# Standardizing Antimicrobial Use in a Resource-Limited Pediatric Surgical Unit in Botswana

## TL;DR

A hospital in Botswana improved appropriate antimicrobial use in pediatric surgery by implementing standardized clinical pathways and ongoing audits.

## Contribution

The study demonstrates that clinical pathways and audits can significantly improve antimicrobial stewardship in a resource-limited setting.

## Key findings

- Appropriate antimicrobial use increased significantly across multiple surgical specialties after implementing clinical pathways.
- Improvements in prescribing were observed across provider categories and years of experience.
- Overall antimicrobial use remained low, with only 34% of patients receiving antibiotics.

## Abstract

Antimicrobial resistance is rampant in low- and middle-income countries. Recent data from Princess Marina Hospital (PMH), Botswana, revealed that 100% of pediatric surgical unit patients received antimicrobials inappropriately.

We implemented a quality improvement initiative to improve antimicrobial use in children admitted to PMH's pediatric surgical ward. With key stakeholders, we developed clinical pathways (CPs) to standardize antimicrobial use across common surgical diagnoses. A CP booklet, informed by the World Health Organization (WHO) Access, Watch, and Reserve (AWaRe) guideline, was distributed to prescribers. We conducted weekly prospective antimicrobial use audits over 1 year, from 3 months pre–CP implementation to 9 months post–CP implementation.

A total of 1099 pediatric surgical patients were admitted and 374 (34.0%) required antimicrobials. The WHO Access group accounted for 360 antibiotic courses (72.4%) and the Watch group for 137 (27.6%), a total of 497. Overall, appropriate antimicrobial use improved significantly (pediatric surgery, 33 [50.8%] vs 99 [93.4%]; orthopedics, 3 [10.3%] vs 26 [89.7%]; neurosurgery, 5 [27.8%] vs 13 [72.2%]; and ear, nose, and throat, 4 [33.3%] vs 19 [95.0%]; each P < .001) in the postimplementation period except for maxillofacial-dental patients (1 [25.0%] vs 3 [75.0%]; P = .264). Improvements were observed across provider categories and years of experience: medical officers (28 [42.4%] vs 38 [91.0%]), interns (7 [33.3%] vs 20 [87.0%]), and specialists (11 [26.2%] vs 64 [97.0%]); years of experience: <2 years (9 [32.1%] vs 22 [91.7%]), 2–5 years (3 [25.0%] vs 50 [92.6%]), and >5 years (34 [38.2%] vs 154 [92.2%]) (P < .001 for each).

Appropriate antimicrobial use improved post–CP implementation. Expanding CPs with ongoing antimicrobial stewardship education will ensure sustained improvement.

Antimicrobial use was overall low on the surgical ward, with 34.0% of admitted surgical patients receiving an antimicrobial at least once. Appropriate use of antimicrobials improved after implementation of clinical pathways. Improvement in prescribing correlated with level of providers’ experience.