Antibiotic prescribing practices according to the AWaRe classification among children under 5 of age attending public primary care centres in four West African countries: a cross-sectional study (AIRE project, 2021-2022)

Abstract

Objective: To describe antibiotic prescribing practices using the WHO AWaRe (Access, Watch, Reserve) classification in West African children under 5 years of age attending public primary health centres (PHCs).

Design: Cross-sectional study.

Setting: The AIRE project implemented the systematic use of pulse oximetry into integrated management of childhood illness consultations in West African countries (Burkina Faso, Guinea, Mali and Niger). We described antibiotic prescriptions for outpatient children at 16 PHCs and for severe cases referred at district hospitals.

Patients: Between 14 June 2021 and 19 June 2022, 15 854 outpatients were included: 968 neonates and young infants (0-28 days) and 14 886 children (2-59 months). Among them, 78 (8.1%) neonates and young infants and 385 (2.6%) children were hospitalised. We evaluated 58 hospitalised neonates and young infants and 275 hospitalised children, respectively.

Main outcome measures: Frequency of antibiotic prescriptions according to the AWaRe classification recommended by WHO.

Results: At the PHC level, proportions of neonates and young infants with ≥1 antibiotic prescription were 83%, 62%, 71% and 59% in Burkina Faso, Guinea, Mali and Niger, respectively. A total of 805 antibiotics were prescribed (85% Access and 13% Watch). The proportions of children with ≥1 antibiotic prescription reached 71%, 66%, 63% and 36% in Burkina Faso, Guinea, Mali and Niger, respectively. Out of the 9630 antibiotics prescribed, 93% were Access (mainly amoxicillin), and 7% Watch. At the hospital level, Watch antibiotics were mainly prescribed for severe cases referred. No Reserve antibiotics were prescribed.

Conclusions: High proportions of antibiotics were prescribed to outpatient children included, the appropriateness of which needs further study. Nevertheless, in every country, the proportion prescribed in the Access group reached the minimum threshold of 60% of all antibiotic prescriptions, as recommended by WHO.

Trial registration number: PACTR202206525204526.

Keywords: child health; epidemiology; low and middle income countries; therapeutics.

Figure 1. Flowchart, inclusion process of children under 5 years of age in the AIRE research project 2021–2022. *Some hospitalised cases from Niger could not have been evaluated due to poor data quality. IMCI, integrated management of childhood illness.

Figure 2. Percentage stacked bar chart, share of Access, Watch, Reserve and Unclassified antibiotic prescriptions among neonates and young infants (0–59 days) at primary health centre (PHC) level (A) and at hospital level (C) and among children (2–59 months) at PHC level (B) and hospital level (D), by country, AIRE project 2021–2022. The colour code green, yellow and red respect the AWaRe classification, Access, Watch, and Reserve, respectively. The grey colour reflects the Unclassified antibiotics. The 60% threshold bar represents the proportion to reach at least 60% of Access antibiotic according to WHO AWaRe recommendation.

Figure 3. Sankey diagram, evolution of prescriptions according to the AWaRe classification for neonates and young infants (A, n=58) and children (B, n=275) transferred from the primary health centre (PHC) to the hospital, AIRE project 2021–2022. The colour code green, yellow, red respects the AWaRe classification, respectively Access, Watch and Reserve. In this diagram, the grey colour reflects the absence of antibiotics and the asterisk reflects Unclassified antibiotics.