# P-893. Comparative Antibiotic Stewardship Practices at Upper-Income versus Lower-Income Hospitals in Southern Malawi

## TL;DR

This study compares antibiotic use and resistance in high- and low-income hospitals in Malawi, finding that stewardship strategies must be tailored to local conditions.

## Contribution

The study provides localized insights into antibiotic stewardship in Malawi, highlighting the need for site-specific interventions.

## Key findings

- Both urban and rural hospitals showed high rates of antibiotic resistance, with rural areas showing higher carbapenem resistance despite lower usage.
- Rural providers were more adherent to national treatment guidelines, but faced challenges in subspecialty wards.
- Antimicrobial resistance was linked to worse patient outcomes, including higher costs and mortality in urban areas.

## Abstract

Malawi suffers from high rates of antimicrobial resistance, with a Drug Resistance Index currently estimated higher than India and Argentina. Stewardship literature in sub-Saharan Africa shows positive impact of regional stewardship programs,though significant variation is seen in control populations and clinical and microbiologic outcomes across study sites.Table 1Descriptive StatisticsTable 2Comparative Antimicrobial Resistance at Urban and Rural Sites

Descriptive Statistics

Comparative Antimicrobial Resistance at Urban and Rural Sites

Clinical antibiograms and provider prescribing data were compared between an urban upper-income referral hospital in Blantyre District, southern Malawi (n=1341) and a rural safety-net hospital in Thyolo District, southern Malawi (n=2366). (Table 1)Table 3Period Prevalence Analysis of Prescribing Practices at Urban and Rural SitesTable 4Antimicrobial Stewardship: PICO Identification of Quality Improvement Interventions

Period Prevalence Analysis of Prescribing Practices at Urban and Rural Sites

Antimicrobial Stewardship: PICO Identification of Quality Improvement Interventions

High rates of ESBL-suspect ceftriaxone-resistant gram negatives were seen at both sites (42.8% versus 52.8% E. coli, 50.7% versus 62.5% Klebsiella) as well as high rates of methicillin-resistant Staph aureus (47.2% versus 29.3%) (Table 2). Despite a substantially lower rate of carbapenem scripts at the rural safety-net site, a higher rate of carbapenem resistance was seen at the rural-safety net site (24.4% E. coli, 43.7% Klebsiella) as compared to the urban upper-income site (7.7% E. coli, 14.9% Klebsiella). Adverse outcomes were associated with antimicrobial resistance in urban and rural settings, including hospital cost (p< 0.01) and patient death (p< 0.01) in the urban cohort as well as length of stay (p< 0.01) in the rural cohort. Rural safety-net providers were overall more adherent to Malawi Standard Treatment Guidelines than urban upper-income providers (Table 3), although rural challenges were noted in subspecialty ward subgroups including neonatology. Additionally, unique local challenges at each hospital (Table 4) were identified as areas for stewardship improvement.

Data suggests that stewardship approaches are not one-size-fits-all in southern Malawi, and need to be tailored to unique local and institutional needs.

All Authors: No reported disclosures