A Case Study of Antibiotic Use, Variability Across Antibiotic Groups, Prescribers, and Prescription Habits in Rwanda

Abstract

Misuse and overuse of antibiotics are the main causes of antimicrobial resistance (AMR), a palpable threat to global health. In Rwanda, data on AMR is inadequate due to various factors, including but not limited to the lack of adequate AMR surveillance systems. The WHO Point Prevalence Surveys (PPS) are a resource-limited, appropriate tool for surveillance that can provide accurate and timely information on antibiotic use and prevalence in health facility settings. The WHO AWaRe classification tool further offers a framework for consumption using categorization based on the spectrum of antibiotic use activity and the potential to develop resistance to promote the prudent use of antibiotics. We deployed the two tools to estimate the prevalence of antibiotic use, understand the distribution of antibiotic agents used, and identify prescribing patterns among providers to identify the scope of interventions to enhance antimicrobial stewardship. A cross-sectional study was conducted in 2021 involving inpatient departments of the three district hospitals in Kirehe, Butaro, and Rwinkwavu in Rwanda. Patients were enrolled if they were on at least one antibiotic agent at 0800 on the day of the survey. Using study-adapted questionnaires, we collected data on patient demographics, prescribed antibiotics, and clinical indications. Additionally, prescribing providers were interviewed, and data on the field of practice, training, and rationale for prescriptions were collected. Antibiotic use prevalence was 67.2%. Among the 314 enrolled patients from three district hospitals, 147 (46.8%) were from Kirehe, 95 (29.9%) from Butaro, and 73 (23.2%) from Rwinkwavu District hospitals. Of those enrolled, 187 (59.5%) were female; 140 (45.5%) were under 5 years old at admission; 6 (1.9%) were HIV positive; and 1 (0.3%) was positive for malaria. Overall, 81 (25.8%) reported they had received one antibiotic, while the majority, 157 (50.2%), received two antibiotics, 55 (17.5%) received three antibiotics, 17 (5.4%) received four antibiotics, and 3 (1%) received a maximum of five antibiotics. Of all the 314 participants, 121 (39%) received penicillin, 81 (26%) received third-generation cephalosporins, and 53 (17%) received aminoglycosides. According to the WHO AWaRe category, of total prescriptions, 69.0% were from the Access group, 30.9% were from the Watch group of antibiotics, and no antibiotics from the Reserve group were prescribed at any of the three hospitals. Of total prescriptions, the use of Access and Watch group antibiotics was high in neonatology (80.1% and 9.9%) and obstetrics and gynecology units (71.8% and 28.2%), respectively. A total of 51 prescribing providers participated in the interview survey, 23 (45.1%) were from Butaro, 15 (29.4%) from Rwinkwavu, and 13 (25.5%) from Kirehe hospitals. The majority, 36 (70.6%), were under thirty years of age, and 46 (90.2%) were male. 40 (78.4%) of the providers were general practitioners. 46 (90.2%) of providers identified prescribing antibiotics before obtaining laboratory results in situations of common clinical presentation of infections and 38 (74.5%) in pre-operative conditions. Our findings point to the high use of a wide range of antibiotics. This underscores the urgent need for public health facility-based interventions to enhance appropriate antibiotic stewardship - including the need for enhanced surveillance of antibiotic use as part of a strong antimicrobial stewardship (AMS) program at national and health facility levels. Corresponding activities in AMS at the health facility level include the implementation of appropriate guidelines, continued in-service review of use, and training on recommended prescription practices.