Current Antibiotic Use Among Hospitals in the sub-Saharan Africa Region; Findings and Implications

Figures & data

Table 1 Findings from Point Prevalence Studies on Antibiotic Use

Study	Findings
Abubakar 2020,^Citation31 Nigeria (3 hospitals) A teaching hospital and two general hospitals approximately 850 beds in each, 321 patients	Antibiotic use prevalence was 80.1% Most of the patients surveyed had two antibiotic agents Community-acquired infections (38.7%) and surgical prophylaxis (22.5%) were the most common indications Antibiotic prescribing for surgical prophylaxis was for more than 24 hours in all cases 56% of the antibiotic prescriptions were intravenous Documentation for antibiotic use was recorded in 75.8% of the cases The most prescribed classes of antibiotic were nitroimidazoles (28.5%), third-generation cephalosporins (18.9%), and fluoroquinolones (13.6%)
Afriyie et al 2020,^Citation10 Ghana (2 hospitals) Keta Municipal Hospital (KMH), a 110 bed capacity Ghana Police Hospital (GPH), a 100 bed hospital	The prevalence of antibiotic use was 65.0% in GPH and 82.0% in KMH Penicillins and other b-lactam antibiotics were the most frequently prescribed in both hospitals, with third-generation cephalosporins mainly used in GPH Antibiotic treatment was mainly empiric and commonly administered intravenously; duration was generally short with timely oral switching There was good documentation of the indications for antibiotic use in both hospitals 50.0–66.7% guideline compliance (although for many indications no guideline existed) Almost all prescribed antibiotics had stop dates and no missed doses No treatment was based on microbiology data in GPH and it was only used for one patient in KMH (2.2%) Duration of use for surgical prophylaxis was generally more than one day (69.0% in GPH and 77.0% in KMH)
Anand Paramadhas et al 2019,^Citation41 Botswana (10 Hospitals) All hospital sectors, 773 inpatients. 4991 total beds	Antibiotic use prevalence 70.6% Cefotaxime and amoxicillin were the most commonly prescribed antibiotics Use of intravenous antibiotics was quite prevalent The duration of surgical prophylaxis also varied. This was typically greater than one day across the surveyed facilities Culture and sensitivity tests were rarely ordered, with most being requested in the specialist and primary hospitals Botswana essential medicines list and guidelines were routinely updated, but not all hospitals had them available for use and decision support tools such as the antibiogram were generally unavailable to guide empiric antibiotic use across hospitals
Bediako-Bowan et al 2019,^Citation44 Ghana (10 hospitals) 4208 total bed capacity. 540 admitted patients	Antibiotic use prevalence, 70.7% Average number of antibiotics, 1.66 Surgical prophylaxis was administered for longer than the recommended one day in 107 of 144 (88.4%) patients. Only 3.7% of patients had microbiological analysis done on clinical samples Frequently prescribed antibiotics were nitroimidazoles, 2nd and 3rd generations cephalosporins, β-lactam/βlactamase inhibitors, fluoroquinolones and lincosamides Patients were prescribed antibiotics for treatment of infections or for prophylaxis, and for 14 patients there were no recorded reason for antibiotic therapy The contribution of surgical prophylaxis to the total antibiotic usage was 32%. For surgical prophylaxis, 88.4% of the patients received antibiotics for more than one day Antibiotics were administered mostly intravenously (54%)
Chijioke et al 2016,^Citation49 Nigeria (9 hospitals) 1585 of all admitted patients	Antibiotic use prevalence, 55.9% Most of the patients (61.9%) received combination therapy Most of the patients were prescribed penicillins
Dlamini et al 2019,^Citation30 South Africa (1 Hospital) 1650-bed hospital, 512 inpatients	Antibiotic use prevalence, 37.7% Beta lactamase inhibitors and antimicrobials for tuberculosis were the most prevalent antimicrobials 98% of antimicrobials prescribed were contained within the current essential medicines list/standard treatment guidelines 46% of patients were on intravenous antibiotics Lack of intravenous to oral switch even though some patients appeared to be suitable candidates based on their notes, 37% of patients’ files, culture and sensitivity tests results were recorded. 17 antimicrobials (5.6%) had no defined infection site for their use documented in the patient records with no evidence of infection and in 5.2% of occasions antibiotics were prescribed other than for treatment
Fowotade et al 2020,^Citation40 Nigeria (1 hospitals) 850 bed capacity hospital, 451 inpatients	Antibiotic prevalence was at 59.6% Most prescribed antibiotics were, Cephalosporins, followed by penicillins and fluoroquinolones 69.9% of the patients were on intravenous antibiotics Only 21.3% of all antibiotics had documented stop and review date 100% of all surgical prophylaxis antibiotics were given for more than one day Reason for antibiotic use was recorded in 92.4% of cases Targeted therapy was only in 6.35 of cases and 93.7% cases were treated empirically Use of biomarkers was only in 2.2% of the patients No compliance to antibiotic guidelines exacerbated by no local antibiotic guidelines
