Use of antibiotics in newborns with infections at rural referral hospital in Uganda: compliance with empirical guidelines

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Introduction Despite global progress, neonatal infections remain a major cause of mortality in low- and middle-income countries. In Uganda, high neonatal mortality and rising antimicrobial resistance underscore persistent challenges in prescribing appropriate treatment. WHO developed a Global Action Plan to promote safe and effective antibiotic use, which forms the basis of Uganda's National Action Plan. Limited evidence exists on how national guidelines are followed, particularly regarding first-line therapy and dosing. The aim is to assess adherence to national guidelines for inpatient use of antibiotics in neonates with suspected infections at Mbarara Regional Referral Hospital (MMRH), and factors affecting the adherence. Methods This cross-sectional study included 300 neonates admitted to the Neonatal Intensive Care Unit at MRRH Uganda, between October and November 2024. Clinical records were analysed to summarize demographics, danger signs, diagnoses, and antibiotic use by WHO Possible Severe Bacterial Infection (PSBI) criteria. Logistic regression was done to assess the predictors for compliance for antibiotics. Results Of the total population ( n = 300), 125 (41.7%) had ≥2 DSs, 124 (41.3%) had 1 danger sign, and 51 (17%) had none. In total, 96.7% received antibiotics, and 16.6% of these had no danger sign. Among those who received antibiotics and had ≥1 danger sign, 58.3% received recommended type and dose. Among those with ≥ 2 danger sign, 98.4% received any antibiotic, 80% received the first-line combination, and 60.8% the correct dose. Higher number of danger sign (OR = 7.96, 95% CI 4.76-13.30, p = <0.001), and the presence of hypoxic ischemic encephalopathy (OR = 4.74, 95% CI 1.13–19.89, p = 0.033), and birth asphyxia (OR = 6.23, 95% CI 1.30–29.83, p = 0.022) were associated with higher adherence. No blood cultures were performed. Discussion Low compliance with guidelines in cases of PSBI and frequent use of antibiotics in neonates with no or only one danger sign was observed. However, only one danger sign is an indication for antibiotics in Uganda's guidelines, indicating that national guidelines may lead to broader antibiotic use than WHO recommendations.

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