Antibiotic prescribing practice and adherence to IMCI guidelines among CNPs in children younger than 5 years withrespiratory tract infections at Crossroads clinic, Cape Town,South Africa: retrospective audit

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Background. Antibiotic use is especially high among children globally. In South Africa (SA), children under 5 years (U5) are typically prescribed an appreciable number of antibiotics in primary health care (PHC). There have been several published studies on antibiotic prescribing practice among Health Care Workers (HCWs) in PHC in low-resource setting. However, no published study has been reported on antibiotic prescribing practice among clinical nurse practitioners (CNPs) in PHC low-resource setting in Cape Town. Antimicrobial Stewardship Programme (ASP) in PHC has strengthened the use of evidence-based guidelines to support appropriate antimicrobial prescribing; however, adherence to these guidelines seems to be low. Objective. To assess antibiotic prescribing practices amongst CNPs and adherence to Integrated Management of Childhood Illnesses (IMCI) guidelines for U5 children with respiratory tract infections (RTIs), as well as to make recommendations with the aim to promote appropriate antibiotic prescribing at PHC Level. Methods. This is a retrospective audit that included folder review of children U5 with RTIs for which antibiotic was prescribed by CNPs for the period July 2021 to December 2021 at Crossroads community day clinic (CDC). Data was obtained on site by sequential non-random sampling of patient folders from medical records in the baby clinic admission book, with a total sample size of 120. This study determined the appropriateness or otherwise of antibiotics prescribed to U5 children by CNPs, and additionally makes recommendations to mitigate the effect of rising prevalence of antimicrobial resistance (AMR) in PHC setting. Results. A total of 120 folders included in this study were audited. Of the 120 folders analyzed, (60%) (n=72) did not adhere to guidelines. Guidelines were adhered to in only (40%) (n=48). Of those non adherent to the guidelines, (18.05%) (13/72) had no diagnosis documented in patient folder, (31.94%) (23/72) had incorrect dose prescribed, (40.27%) (29/72) had no weight documented, (18.05%) (13/72) had no allergies documented; duration of antibiotic prescribed not documented in (9.72%) (7/72), the antibiotic prescribed was different from what was recommended in the IMCI guidelines in (6.94%) (5/72) and only (6.94%) (5/72) were non adherent owing to frequency of antibiotic prescribed per day not documented. Adherence variation was observed between the 3 antibiotics, with significantly higher adherence to guidelines for prescriptions containing Amoxicillin (53.53%) (53/99) than other antibiotics. Adherence to guidelines also differed by diagnosis, prescriptions for pneumonia was more likely to adhere to guideline (55.00%) (33/60) than other RTIs. A strong association was observed between weight documented and adherence to guidelines. 51.64% (47/91) of the prescriptions in which weight was done adhered to guidelines. When weight was done, the prescriptions were more likely to be correct, Fishers exact test = 0.000 (P<0.05). Conclusions. In a resource-limited environment, CNPs play a pivotal role in order to meet community healthcare needs. This study gives insight into antibiotic prescribing practices amongst CNPs and it demonstrated low adherence to IMCI guidelines. Focus should be directed towards CNPs prescribing adherence with aim of improving appropriate antibiotic use and the fight against AMR in PHC in low-resource setting in Cape Town. Future clinical research in this setting should explore qualitative research approach including interviewing both CNPs and caregivers to assess their knowledge and understanding of prescribing guidelines and antibiotic use respectively. The views and expertise of stakeholders should be incorporated to shape policies in the fight against AMR in PHC.