Horumpende et al 2020,^Citation33 Tanzania (3 hospitals) 1 tertiary hospital, 1 regional and district hospital with 640, 300 and 100 bed capacity, respectively. 399 patients	Overall, prevalence of antibiotic use was 38% at Kilimanjaro Christian Medical Centre, 59% in Mawenzi and 63% in St. Joseph. Ceftriaxone (n = 94; 28.5%), metronidazole (n = 79, 23.9%) and penicillins (n = 89; 26.9%) were the most commonly Indications for antibiotics were treatment of a community acquired infection (n = 79; 42%), an acute hospital acquired infection (n = 19; 10%), surgical prophylaxis (n = 57; 30%) or medical prophylaxis (n = 1; 0.5%) and unknown reason (n = 21; 11%) All patients except one received multiple doses of antibiotics and surgical prophylaxis was continued >3 days in more than half of patients Overall, 36% of the antibiotics were given to cases in whom a bacterial infection was deemed unlikely Biomarkers of inflammation, relevant radiology or a microbiology test were performed, respectively, in 13 (15%), 21 (24%) and 12 (14%) patients. Only 3% (n = 3) of the treatment was targeted, ie, based on the result of a bacterial culture
Labi et al 2018,^Citation50 Ghana (3 hospital) 4208 bed capacity. 716 pediatric inpatients	Antibiotic use prevalence, 70.6% Majority of patients were prescribed 2 antibiotics Mostly prescribed antibiotics were 3rd cephalosporins, followed by aminogylcosides amd 2nd gen cephalosporins 83.5%nof patients were prescribed intravenous antibiotics
Maina et al 2020,^Citation42 Kenya (14 hospitals) 4152 total capacity, 3590 hospitalized patients	Antibiotic use prevalence, 46.7% Most patients had 2 antibiotics Commonly prescribed antibiotics were the cephalosporins, followed by nitroimidazole Two patients (0.1%) had treatment based on available antibiotic susceptibility tests Appropriate treatment was assessed in 1502 patients who had a single diagnosis. Of these, 805 (53.6%) received appropriate treatment Physical availability of treatment guidelines increased the odds of receiving appropriate treatment
Momanyi et al 2019,^Citation32 Kenya (1 hospital) 532 bed tertiary hospital, 179 patients	Antibiotic use prevalence, was 54.7% Most antibiotics were prescribed for treatment (75.4%) as opposed to prophylaxis (29%) Surgical prophylaxis was >24 hours in 76.9% of the cases with only 9.6% on a single dose as per current guidelines Penicillins (46.9%) followed by cephalosporins (44.7%) were the most prescribed antibiotic classes The indication for antibiotic use was documented in only 37.3% of encounters Generic prescribing was 62.5% and empiric prescribing was seen in 82.6% of encounters Guideline compliance was 45.8% Majority of patients were on combination therapy
Oduyebo.et al 201,^Citation39 Nigeria (4 Hospitals) All wards, 828 hospitalized patients	Antibiotic use prevalence was 69.7%, most prescribed antibiotics being cephalosporins, followed by nitroimidazoles and quinolones Indication for antibiotic use was recorded in 61.8% of the cases Start and stop dates were indicated in 27.8 of the cases Guidelines were present, and adherence to guidelines was at 7% for medical cases and 4% for surgical cases Biomarkers were utilized in 1% of the cases. Targeted treatment was recorded for 14.9% of medical cases and 11.3% of surgical cases 48% of the antibiotics were used for Surgical prophylaxis and in 95% of the cases surgical prophylaxis was indicated for more 24hours
Ogunleye.et al 2021,^Citation27 Nigeria (2 hospitals) One hospital had a bed capacity of 774 and the other had 250 bed capacity, a total of 491 hospitalized patients	Antibiotic use prevalance, 80.6% Mostly used antibiotics in the secondary hospital were parenteral metronidazole (32.4%), ceftriaxone (27.5%) and amoxicillin + clavulanate (8.2%) while the mostly used in the tertiary hospital were ceftriaxone (25.3%), parenteral metronidazole (19.1%) and Amoxicillin +Clavulanate (9.3%). Considerable lack of specific functional capacities, policies and processes to promote appropriate antimicrobial use
Seni.et al 2019,^Citation51 Tanzania (6 hospitals) 553 total capacity, 948 all admitted patients	Antibiotic use prevalence, 62.3% The overall adherence of antibiotic prescriptions to the Tanzania STG was high (84.0%) Only 2 of 591 patients were prescribed antibiotics based on culture and antimicrobial susceptibility testing results. Majority of patients were on 2 antibiotics Most antibiotics were used for community-associated infections (36.7%), followed by Surgical prophylaxis (30.2%) and medical prophylaxis (24.0%) Antibiotic use for a purpose other than treatment was reported in 127 (19.0%) patients and in 32 diagnoses (4.8%) where there was a completely undefined site with no systemic inflammation
Umeokonkwo et al 2019,^Citation34 Nigeria (1 hospitals) 720 bed capacity, 220 hospitalized patients	Antibiotic use prevalence, 78.2% Antibiotics commonly used were 3rd generation cephalosporins Most therapeutic treatments were empirical Surgical prophylaxis constituted 44.0% of antimicrobial prescriptions There was limited use of guidelines but clear documentation of stop/review dates and reasons for antimicrobial use
Wambale et al 2016,^Citation43 Republic of Congo (11 hospitals) 700 hospitalized patients	The prevalence of the antibiotic use was 68% Antibiotics are prescribed either alone or in combination Most prescribed antibiotic was ampicillin (35%) followed by gentamicin (13.6%), amoxicillin (13.5%), ceftriaxone (11%) and metronidazole (10.3%) The prevalence of combined therapy was 34.9% among patients who received more than one antibiotic. The most common route of administration was the intravenous (68.2%). The choice of these antibiotics is usually probabilistic because the sensitivity tests were not conducted prior the antibiotic prescription and, in many hospitals, antibiotic use guidelines were not available

