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Ukw Pub H. 2024; 24(10): 1-15. Published Online 2024 October 10 DOI
UkwSciID: USPH3
A MULTI-LEVEL STUDY OF A PEDIATRIC POPULATION ATTENDING A TEACHING HOSPITAL IN SOUTH-SOUTH NIGERIA (MuSPePATHS). PART 3: PREVALENCE OF ANTIBIOTICS USE AMONG THE CHILDREN
Edmund Ikpechi Ukwuru, and Onyinye Lydia Okeke
1
1, 2
Ukwuru, E.I. and Okeke, L.O. (2024). A Multi-Level Study Of A Pediatric Population Attending A Teaching Hospital In South-South Nigeria (Muspepaths). Part 3: Prevalence Of Antibiotics Use Among The Children. Ukwuru Public Health, 24(1): 1-15.
Abstract
Background
Antibiotics are commonly administered following the diagnosis of infectious diseases. Our findings from part 1 and part 2 indicated that children presented with one or more pathogenic diseases. In this part 3, we investigate antibiotic use prevalence, and the existence of statistically significant associations between antibiotic use and various variables.
Method
Antibiotic use data were extracted for each of the 1,000 patients. The number of antibiotics administered to each child was also documented to enable identification of the number of antibiotics administered to each child. Chi-Square and Correlation statistics were used to determine the level of significant association at 1% level of prevalence.
Findings
A total of 622 (62.2%) children received antibiotics. Gentamycin was the most frequently prescribed antibiotic, administered to 181 children, while cephalosporins were the most frequently prescribed class of antibiotics, administered to 388 children. We found that the number of antibiotics administered were associated with educational status, being an in-patient, and the number of hospital days (p<.001).
Conclusion
We conclude that there is high prevalence of antibiotics use among children, significant pressure is placed on cephalosporin antibiotics.
Recommendations
Necessary steps to reduce incidence of infectious diseases should be prevented. This will limit the prevalence of antibiotic use among children.
Keywords: Keywords: Children, antibiotics, combination therapy, infectious disease
Introduction
Children take ill from time to time and they are generally administered antibiotics following confirmed diagnosis of a pathogenic disease. Even among non-pathogenic illnesses, when suspected exacerbation implicates a pathogen, antibiotics are administered to facilitate health care outcomes. Following our findings from part 1 Ukwuru and Okeke, (2024a), and part 2 Ukwuru and Okeke, (2024b) the evidences are that majority of the children (62%) received antibiotic treatments. Most of the children received up to 2 antibiotic combination treatments.
Administering antibiotics to children have also been discussed in the findings of Briggs et al. (2023). Especially in our study where, children less than five years of age presented with various types of illnesses, and there was a statistically significant association between age and pathogenic illnesses (Ukwuru and Okeke, 2024b). Findings from Bert et al. (2022) revealed that children received antimicrobial self-medication. This is different from the evidences in our study because most of the children were admitted into hospital, or received antibiotics upon visiting hospital for treatment. Nonetheless, children receive antibiotics, and it can result in antibiotic abuse and antibiotic resistance. This is because as children progress in age, such early exposure to antibiotics without poor participation of the immune system can result in challenges. Besides, there is a propensity that not all infectious pathogens are cleared out following antibiotic use. Those that remain may pick up resistance and contributing to the spread of resistant pathogens. Also, because children reside in an environment wherein they receive treatment, the possibility that antibiotics that are excreted into the environment or not properly disposed may facilitate the spread of resistant pathogens can be detrimental to children as they grow up. Findings from Umeokonkwo et al. (2023) revealed high prevalence of antibiotics use (85.9%), that underpins our concerns about high rate of antibiotic use among children. This is why we are carrying out this part of the investigation.
We seek to identify the facilitators and predictors of antibiotic use, consequent to identifying the prevalence of antibiotic use, and the various types of antibiotics used. We hope to argue that the high rate of antibiotic use is facilitated by exposure to diseases and necessary action should be taken to prevent illness that leads to antibiotic use among children. Especially among neonates who are exposed to various illnesses; the second part of this multi-level study Ukwuru and Okeke, (2024b) revealed that children below the age of five years were the most likely to present with illnesses. We anticipate that our findings will encourage the need to take action that can prevent the prevalence of antibiotic use among children.
Method
The method for this third part of our multi-level study relies on the methods described in Ukwuru and Okeke, (2024a). The method of data analysis have been described in Ukwuru and Okeke, (2024b). Throughout this study, we refer to findings in the preceding studies; Ukwuru and Okeke, (2024a; 2024b).
