Healthcare-associated Infections Drive Antimicrobial Prescribing in Pediatric Departments at Three Academic Hospitals in South Africa

Abstract

Background: The prevalence of antimicrobial prescriptions for healthcare-associated infections (HAI) in South Africa is largely unknown. This study aimed to estimate the point prevalence of pediatric antibiotic and antifungal usage in 3 South African academic hospitals. Methods: This cross-sectional study included hospitalized neonates and children (0–15 years). We used the World Health Organization methodology for antimicrobial point prevalence studies, with weekly surveys to achieve a sample size of ~400 at each site. Results: Overall, 1,946 antimicrobials were prescribed to 1,191 patients. At least 1 antimicrobial was prescribed for 22.9% [95% confidence interval (CI): 15.5–32.5%] of patients. The prevalence of antimicrobial prescribing for HAI was 45.6%. In the multivariable analysis, relative to children 6–12 years, neonates [adjusted relative risk (aRR): 1.64; 95% CI: 1.06–2.53], infants (aRR: 1.57; 95% CI: 1.12–2.21) and adolescents (aRR: 2.18; 95% CI: 1.45–3.29) had significantly increased risk of prescriptions for HAI. Being preterm (aRR: 1.33; 95% CI: 1.04–1.70) and underweight (aRR: 1.25; 95% CI: 1.01–1.54) was predictive of antimicrobial usage for HAI. Having an indwelling device, surgery since admission, blood transfusions and classification as rapidly fatal on McCabe score also increased the risk of prescriptions for HAI. Conclusions: The high prevalence of antimicrobial prescribing for HAI to treat children with recognized risk factors in academic hospitals in South Africa is concerning. Concerted efforts need to be made to strengthen hospital-level infection prevention and control measures, with a critical review of antimicrobial usage through functional antibiotic stewardship programs to preserve the available antimicrobial armamentarium at the hospital level.

Policy brief: Optimising antimicrobial usage in paediatric inpatient hospital settings

“…1). [15] The top primary reasons for which antimicrobials were prescribed were HAI sepsis (32%, 382), clinical sepsis (24%, 287), surgical prophylaxis (10%, 123), lower respiratory tract infections (7%, 92), medical prophylaxis (5%, 66) and central nervous system infections (3%, 42) (Fig. 2).…”

“…Furthermore, preterm birth (aRR 1.33; 95% CI 1.04 -1.70) and underweight (aRR 1.25; 95% CI: 1.01 -1.54) were independently associated with antimicrobial prescribing to treat confirmed and suspected HIA. [15]…”

“…The study methodology adhered to the guidelines provided by the WHO methodology for conducting antimicrobial point prevalence surveys (PPS) in hospitalised children. [15]…”

“…In a cross-sectional study that evaluated antimicrobial usage in three academic public sector hospitals in SA to improve appropriateness, 22.9% of hospitalised children received at least one prescribed antimicrobial, with neonates, infants and adolescents having higher prescription rates for HAIs. [4,15] Common antimicrobials prescribed included beta-lactamase-sensitive penicillin, aminoglycosides and carbapenems. Antimicrobial selection aligned with the World Health Organization (WHO) Access Watch and Reserve (AWaRe) classification system.…”

“…This policy brief presents findings and recommendations from a from this study. [15] Corresponding author: J Cloete (jeane.cloete@up.ac.za) This policy brief document utilised an original published study from three academic hospitals in South Africa (SA) and all relevant published literature to develop recommendations on several strategies, summarised by the acronym 'PRACTICE' , to optimise antimicrobial prescribing practices. These include implementing standardised policies for empirical antimicrobial use, routine review of antimicrobial therapy, age-specific antimicrobial stewardship programmes and continued collaborative efforts and research.…”