Table 2 Antibiotic Use Quality Indicators Most Reported in sub-Saharan Africa

Study and Country	Antibiotic use Prevalence %	Highest Prevalence ABX Class	IV Antibiotics by %	IV -Oral switch /De—Escalation	Indication Documented	Start and Stop date Indicated %	Guideline Compliance %	Microbiology Culture Performed %	% Targeted Treatment	% Empirical Treatment	Surgical Prophylaxis >24hrs
Abubakar 2020,^Citation31 Nigeria	O	O	O	X	O	X	X	X	X	X	O
Afriyie et al 2019,^Citation10 Kenya	O	O	O	X	O	O	O	O	O	X	O
Anand Paramadhas et al 2019,^Citation41 Botswana	O	O	O	X	X	X	X	O	X	O	O
Bediako-Bowan et al, 2019,^Citation44 Ghana	O	O	O	X	X	X	X	O	X	X	O
Chijioke et al 2016,^Citation49 Nigeria	O	O	X	X	X	X	X	X	X	X	X
Dlamini et al 2019,^Citation30 South Africa	O	O	O	O	O	X	X	O	X	X	X
Fowotade et al 2020,^Citation40 Nigeria	O	O	O	X	O	O	O	O	O	O	O
Horumpende et al 2020,^Citation33 Tanzania	O	O	X	X	O	X	X	O	O	X	O
Labi et al 2018,^Citation50 Ghana	O	O	O	X	O	X	O	X	X	X	X
Maina et al 2020,^Citation42 Kenya	O	O	X	X	X	X	O	O	X	X	X
Momanyi et al 2019,^Citation32 Kenya	O	O	X	X	O	X	O	X	X	O	O
Oduyebo et al 2018,^Citation39 Nigeria	O	O	O	X	O	O	O	O	0	X	X
Seni et al 2019,^Citation51 Tanzania	O	O	X	X	O	X	O	O	X	X	X
Umeokonkwo et al 2019,^Citation34 Nigeria	O	O	O	X	O	O	O	O	O	O	X
Wambale et al 2016,^Citation43 Congo	O	O	O	X	X	X	X	0	X	X	X

Notes: O=quality indicator assessed. X=quality indicator not assessed.

