Antibiotics are the most commonly prescribed drugs, and their use in the pediatric population is a huge concern in some countries (36,37). Today, antibiotic resistance is one of the biggest serious public health problems that has grown through the excessive and inappropriate use of antibiotics, both in humans and animals (38).
Description of antibiotics used
Studies have shown that antibiotics are more used among pediatric patients. This study found a higher prevalence (97.5%) of using these medications. This prevalence converges with that found by Abubakar, in a hospital in Nigeria (80.1%) and by Monteiro LGS et al., in two hospitals (Central and Geral) in Maputo (97.6%) (39,40). Very low prevalence (43.5%) was found by Wai et al., in a tertiary hospital in Malaysia (41). In this study, gastroenteritis (39.9%), pneumonia (21.8%) and malaria (9.1%) were the diagnoses for which antibiotics were commonly prescribed. Chaw et al., in their research, similarly evidenced that antibiotics have been prescribed to patients suffering from pneumonia (37.1%), followed by sepsis (14.1%) (42). Whereas, Monteiro LGS et al., identified that 100% of antibiotics were more prescribed for patients suffering from pneumonia, fevers, sepsis and gastroenteritis, while 97.8% for patients suffering from malaria (40). Regarding the most used dosage form, the research revealed more prescriptions for systemic antibiotics (95.5%). Labi et al., found a convergent frequency (83.5%) (43). Monteiro LGS et al., noted a very low frequency (52.9%) that the most used antibiotics were systemic (52.9%) (40), while Mgbahurike et al. observed a very high rate of oral antibiotics (86.3%) (44). Regarding the most used antibiotics, this study observed that crystallized penicillin (33.4%), ceftriaxone (20.5%), cotrimoxazole (18.5%) and gentamicin (11.2%) were the most used antibiotics. Muslim and Meinisasti found a convergent frequency of gentamicin (34.9%) and a divergent frequency of ampicillin (34.3%) (45). Labi et al., found a higher rate of use of ceftriaxone (80.5%), followed by of gentamicin (76.5%) (42), while Chaw et al. identified ampicillin (19.5%), followed by gentamicin (14.5%) and ceftriaxone (12.8%) as the most common antibiotics used (42,43). These antibiotic prescribing rates are alarming, being extremely high than those recommended By WHO, which recommends that frequency of antibiotic use in hospitals should be 20.0-26.8%, while injectables (systemic or parenteral) should be 13.4–24.1 % (46). This high use of antibiotics may be due to the range age of patients and the severity of infections and their clinical conditions. It could also be because of the country's limited resources. However, when antibiotics are used unnecessarily and excessively, they can provide a means for the development of antibiotic-resistant microorganisms, which can lead to ineffective treatment, recurrent infections, increased treatment costs or even worse, mortality.
Description of antibiotic use errors
This research observed 36.5% of medical prescriptions containing errors, with a total of 34.5% of antibiotics being improper prescribed. Iftikhar et al., and Denny et al., observed convergent rates of 40.8% and 22.9% improper prescriptions, respectively (47,48). A survey by Santander et al. found a convergent rate of 51.9 % of improper medical prescriptions, Okello et al., (68.4%) (49,50). In this research, 57.1%, 27.7%, 11.6% and 3.6% of the prescriptions presented a, two, three and four errors respectively. Iftikhar et al. found that 47.2% of prescriptions had an error, while 21.7% and 30.9% respectively had two and three or more prescription errors (47). The errors detected in this research were related to dosage (25.4%) and duration of treatment (74.6%). Fekadu et al. observed dosage (low doses = 27.1%, high doses = 7.03%), dosage (low = 20.54%, high = 3.78%) and duration of use (short duration = 13.51%, prolonged = 0.54%) were the most common errors (51). Shiva et al., observed dosage errors in less than 7% and prolonged duration in 25.6% (52). Oguz et al., found that 55.69% of antibiotics were prescribed less than necessary, (25.88%), route of administration (16.08%) and dosage errors (2.67%) (53). These results are alarming, since the inappropriate use of these drugs constitutes a main issue for the emergence, growth and dissemination of resistant microorganisms. Therefore, the high inappropriate use of antibiotics may be due to the careless or poor judgment of prescribers regarding the proper use (prescription) of these drugs, considering the characteristics of patients and guidelines.
Analysis to determine risk factors for inappropriate use of antibiotics
The study showed that patients prescribed ≥3 antibiotics per prescription are more likely (about 3 times more) to have some inappropriate use of antibiotics than those prescribed an antibiotic, and that patients with a short hospital stay have about 2 times more chances of experiencing some inappropriate use of antibiotics. Iftikhar et al., they found similar results that prescribing three antibiotics or more (OR = 1.7, 95% CI = 1.1–2.1, p-value = 0.020) is a greater risk factor for inappropriate use of antibiotics compared to patients prescribed one antibiotic by medical prescription and, in contrast, these authors found that long hospital stay (OR = 12.5, 95% CI = 10.1–17.6, p-value < 0.001) constitutes a risk factor for experiencing some incorrect use of antibiotics (47). Some reasons may lead prescribers to Recommend three or more antibiotics per prescription, such as an uncertain diagnosis due to the clinician's poor hability to differentiate viral from bacterial infections, non-compliance with guidelines, and poor practice of antibiotic prescribing principles. Meanwhile, the pressure exerted on physicians by family members and guardians of pediatric patients may be a reason for their short hospital stay. However, antibiotics are the widely prescribed therapeutic agents and their use in pediatrics is concern in some countries (54). Antimicrobial resistance is the biggest health problem especially in countries where resources are limited and levels of infectious diseases are high (42,55). The inappropriate use of this class of drugs is one of the major factors for the development of resistant microorganisms. Indeed, interventions on the use of these antibiotics in order to reduce their use taking into account this age group, consequently reducing antimicrobial resistance are necessary. These interventions aim to improve the appropriate use of antibiotics by promoting selection of the best therapeutic regimen, dose, duration of treatment and route of administration, obtaining better clinical results related to the use of antibiotics, reduction of adverse effects, such as toxicity or others, reduction of costs, and limit the selection of resistant microorganisms (54).