This study represents the first in Mozambique to assess the patterns of antibiotic use in hospitalized children in a quaternary care hospital, using the WHO AWaRe classification. The research findings show the worrying trend of inappropriate prescribing in the country. This puts an additional burden on patients, who are forced to bear the costs of this irrational prescribing.
In this study, it was noted that antibiotics were predominantly prescribed for children between 1 and 3 years of age (39.91%) and between 28 days and 12 months (37.07%). For children aged 28 days to 1 year, the most prescribed drugs were sulfamethoxazole and trimethoprim, crystallized penicillin, ceftriaxone, ampicillin, and gentamicin. On the other hand, for children aged 1 to 3 years, the most common were metronidazole, ampicillin, ceftriaxone, and gentamicin. These findings are aligned with another study conducted in pediatric patients from a hospital in Ghana, which also highlighted the frequency of gentamicin and ampicillin. In addition, ceftriaxone, gentamicin, ampicillin, crystallized penicillin, and metronidazole were the most prescribed antibiotics for both age groups [17]. In a study conducted in Ethiopia, a combination of ampicillin and gentamicin were prescribed for patients under one month of age, between one month and 1 and 5 years of age. A high prevalence of ceftriaxone was found in children aged 1 month to 1 year [18]. These studies present similar prescribing patterns for some specific reasons related to the context of sub-Saharan African countries.
In relation to the distribution of antibiotics according to specific diseases, in this study, it was observed that crystallized penicillin was more frequently prescribed for bronchopneumonia, followed by febrile seizures, malaria, and gastroenteritis. Sulfamethoxazole and trimethoprim were the most prescribed antibiotics for cases of gastroenteritis, while ceftriaxone was preferentially used to treat gastroenteritis, malaria, and febrile convulsions. Gentamicin was predominantly used in the treatment of bronchopneumonia and malaria. Other studies have revealed that ceftriaxone and gentamicin [17], as well as ceftriaxone and crystallized penicillin [18], were the most frequently prescribed antibiotics for bronchopneumonia. The danger of the irrational use of antibiotics is reflected in the future emergence of resistant bacteria [19]. One of the concepts of inappropriate antibiotic use is the inappropriate indication of these drugs, in our case, the use of antibiotics to treat malaria or gastroenteritis. The first condition is not caused by a bacterium. Gastroenteritis in most cases does not require treatment with antibiotics, since the infection is of viral origin and the disease is usually self-limiting, regardless of the causative pathogenic agent, requiring rehydration [20].
About the WHO AWaRe classification, in this study, 74.8% of the antibiotics prescribed belonged to the Access group, while 23.7% belonged to the Watch group. There were no prescriptions of antibiotics from the Reserve group. Among the antibiotics in the Access group, crystallized penicillin (155 prescriptions), sulfamethoxazole and trimethoprim (86 prescriptions), and gentamicin (52 prescriptions) were the most common. In the Watch group, ceftriaxone was the most prescribed antibiotic (95 prescriptions). A study conducted at a hospital in Okinawa, Japan, when comparing targeted therapy with empirical therapy, the categories were similar to the general results and aligned with the results found in this study, where most of the antibiotics prescribed were from the Access and Watch groups (more prevalent) [21]. Another study found greater use of antibiotics from the Watch group [22]. A study conducted in the Caribbean observed a high prevalence of the Access group (57.6 and 71.0%). There were no prescriptions of antibiotics from the Reserve group [23]. A study conducted in Zambia found a high prevalence of antibiotics from the Watch group, with ceftriaxone being the most prescribed [24]. In this study, the most prescribed antibiotic from the Watch group was ceftriaxone. Research conducted in China found similar results to those of Zambia. In this study, the most prescribed group was Watch, in which azithromycin and third-generation cephalosporins were the most common [25]. In Bangladesh, the most prescribed groups were Watch (64.0%), Access (35.6%), and the Reserve (0.1%). These studies portray a real-world and common scenario in these countries and highlight some unresolved issues about the pattern of antibiotic prescribing in pediatric and adult practice after the implementation of a national antimicrobial optimization strategy.
About the WHO/INRUD prescribing indicators, in this study, the average number of antibiotics per prescription was 1.51 (SD ± 0.725), with a maximum of 4 antibiotics per prescription. The percentage of antibiotic prescribing was 97.5%, with 96.20% by injection. All antibiotics prescribed were on the essential medicines list. Except for the average number of antibiotics per prescription, use of the essential medicines list, and prescription by the generic name of the same, other key indicators exceeded the values recommended by the WHO, suggesting inappropriate prescriptions in this study [16]. Similar results were found in studies such as Tanzania [26], Pakistan [16], and India [27]. Low results were observed in Saudi Arabia, where the average was 1.26, antibiotic prescription rate of 17.6%. Among antibiotic prescriptions, the percentage of injectable antibiotics was 15.2% [28]. Various factors can contribute to these varieties, for example, rates may be inflated due to lack of compliance of physicians with practice standards, or lack of hospital resources to confirm infections through cultures. In Saudi Arabia, the health sector is widely supported and funded by the government, thanks to the high economic revenues generated by the oil industry. They have the ability to request laboratory cultures and confirm any suspected microbe before prescribing antibiotics[29].
About the WHO AWaRe classification, in this study, 74.8% of the antibiotics prescribed belonged to the Access group, while 23.7% belonged to the Watch group. There were no prescriptions of antibiotics from the Reserve group. Among the antibiotics in the Access group, crystallized penicillin (155 prescriptions), sulfamethoxazole and trimethoprim (86 prescriptions), and gentamicin (52 prescriptions) were the most common. In the Watch group, ceftriaxone was the most prescribed antibiotic (95 prescriptions).
In the face of the growing challenge of antimicrobial resistance, it is imperative to strengthen antimicrobial optimization under government guidance. It is recommended to adopt the WHO AWaRe guidelines and indicators at all levels of health units, as essential tools for the effective management of antibiotics. All clinicians at all levels should be informed and trained about current antibiotic use scenarios and the importance of the AWaRe classification to limit the irrational use of these drugs in all units, especially government-run units. These parameters provide a fixed basis for monitoring, evaluating, and improving antibiotic use, crucial to preserving the effectiveness of treatments in a constantly evolving resistance landscape [25, 30].
The present study has some limitations. First, the study was conducted in a single quaternary care setting, and the results cannot be generalized to other types of settings or populations. Second, as a retrospective study, some prescriptions may have been omitted, although methods were applied to ensure sample representativeness. Some information was not collected as the study was based on medical record review. Despite these limitations, this study provides important information on the prescribing pattern in an important referral hospital in the region of the country.