Abbreviation: IV, intravenous.

Table 3 Summary of a Number of the ASP Studies and Outcomes

Study	Intervention Employed	Outcomes	Other Observations
Abubakar et al (2019),^Citation52 Nigeria	Development of protocol; educational meeting; audit and feedbacks, posters to improve compliance with surgical antibiotic prophylaxis practice in obstetrics and gynecology surgeries	Increase in compliance with timing from 14.2% to 43.3% and duration from 0% to 21.8% Reduced the prescription of third-generation cephalosporin (−8.6%), redundant antibiotic (−19.1%), antibiotic utilization (−3.8 DDD/procedure) and cost of antibiotic prophylaxis (-$4.2/procedure)	Still room for improvement, particularly in emergency surgical procedures as antibiotics were administered after incision in many surgical procedures in emergency cases.
Aiken et al (2013),^Citation53 Kenya	Development of an Antibiotic prophylaxis policy that advised pre-operative antibiotic prophylaxis and discouraged extended post-operative antibiotics use	Rapid adoption of the use of pre-operative antibiotic prophylaxis (60% at 1 week; 98% at 6 weeks) Substantial decrease in the use of post-operative antibiotics (40% of at 1 week; 10% at 6 weeks) Marked reductions in the costs associated with antibiotic use, the number of intravenous injections performed, and nursing time spent	Limited awareness of national clinical policy documents, resulting in a marked policy-to-practice gap. Poor access to appropriate medicines for surgical prophylaxis. Amongst clinicians there was a marked concern about negative outcomes, especially regarding nosocomial infections, that hindered changes in antibiotic usage. Lack of awareness amongst hospital management of the overall potential for cost-savings associated with such a policy change.
Alabi (2022),^Citation54 Liberia	Implementation of a bundle of three measures (local treatment guideline, training and regular ASP ward rounds) to guide antibiotic use	Adherence to the local guideline improved for the selection of antimicrobial agents from 34.5% to 61.0%, p < 0.0005, dosage from 15.2% to 36.5%, p < 0.0005 and duration from 13.2% to 31.0%, p < 0.0005 79.7% of patients had samples sent for microbiological analysis. Proportion of patients receiving ceftriaxone significantly reduced after the ASP ward rounds from 51.3% to 14.2% (p < 0.0005)	In addition to changing prescribing behavior, ASPs face the challenge of underfunding and limited access to experts, expertise and training. Long-term engagement is therefore necessary to make ASPs in low- middle income countries sustainable.
Bashar et al (2021),^Citation55 South Africa	Dedicated ASP weekly round	Reduction in the volume of antibiotic consumption from a total 739.30 DDDs/1000 to 564.93 DDDs/1000 patient days Reduction in inappropriate antibiotic use from 35% to 26% from baseline to antibiotic stewardship program stages Increase in culture targeted therapy in both wards in the antibiotic stewardship program stage	Possible measures to improve appropriate antibiotic use for surgical prophylaxis could include adherence to national guidelines and educational program targeting theatre staff and surgeons on rational antibiotic usage.
Bassiouny et al (2020),^Citation56 South Africa	AMS guidelines implementation, ward rounds by a pharmacist on the surgical neonatal intensive care unit	86% compliance to guidelines SSI rate decreased to 20% Days of Therapy (DOT) per 1000 patient days showed a significant decrease in antibiotic utilization Drug cost showed a 1185.97 Egyptian pound decrease post-intervention (p = 0.714) Decreased LOS by a mean difference of 2.5 (p = 0.027)	Recommended introduction of automated techniques to shorten the turnaround time of lab investigations as an essential factor for correct implementation and achievement of the ASP goals.
Boyles et al (2013),^Citation57 South Africa	Introduction of antibiotic prescription use in 2 medical wards chart and ward rounds to improve antibiotic	19.6% decrease in volume with a cost reduction of 35% of the pharmacy’s antibiotic budget Increase in laboratory tests No difference in inpatient mortality or 30-day readmission rate during the control and intervention periods	Interventions to reduce antibiotic utilization must be introduced alongside strengthening of basic infection control practices, such as hand washing.
