This study aimed at determining the rationality of antibiotic prescriptions and associated in-patient treatment outcomes in children aged 2–59 months with severe pneumonia at Bwizibwera Health Center IV, Mbarara District in south-western Uganda from 1st May 2018 to 30th April 2019.
The 75.1% of irrational antibiotic prescriptions, this could be as a result of the indicators that were used to measure irrational antibiotic prescriptions in this study. This finding is higher than the 35.1% reported by a retrospective study conducted at Mekelle General Hospital, Ethiopia on irrational use of antibiotics in children [6]. The difference in the reported proportions of irrational antibiotic prescriptions might be due to the use of dissimilar indicators for classification of irrational prescriptions, and different study sites. The study by Sebsibie and Gultie [6] utilized antibiotic use indicators like percentage of antibiotics prescribed, frequency, route of administration, antibiotics prescribed from Standard treatment guideline, proportion of antibiotics, cost of antibiotics per antibiotics days, incidence and antibiotics utilization ratio while in the current study we looked at indication, regimen, dose, dose frequency route of administration and duration of treatment, in relation to the Uganda clinical guidelines [11].
In the previous studies slightly smaller percentages of irrational prescribing were reported in Mongolia (56.6%) and Turkey (56.5%) [7, 8]. These differences may have been due to studying only children below 5 years of age. The study by Remesh, Salim [9] showed that most of the prescribed antibiotics are inappropriately prescribed.
While this current study revealed a higher percentage (75.1 %) of irrational antibiotic prescription than the one reported in Kenya, probably because we focused on right regimen, duration of treatment and frequency of administration. A one year retrospective chart review in Kenya evaluated 394 cases and revealed inappropriate prescriptions with 33.4% treatment antibiotics and mean duration of antibiotic administration of 6 days [3]. This could be because their inappropriate antibiotic use focused on the choice, duration and indication of the antibiotics prescribed.
The findings from this study revealed that 24.9% of antibiotic prescriptions were rational. This was based on the right regimen, right duration and frequency of drug administration. The percentage of rational antibiotic prescriptions in the current study is lower than that reported by an earlier study in Tanzania. The study conducted in health care facilities in Tanzania showed that rational antibiotic prescribing was 44 % [12]. The difference in the reported percentage of rational prescriptions by the study in Tanzania and our study could have risen due to the fact that the Tanzanian study was a multi-center study and involved patients with several disease conditions other than just pneumonia.
Another study revealed that during patients’ hospital stay, up to 60% of the children received at least one antibiotic with a high appropriate use of antibiotics in children [13]. The high appropriate use of antibiotics reported by Herigon, Hersh [13] was not surprising since the study was conducted in a developed country with good health systems and adequate enforcement of health policies regarding appropriate antibiotic use.
A study conducted by Trap, Ladwar [14] in public health care facilities in Uganda reported that rational prescribing was 12.4%. This percentage of rational prescription is lower than the 24.9% revealed by the current study. The earlier study recorded, low use of generic names, over-use of antibiotics and low adherence to standard treatment guidelines [14]. The variation in percentage could be because this study looks at antibiotic prescription in one condition and in only one health facility, while Trap, Ladwar [14] looked at all levels of health care facilities in Uganda and the general performances in the country.
The study conducted in Kampala International University Teaching Hospital, Western Uganda on assessment of rational prescribing reported 61.88% of antibiotic prescriptions, and 78.96 % of all prescriptions were in line with the UCG 2016 and rational drug prescribing index of 4.85 [5]. Akunne, Lam [5] conducted their study in the general Outpatient department unlike in our study which was conduct among peadiatric in-patients.
In Turkey, the rate of appropriate antibiotic use was reported to be 11.3 % [15]. Compared to the current study which reports 24.9 % rational antibiotic prescriptions, Tunger and colleagues evaluated the rational antibiotic use and the impact of the implementation of a new restriction policy on the hospital wide use of antibiotics.
Our study used the Uganda clinical guide line and included children aged 2–59 months with pneumonia only. The difference in study settings could also explain the observed differences. In addition, we used a retrospective study design while they combined both retrospective and prospective study design [15].
The majority (73.7%) of those who received rational prescription were on treatment with a combination of benzyl penicillin plus gentamycin while the other 26.3% were on a combination of ampicillin plus gentamycin. These findings are consistent with the recommendations for treatment of severe pneumonia in children under 5 years [16].
All patients in this study received empirical antibiotics treatment but the empirical antibiotics therapy was not always given according to the recommended guideline, such as with the use of Ampicillin plus cloxacllin and Cotrimoxazole. Earlier studies found that despite the availability of treatment guidelines, Uganda’s health care system is still challenged with high rates of irrational antibiotic use [17–20]. The outcomes of antibiotic treatment were categorized into good and unfavorable in the current study. A child was considered to have a good outcome if he or she improved and was discharged home. Development of complications, referral to the hospital, death, and discharge on request were considered unfavorable outcomes.
The majority (95.6%) of children in the current study exhibited good outcomes following treatment irrespective of the rationality of a prescription. For those (4.4%) with unfavorable outcomes 2 died, 1 developed complication, 4 referred to hospital and 3 were discharged on request.
All the 57 (24.9%) patients who received rational antibiotic prescriptions had good outcomes, meaning they improved following treatment with the right regimen, administered at the right frequency and for the right duration and were discharged home. However, also the 162 patients who had irrational antibiotic prescription also had good outcomes.
In this study, the duration of hospitalization ranged from 1–13 days, the mean duration was 3days, the interquartile range of 2 days. However, Keng, Thallner [21] in their study reported a range of 1–33 days of hospitalization. Another study reported that improved use of antibiotics among hospitalized children can improve outcome by shortening length of stay [22]. In another study, the mean value of hospitalization length in children with prescribed antibiotic therapy was 5 days. The longest hospitalization length was 14 days, and the shortest hospitalization length was 3 days [23].
This study reported 2 deaths (20%), which is near to the study done in pediatric ward at Dr. Sardjito Hospital, Yogyakarta, Indonesia on the prevalence of irrational prescription and clinical outcomes in children with pneumonia which revealed that out of 46 children who met eligibility criteria, 13 (28.3%) used antibiotics irrationally and 7 (15.2%) died [4]. The Sardjito study reported that the majority of children were less than 1 year (54.3%) and 1-<5 years (39.1%), 50% were referred from other hospitals and 60.95 stayed in hospital for more than 7 days. The female to male ratio was 1:1 [4]. Looking at the current study children with unfavorable outcomes aged less than 1 year (70%) and 1-<5 years (30%); the female to male ratio was 1:1, which is similar to the findings by Yusuf, Murni [4]. This could be attributed to study design, they did a cross sectional study for 2 year versus one year retrospective in this study, although both studies obtained data from medical records.
In relation to age, majority of children aged 6–11 months 71(32.4%) had good outcomes. Similarly, they had high number of those with unfavorable outcome. Females had slightly better outcomes 114 (52.0%), compared to males. The majority (97.7%) of children with good outcomes were non referrals from lower health facilities.