Results
Antibiotic Use Status
Out of the 1,000 children, 622 (62.2%) received antibiotics while 375(37.5%) did not receive antibiotics. This high prevalence of antibiotic use among the children is consistent with the various diseases that the children presented with. Although, our earlier analysis Ukwuru and Okeke, (2024b) showed that non-pathogenic diseases were the most dominant; the finding was mainly focused on primary diagnosis not on comorbidities. Hence, some of the children were receiving antibiotics for comorbidities caused by pathogens. This explains the high rate of antibiotic use among the children (figure I).
Figure I: Antibiotic Use status among children
Number of Antibiotics Administered
The number of antibiotics administered in total was 1,168. This total count includes the primary antibiotics and various antibiotics that were administered as combination therapies. Gentamycin was the most administered antibiotic 181(18.1%). Among the 622 children who received antibiotics, there was also high prevalence of cefuroxime 154(15.4%), ampicillin 134(13.4%), and ceftriaxone 100(10.0%). With respect to ampicillin, the high count was because it was often administered as a combination of ampicillin and cloxacillin. Other combination therapies such as amoxicillin and clavulanic acid are well represented; amoxicillin was also high in prevalence (9.5%).
Figure II: Prevalence of Antibiotics Used in this study
Classes of Antibiotics
Seventeen classes of antibiotics were used. Majority of antibiotics used were cephalosporins (388). This includes all antibiotics with the “cef” prefix. Penicillins accounted for 277, encompassing amoxicillin, cloxacillin, ampicillin, and clavulanic acid type antibiotics. Aminoglycosides (188) and beta-lactam (141) antibiotics were also represented (figure III). Thematic description of classes of antibiotics and their comprising antibiotics are provided in figure IV.
Figure III: Class of Antibiotics
Figure IV: The Classes and Types of Antibiotics administered
Number of Combination therapies Administered
Most of the children received two antibiotics 245(24.5%) As the number of combination therapies increased, the number of children administered decreased. Hence, only one child received seven antibiotics (figure V).
Figure V: Combination therapies administered in this study
Associations between Age and the Number of Antibiotics
Chi-square analysis did not return a statistically significant association between age and the number of antibiotics used. Implying that age was not a determinant of how many antibiotics were administered to a child. The correlation statistics supported the chi-square analysis by returning a negative pearson’s R (-.258) and a negative Spearman correlation (-.423); both were statistically significant. This implied that as age increased, there was a decrease in the number of antibiotics that were administered to each child (table I).
Table I: As age increases, the number of antibiotics administered decreased, and this was statistically insignificant
P value = .003. Linear-by-linear association; p = <0.001 Pearson’s R = -.258 with an approximate significance (<.001). Spearman correlation -.423 with an approximate significance (<0.001).
Number of Antibiotics and Sex
Sex was not associated with the number of antibiotics administered. The finding implies that any child could have received any number of antibiotics (table II).
Table II: Sex was not a determinant of the number of antibiotics administered
Chi Square Asymptotic significance p = 0.462.
Number of Antibiotics and Educational Status
Educational status was statistically associated with the number of antibiotics administered. The difference was strongest among children who were not schooling (table III).
Table III: Not schooling was a strong determinant of the number of antibiotics received
Chi Square Asymptotic significance (p=<.001)
Number of Antibiotics and Residential Area
A statistically insignificant association was obtained for the relationship between number of antibiotics and residential area (table IV).
Table IV: Residential area was not a determinant of the number of antibiotics administered
Chi Square Asymptotic significance (p=0.874)
Number of Antibiotics and Patient Status
There is a statistically significant association between the number of antibiotics administered and the status of patients (p<.001). Thus, those patients who were in-patients were more likely to receive the highest number of antibiotic doses (table V).
Table V: Being an in-patient was a determinant of the number of antibiotics received
Pearson Chi Square p<0.001. Likelihood ratio p<0.001
Number of Hospital Days versus Number of Antibiotics
There is a statistically significant association between number of antibiotics and the number of hospital days (p<.001). Children who spent 1 week in the hospital were the most likely to receive the most number of antibiotics; being that the highest number of combination therapies administered was 2, followed by 3. As the number of hospital days decreased, the number of antibiotics administered also decreased (table VI).
Table VI: The number of hospital days is a determinant of the number of antibiotics administered
Chi-Square asymptotic significance (p<0.001) Linear-by-Linear association (p<0.001): Pearson R is significant at p<0.001. Spearman correlation p<0.001
Number of Antibiotics and Disease Type
The diseases for which the children were diagnosed with was not statistically associated with the number of antibiotics administered (table VII).
Table VII: Diseases type was not a predictor of the number of antibiotics
Chi Square p = .353
Number of Antibiotics and the Number of Comorbidities
The number of comorbidities did not influence the number of antibiotics administered. Children received any number of antibiotics depending on other factors (table VIII).