Brink et al (2017),^Citation58 South Africa	Prospective audit and feedback strategy involving change management and improvement principles to achieve a reduction in SSIs across a heterogeneous group of 34 urban and rural South African hospitals	Improvement in compliance with all process measures from 66.8% to 83.3% (representing a 24.7% increase (p < 0.0001) SSI rate decreased by 19.7% from a mean group rate of 2.46 pre-intervention to 1.97 post-intervention	ASP implementations require leadership commitment from all quarters—governmental, hospital and clinical—to acknowledge and support the cardinal role played by non-specialized pharmacists in recruiting multidisciplinary teams and in coordinating interdisciplinary engagement which was key to success.
Gebretekle et al (2020),^Citation59 Ethiopia	Weekly audit and immediate (verbal and written) feedback sessions on antibiotic prescriptions of patients admitted in 2 pediatric and 2 adult medicine wards	96% of the recommendations made by the ASP team were accepted Once the intervention ceased, total antimicrobial use increased by 51.6% and mean duration of treatment by 4.1 days/patient Mean LOS stay as well as crude mortality also increased significantly in the post-intervention phase (LOS: 24.1 days vs 19.8 days; in hospital death 14.7 vs 6.9%)	Implementation of ASPs need a sustained effort. Commitment of organizational leadership required to sustain enabling antimicrobial stewardship activities.
Lester et al 2020),^Citation60 Malawi	A prescribing application for smartphones and regular point-prevalence surveys with prescriber feedback aimed to evaluate the impact of the intervention on 3GC usage and on the cost of providing antibiotics	53.6% reduction in the proportion of 3GC antibiotic prescriptions with no change in the case-fatality rate The cost analysis estimated an annual savings of US$ 15,000. Qualitative research revealed trust in the guideline and found that its accessibility through smartphones helpful to guide clinical decisions	ASPs challenged by the dual burden of a high prevalence of severe, often drug-resistant infections alongside insecure, variable access to a range of effective antimicrobials.
Ngonzi et al (2021),^Citation61 Uganda	An educational intervention, daily audit and feedback aimed at clinicians to increase the use of the WHO SSC and prophylactic antibiotics for cesarean delivery	Increase in use of WHO SSC from 7% in the pre-intervention phase to 92% in the intervention phase (P < 0.001), and 77% in the post-intervention phase (p < 0.001). Pre-intervention antibiotic receipt was 18% compared to 90% in the intervention phase (p < 0.001) and 84% in the post-intervention phase (P < 0.001) The documented SSI rate in the pre-intervention phase was 15% compared to 7% in the intervention phase (p = 0.02) and 11% in the post-intervention phase (p = 0.20)	Research to understand factors influencing the checklist use and antibiotic prophylaxis including prescriber knowledge, motivation and clinical process is required. Implementation interventions to sustain usage and impact on clinical outcomes need to be explored.
Opondo et al (2011),^Citation62 Kenya	Training of health workers, facilitation, supervision and face-to-face feedback, aimed to assess whether intervention reduced inappropriate use of antibiotics in children with non-bloody diarrhea and no co-morbidities requiring antibiotics	Inappropriate antibiotic use decreased from 74% to 42% (p = 0.04)	Modest financial investments required for comparatively substantial improvements in quality of care. Enhanced medical education focusing on rational use of antibiotics is necessary to improve clinicians’ prescribing habits.
van den Bergh et al (2020),^Citation63 South Africa	Development of a CAP bundle of seven process measures that pharmacists used to audit compliance and provide feedback	Overall CAP bundle compliance improved from 47·8% to 53·6% p < 0·0001) No difference in mortality between the pre-implementation and post-implementation phase, 4·4% (vs 3·9%; (p=0·54), median LOS or IR LOS 6·0 vs 6·0 days (p=0·20) and 5·0 vs 5·0 days (p = 0·40)	Opportunity for frontline stewards across different settings to collaborate in coordinated interventions and accelerate implementation of ASPs through upskilling existing resources and enabling interdisciplinary engagement across health systems.

Abbreviations: 3GC, 3rd generation cephalosporins; ASP, antimicrobial stewardship programs; CAP, community-acquired pneumonia; DDD, defined daily dose; LOS, length of hospital stay; SSI, surgical site infection; US, United States; WHO SSC, World Health Organization surgical safety checklist.

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