Antimicrobial stewardship practices and quality of antibacterial use in children under five and women in labour with obstetric risk factors in selected health facilities in Uganda

Abstract

Introduction Bacterial infections are a leading cause of morbidity and mortality in Ugandan hospitalised children under the age of five. Disparities exist in using antibacterial agents to treat bacterial infections at various health facilities in Uganda, resulting in various clinical outcomes that may be appropriate or inappropriate, compromising the quality of antibacterial usage in children under the age of five. The World Health Organisation and Ministry of Health have recommended implementing multifaceted interventions like (Medicine and Therapeutic committees (MTCs) and antimicrobial stewardship programmes (ASPs) to improve the quality of antibacterial use from birth to five years if child survival is to be achieved in health facilities low and middle-income countries. However, the extent of implementation of the multifaceted intervention) has remained undetermined amidst practices of off-label antibacterial use and inappropriate intrapartum antibacterial prophylaxis (IAP) during maternal labour in different health facilities in Uganda. Nevertheless, there is little evidence about the impact of these variables on the use of antibacterial medication in children under the age of five. Aim The study aimed to investigate antimicrobial stewardship practices and the quality of antibacterial use in children under five and women in labour with obstetric risk factors in selected health facilities in Uganda. Methods Sub-study I was an explanatory sequential mixed-method study conducted from August 2019 to February 2020 in a two-stage approach to determine the structure and functional role of MTCs in supporting optimal antibacterial use in selected health facilities. Sub-study II was conducted in three parts to determine antimicrobial stewardship practices to optimise antibacterial use in selected health facilities in Uganda. It was a cross-sectional study conducted using an interviewer-administered questionnaire among healthcare providers in selected health facilities in Uganda from October 2019 to February 2020. Sub-study III was a concurrent mixed-method design to investigate the extent of off-label antibacterial use among hospitalised children with suspected bacterial infections from May to October 2019 in seven tertiary hospitals in Uganda. Lastly, Sub-study IV was a cross-sectional study conducted to examine the extent of maternal intrapartum antibacterial exposure among women in labour with obstetric risk factors in selected health facilities in Uganda from May to October 2019. A retrospective review of medical records for one year (2018 to 2019) was conducted in seven tertiary hospitals. Results In this study, MTCs were more established in tertiary health facilities (RRH (n=10) and PNFPs (n=3) than in general hospitals (n=3). The most notable structure in the 16 MTCs that supported optimising antibacterial use included a membership ranging from 7 to 14 (median 10), and the mean (standard deviation) of subcommittees was 4 (+ 1.03) with the most frequent subcommittees as supply chain and logistics (14/16, 88%), antimicrobial stewardship (13/16, 81%), and infection control (12/16,75%) subcommittees. The most frequent activities supporting optimising antibacterial use included evaluating and selecting an antibacterials list (n=14, 88%) and conducting an antimicrobial stewardship activities list (n=15, 94) (substudy I). Of the 582 healthcare providers interviewed, 87% acknowledged the importance of antibacterial resistance in their hospitals, and 92% acknowledged its importance nationally. Furthermore, 91% of healthcare providers agreed that antibacterial resistance impacted their choices of antibacterial agents, while 85% agreed that it affected patients' clinical outcomes. The three top-ranked causes of antibacterial resistance, as determined by the relative importance index (RII) analysis, were prescribing an antibacterial when not needed (RII=0.879) and poor adherence of patients to prescribed antibacterial courses (RII=0.865), prescribing the wrong antibacterial (RII=0.833). Only 11% of healthcare providers had a high perception that their hospitals had effectively adopted hospital policy action to combat antibacterial resistance. The most perceived adopted policy actions were standard treatment guidelines, infection prevention and control, and distribution of high-quality antibacterials. Furthermore, within the 32 health facilities, 58% (340/582) of the healthcare providers had a high AMS attitude level. The AMS attitude levels were significantly associated with the sex of the female (aOR: 0.66, 95% CI: 0.47–0.92, P < 0.016), as well as with having a degree of bachelor's (aOR: 1.81, 95% CI: 1.24–2.63, P < 0.002) and master's degree (aOR: 2.06, 95% CI: 1.13–3.75, P < 0.018). Pharmacists among all interviewed healthcare providers had the highest mean AMS attitude scores. Conversely, 46% ( 261 / 582) of the healthcare providers had fair AMS practices. Medical officers had the highest mean AMS practice scores compared to other healthcare providers. Healthcare providers in western Uganda were significantly less likely to score high AMS practices (aOR: 0.52, 95% CI 0.34–0.79, P < 0.002). Lastly, despite the limited adoption of ASP (n=14, 44%), 30 of 32 healthcare institutions used at least one AMS strategy to support optimal antibacterial use. The core AMS strategy that was most implemented to optimise antibacterial use was preauthorization and approval, while combinational therapy was the most implemented supplemental AMS strategy (Substudy II). In the seven tertiary institutions, 88% (CI 86% to 89%) of 968 children under five had used off-label antibacterials. The age groups with the highest rates of off-label antibacterial use were newborns (94%; 97/103), hospitalised children (91%; 381/421), and those receiving ampicillin (91%; 384/420). The most common factors influencing off-label antibacterial usage were healthcare providers, hospitals and drug-related drivers (Sub-study III). The prevalence of inappropriate maternal intrapartum antibacterial prophylaxis exposure was 54.9% (95% Cl 51.5-58.1). The most frequent reason for inappropriate maternal intrapartum antibacterial prophylaxis was inappropriate timing of IAP (n=589, 67.5%), inappropriate dosing (618/873, 70.8%), and inappropriate antibacterial agent (n=479, 54.9%). Factors associated with inappropriate maternal intrapartum antibacterial exposure were mothers delivering from PNFP (PR 1.59 (95% CI 1.40-1.82), mothers being divorced or separated (PR1.38 ( 95% CI 1.11-1.71), mothers not referred to a health facility (PR 1.24(95% CI 1.08-1.42), mothers admitted before labour (PR 1.26(95% CI 1.06-1.36), mothers with no reported peripartum fever (PR 0.54( 95% CI 0.46-0.64) (Sub-study IV). Conclusion The implementation of multifaceted interventions (MTCs and antimicrobial stewardship programmes) to support optimal antibacterial use in children under five and women in labour with obstetric risk factors is still low in Uganda. MTC structures were more developed in tertiary hospitals than in general hospitals, they supported the formulary management and establishment of antimicrobial stewardship practices. Despite health facilities' low implementation of antimicrobial stewardship programmes, they adopted preauthorization and approval as a core AMS technique to optimise antibacterials in children underfive. Most healthcare providers have a high antimicrobial stewardship attitude and fair practice scores, and few perceived their hospitals to be effective in adopting policy actions to support the establishment of antimicrobial stewardship programmes in health facilities in Uganda. The low implementation of multifaceted interventions has not rendered improvement in the quality of antibacterial use in hospitalised children under five and women in labour with obstetric risk factors. The high prevalence of off-label antibacterial administration in children under five, along with high inappropriate maternal intrapartum antibacterial prophylaxis exposure among women in labour with obstetric risk factors, indicatied a low improvement in the quality of antibacterial use in children under five and women in labour.