Surveillance of antimicrobial utilization in Africa: a systematic review and meta-analysis of prescription rates, indications, and quality of use from point prevalence surveys

Abstract

Background: Antimicrobial resistance (AMR) is a global public health concern that is fueled by the overuse of antimicrobial agents. Low- and middle-income countries, including those in Africa,. Point prevalence surveys (PPS) have been recognized as valuable tools for assessing antimicrobial utilization and guiding quality improvement initiatives. This systematic review and meta-analysis aimed to evaluate the prescription rates, indications, and quality of antimicrobial use in African health facilities.

Methods: A comprehensive search was conducted in multiple databases, including PubMed, Scopus, Embase, Hinari (Research4Life) and Google Scholar. Studies reporting the point prevalence of antimicrobial prescription or use in healthcare settings using validated PPS tools were included. The quality of the studies was assessed using the Joanna Briggs Institute (JBI) critical appraisal checklist. A random-effects meta-analysis was conducted to combine the estimates. Heterogeneity was evaluated using Q statistics, I² statistics, meta-regression, and sensitivity analysis. Publication bias was assessed using a funnel plot and Egger's regression test, with a p-value of < 0.05 indicating the presence of bias.

Results: Out of 1790 potential studies identified, 32 articles were included in the meta-analysis. The pooled prescription rate in acute care hospitals was 60%, with significant heterogeneity (I² = 99%, p < 0.001). Therapeutic prescriptions constituted 62% of all the prescribed antimicrobials. Prescription quality varied: documentation of reasons in notes was 64%, targeted therapy was 10%, and parenteral prescriptions were 65%, with guideline compliance at 48%. Hospital-acquired infections comprised 20% of all prescriptions. Subgroup analyses revealed regional disparities in antimicrobial prescription prevalence, with Western Africa showing a prevalence of 65% and 44% in Southern Africa. Publication bias adjustment estimated the prescription rate at 54.8%, with sensitivity analysis confirming minor variances among studies.

Conclusion: This systematic review and meta-analysis provide valuable insights into antimicrobial utilization in African health facilities. The findings highlight the need for improved antimicrobial stewardship and infection control programs to address the high prevalence of irrational antimicrobial prescribing. The study emphasizes the importance of conducting regular surveillance through PPS to gather reliable data on antimicrobial usage, inform policy development, and monitor the effectiveness of interventions aimed at mitigating AMR.

Keywords: Africa; Antimicrobials; Indications; Prescription rates; Quality of use.

Fig. 1

PRISMA Flow diagram for the inclusion of studies for the systematic review and meta-analysis of antimicrobial utilization surveillance in Africa focusing on: prescription proportion, indications, and quality of use

Fig. 2

Pooled estimate of antimicrobial prescription in African health facilities acute care settings

Fig. 3

Univariate Meta regression of sample size (A), number health facilities (B) and year of publication (C)

Fig. 4

Subgroup analysis of antimicrobial utilization surveillance in African health facilities by regions. WA: Western Africa, SA: Southern Africa, EA: Eastern Africa, NA: Northern Africa

Fig. 5

Subgroup analysis of antimicrobial utilization surveillance in African health facilities by study populations

Fig. 6

Funnel Plot Showing the Prevalence of Antimicrobial Prescriptions among Hospitalized Patients in African Health Facilities