# Health system and treatment regimen determinants of delayed first-dose antibiotic administration in hospitalized adults in Uganda

## TL;DR

This study in Uganda finds that health system issues and complex treatment regimens cause delays in starting antibiotics for hospitalized adults.

## Contribution

Identifies modifiable health system and treatment factors causing delayed antibiotic administration in low-resource settings.

## Key findings

- Delays were strongly linked to long wait times before initial consultation and inadequate staffing.
- Prescribing three antibiotics instead of one significantly increased the odds of delay.
- Patients with low income had lower odds of experiencing delays.

## Abstract

Delayed first-dose antibiotic administration among hospitalized adults partly contributes to poor treatment outcomes. However, the operational drivers of such delays remain poorly characterized in low-resource settings. We sought to delineate the possible operational drivers of these delays, and suggest potential healthcare in Uganda.

We conducted a cross-sectional study of 606 adult inpatients with suspected or confirmed bacterial infections at two public health facilities in Uganda. Delayed administration/initiation was defined as administration of the first antibiotic dose 〿 48 hours after prescription. Data were obtained through interviewer-administered questionnaires and medical record review. Data analysis was performed using multivariable logistic regression.

Among 606 participants, 36 (6.0%) experienced delayed antibiotic administration. Delays were strongly associated with health system determinants, such as waiting for more than 12 hours before initial consultation (aOR 5.35, 95% CI 2.43–11.78), lack of convenient facility hours (aOR 5.02, 95% CI 2.41–10.44) and inadequate medical staffing (aOR 2.37, 95% CI 1.06–5.27). Treatment complexity was a key clinical driver, where prescription of three antibiotics but not monotherapy, was associated with substantially higher odds of delay (aOR 5.69, 95% CI 1.85–17.52). Generally, patient demographic characteristics were not associated with delay. Patients reporting inadequate household income had lower odds of delay (aOR 0.29, 95% CI 0.12–0.67).

Although delayed first-dose antibiotic administration was uncommon, it was driven by modifiable health system inefficiencies and regimen complexity. Targeted operational interventions like improving triage processes, extending facility hours, ensuring adequate medical staffing and streamlining multi-drug regimens reduce such delays. This could consequently support effective antibiotics use towards intended treatment outcomes in resource-constrained settings.