Antimicrobial usage among acutely ill hospitalised children aged 2‒23 months in sub-Saharan Africa and South Asia

Abstract Background Understanding patterns of antimicrobial use is critical to supporting antibiotic stewardship and limiting antimicrobial resistance (AMR). We aimed to describe antimicrobial prescribing in acutely ill hospitalised children aged 2-23 months across a range of rural and urban hospital settings in sub-Saharan Africa and South Asia. Methods The CHAIN cohort collected data daily throughout hospitalisation from children with acute illness aged 2-23 months admitted to nine hospitals from November 2016 to January 2019. We determined proportions of children receiving antimicrobials, inpatient-days receiving antimicrobials, antimicrobial classes, WHO Access, Watch, and Reserve (AWaRe) classifications, and examined factors associated with Watch antimicrobial use. Results Of 3101 admissions, 1422 (46%) received antimicrobials prior to hospitalization. 2816 (91%) children received antimicrobials during 19398/21807 (93%) inpatient child-days. 2477 (76%), 1092 (35%), and 12 (0.3%) children received Access, Watch, and Reserve antimicrobials, mostly <48 hours from admission. 341 (11%) of admissions received an antimicrobial without any indication. Prior admission, chronic illness, diagnoses of sepsis or meningitis, hypoglycemia and duration of admission were associated with receiving Watch antimicrobials, whilst WHO danger signs, severe malnutrition, HIV and receipt of prior antimicrobials were not, despite their known association with mortality and AMR. Conclusions Antimicrobial use was similar across sites with some overuse, and notably limited escalation and de-escalation, likely due to guideline adherence. Guidelines need updating for the absence of relevant antimicrobial sensitivities, to include risk-based antimicrobial prescribing considering mortality risk and prior exposure to antimicrobials and the hospital environment. Hence, clinical trials of risk-differentiated care are needed.