Excessive Rates of Antibiotic Prescriptions for Children in Low- and Middle-Income Countries

14.12.2019

Between 2007 and 2017, children in eight low- and middle-income countries received, on average, 25 antibiotic prescriptions from birth through age five - up to five times higher than the already high levels observed in high-income settings. Many of the prescriptions are unnecessary and might exacerbate resistance. The number of antibiotic prescriptions for young children ranged from one per year for children in Senegal to 12 per year for children in Uganda.

Children in LMIC receive on average 25 antibiotic prescriptions from birth through age five. (Photo: Danielle Powell/Swiss TPH)

Children in low- and middle-income countries (LMICs) are receiving an average of 25 antibiotic prescriptions during their first five years of life, an excessive amount that could harm the children's ability to fight pathogens as well as increase antibiotic resistance worldwide, according to a new study from the Swiss Tropical and Public Health Institute (Swiss TPH) and Harvard T.H. Chan School of Public Health.

"We knew children in LMICs are sick more often, and we knew antibiotic prescription rates are high in many countries. What we did not know was how these elements translate into actual antibiotic exposure-and the results are rather alarming," said Günther Fink, lead author of the study and head of the Household Economics and Health Systems Research unit at Swiss TPH.

The study - the first to look at total antibiotic prescribing in children under the age of five in LMICs - was published on 13th December in The Lancet Infectious Diseases.

Global health threat

Antimicrobial resistance is one of today's biggest threats to global health and development, according to the World Health Organization. One factor contributing to this global health threat is the excessive use of antibiotics worldwide. Previous studies have shown that antibiotics are overprescribed to children in many countries. In Tanzania, for instance, several studies have shown that over 90% of children who visit a health facility receive an antibiotic, although only in about 20% of the cases the infection was due to a bacterial infection.1

The research team from Swiss TPH and Harvard Chan School analysed data from 2007-2017 from health facilities and household surveys from eight countries: Haiti, Kenya, Malawi, Namibia, Nepal, Senegal, Tanzania, and Uganda. The study found that, on average, children received 5 antibiotic prescriptions per year through age five-a "remarkable" estimate, the authors wrote, given that two antibiotic prescriptions per year is considered excessive in many high-income settings. Results showed that antibiotics were administered in 81% of cases for children with a respiratory illness, in 50% for children with diarrhoea, and in 28% for children with malaria.

The researchers found that the number of antibiotic prescriptions in early childhood varied from country to country: While a child in Senegal received approximately one antibiotic prescription per year in the first five years of life, a child in Uganda was prescribed up to 12. In comparison, a prior study showed that children under five in Europe receive less than one antibiotic prescription per year on average.2 "Even that number is still high given that the vast majority of infections in this age group are of viral origin," said Valérie D'Acremont, a study co-author and head of the Management of Fevers group at Swiss TPH.

"What is unique about this study is that it provides a much more comprehensive picture of pediatric antibiotic exposure in LMICs than what has been reported previously. It combines both household data on where and when children are brought for care with data from direct observations of health care workers caring for sick children," said Jessica Cohen, at Harvard Chan School and senior author of the study.

Impact on children

"The consequences of antibiotic overprescription not only pose a huge threat to global health, but can also result in a concrete health impact for these children," said Valérie D'Acremont. "Excess antibiotic use destroys the natural gut flora which is essential to fighting pathogens and building immunity defences."

A Swiss TPH research project is underway to better comprehend the health impact of overusing antibiotics on children. "Understanding the concrete impact on individual children is crucial to achieve a policy change," said Fink. His research team is currently comparing policies at a country level to identify best practices that lead to lower antibiotic prescription rates.

Tackling resistance with digital health tools

The most decisive factor, however, are the health workers. "Training and supervision have the biggest effect on reducing unnecessary antibiotic prescriptions." said Valérie D'Acremont. To that end, her research team at Swiss TPH and Unisanté in Lausanne developed an electronic Point of Care Tool (ePOCT), which guides health workers through diagnosing and treating sick children.

Introducing ePOCT in health facilities resulted in improved clinical outcomes and a drastic reduction in the prescription of antibiotics from 95% to 11% according to a study conducted by Kristina Keitel, Scientific Project Leader at Swiss TPH.3 The tool is being further enhanced to include artificial intelligence-based algorithms in collaboration with Unisanté, the École polytechnique fédérale de Lausanne (EPFL) and Tanzanian and Rwandan partners, with support from Fondation Botnar and the Swiss Development Cooperation.

1 D'Acremont V, Kilowoko M, Kyungu E, Philipina S, Sangu W, Kahama-Maro J, Lengeler C, Cherpillod P, Kaiser L, Genton B. Beyond malaria: causes of fever in outpatient Tanzanian children. New England Journal of Medicine 2014; 370(9): 809-17.

2 Holstiege J et al. (2014). Systemic antibiotic prescribing to paediatric outpatients in 5 European countries: a population-based cohort study. BMC Pediatr.

3 Keitel K et al. (2017). A novel electronic algorithm using host biomarker point-of-care tests for the management of febrile illnesses in Tanzanian children (e-POCT): A randomized, controlled non-inferiority trial. PLOS Medicine.

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