licensed indication for use (60, 61), while in Belgium it was found to be prescribed off label and did not follow bacteriological findings (55). Though contraindicated, reasons for use in children include local antibiogram results, poor response to other conventional antibiotics and studies showing the apparently less toxicity in human(57, 62)

As shown by the PPS, there was an increase in HAI rates in neonates from 15.8% in 2015 to 26.3% in 2019. To address this, a robust and sustained infection prevention and control programme within the hospital AMS program would be required. The affected neonates had to prolonged hospital stay, invasive procedures like insertion of central catheter and ventilatory support. These HAI rates are similar to rates found in Northern Nigeria 14.3% (63) implying these sustained IPC program is desirable in Nigeria so we can attain lower rates recorded in Ghana (8.2% ) (64) and USA (2.98–3.13%) (65).

Antimicrobial prescription rates generally reduced with the hospital antimicrobial stewardship program. However, there is still extensive use of antibiotics in our children with use of multiple antibiotics and reserve antibiotics with the major diagnosis being sepsis. Cephalosporin was the antibiotic most often prescribed. There is still need to continuously educate and train health care professionals on the use of the guidelines as well as the use of diagnostic test before commencement of antibiotics in order to avoid irrational use of antibiotics.

The authors declare that this work has not been submitted to another journal.

Consent for publication Not applicable.

Acknowledgement: Authors wish to acknowledge all staff of the paediatrics, doctors, nurses, and pharmacist for their cooperation during the data collection.

Ethical Approval

Ethical approval was obtained from the Lagos University Teaching Hospital (LUTH) Human Research and Ethics Committee (HREC). (ADM/DST/HREC/APP/045). This is an improvement project of the hospital and not an experimental study. The LUTH HREC waived informed consent, All methods were carried out in accordance with relevant guidance and regulations.

Competing interests

The authors declare that there is no competing interest.

Authors' contributions

O.O, P.O C. O, designed the initial concept. while O.O.I, O.O, P.O, C, O. A.R, collected the data.

P. A, and P.O, O.O, wrote up the introduction, tables, and discussion. P,A P.O, A.R, I.F, and E.T did the manuscript review.

All authors equally contributed to the review and editing of the final manuscript.

Source of Funding

The Global Point Prevalence Survey is coordinated by the University of Antwerp Belgium and sponsored through an unrestricted grant annually by bioMerieux. However, the participating hospitals did not receive any funding support directly.

Availability of data and materials

The datasets used and/or analysed during the current study will be available from the corresponding author on reasonable request

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Point Prevalence Surveys of Antibiotic Prescribing in Children at a Tertiary Hospital in a resource constraint, low- income sub-Saharan African country.

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Abstract

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Introduction

Materials And Methods

Results

Antimicrobial Prophylaxis In Neonates

Antimicrobial Therapy/treatment In Neonates

Older Children

Antimicrobial Prophylaxis In Older Children

Antibiotic Treatment In Older Children

Use Of Quinolones

Discussion

Conclusion

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References

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