Table VIII: There is no statistically significant association between the number of antibiotics and the number of comorbidities
Chi Square p = .312 Linear-by-Linear association p=0.007
Pearson’s R = 0.007, Spearman Correlation = 0.011
Discussion
We found that there was high prevalence of antibiotic use among the children (62.2%). However, this was lower than the prevalence recorded by Briggs et al, (2023) (77.4%). Umeokonkwo et al. (2023) also recorded a high prevalence of antibiotic use (85.9%) among children. This high prevalence of antibiotic use is concerning and should be given attention. reduction of antibiotic use should begin with taking preventive steps towards infectious diseases, or exposure to pathogens that could exacerbate non-pathogenic diseases among children. This speaks to the importance of health education and health promotion. These studies; Briggs et al. (2023) and Umeokonkwo et al. (2023) were conducted among children across all ages within hospitals. Our study showed that children below the age of five years presented with the highest number of diseases and consequently, the highest number of antibiotic use cases. Our study did not find a statistically significant association between age and the number of antibiotics used. However, earlier evidence from Ukwuru and Okeke, (2024b) revealed that as age increased, the number of diseases decreased. Meaning that antibiotic use was likely to be highest among infants, than adolescent children.
According to Bert et al. (2022) Africa ranks second (22%) next to middle-east (34%) for high prevalence of antibiotics. Which explains why studies such as Briggs et al. (2023) and Umeokonkwo et al. (2023) resulted in high prevalence of antibiotic use. This is not different from the findings in this study, where high rate of antibiotic use was identified. Evidently, Africa is rife with several diseases that result in the use of antibiotics. The presence of comorbidities compounds the issue of antibiotics use. Although, we did not find a statistically significant association between the number of comorbidities and the number of antibiotics. However, some comorbidities may have led to increased antibiotic use, or simply facilitate the need to use antibiotics. For example, children who presented with malaria or typhoid and letter presented with sepsis as a result of either of these conditions. This resulted in the need to use more antibiotics. This explains the high counts of antibiotics such as gentamycin, amoxicillin, cloxacillin, and ceftriaxone. In general, cephalosporins led the ranks in terms of antibiotic use. Cephalosporins are broad spectrum antibiotics that are likely to be administered as the number of pathogenic comorbidities increased. Similar findings are confirmed in the study by Babaiwa et al. (2019) which revealed that children who were attending the University of Benin Health care center presented with malaria fever (31.8%), respiratory tract infections (28.0%). This type of comorbidities commonly result in the use of more than one antibiotic. In their study, Babaiwa et al. (2019) found that beta-lactam antibiotics were the most prescribed, and the percentage of antibiotic prescriptions was 34.2% with an average of 3.71 antibiotics per prescription.
Our study revealed that number of hospital days was determined by the number of antibiotics and vice versa (p<.001). The number of days spent in the hospital is influenced by the severity and length of illness. Our study did not cover severity of illness; however, this described as the number of hospital days. Thus, those children who received the most number of antibiotics (2), only spent four weeks in the hospital. The difference was statistically significant because receiving 2 antibiotics was a predictor of the number of days spent in the hospital. Our findings are consistent with the findings of Mambula et al. (2023); although, the studies were conducted in a different country, they indicate high rate of antibiotic use and various factors affecting antibiotic use among children.
Our study did not identify wrong use of antibiotics. However, antibiotics were given under conditions of comorbidity such as children who presented with vaso-occlusive crises and sepsis due to typhoid or malaria. Even those children who presented with neurological diseases such as epilepsy received antibiotic therapy when required. There is nothing wrong with this practice as there are no known drug interactions that emerged during the treatment of children in this study. What Aika and Enato, (2023) intended to achieve was to prevent the wrong use of antibiotics. This is not applicable to this study, as antibiotics use reflected accurate, professional, and knowledgeable practice. Nonetheless, this is an important area of focus while considering the impact of high antibiotic use among children. Our findings are similar to the findings of Osarenmwinda and Odama, (2024) who showed that there was high use of antibiotics among children; 38% of the children presented with comorbidities. It is not unexpected that children may present with various cases of comorbidities that may or may not warrant the use of antibiotics. However, if such conditions are likely to be exacerbated by pathogens, then antibiotics use becomes a necessity.
Conclusion
Our findings showed that there was high usage of antibiotics among the children (62.2%). This high prevalence is consistent with the high number of comorbidities and primary diagnosis that are of pathogenic origin. We identified that among the classes of antibiotics, cephalosporins were the most frequently used antibiotics, and this was led by cefuroxime. Gentamycin was the most frequently administered antibiotic, it was used for various conditions. there was a statistically significant association between the number of antibiotics administered and the number of hospital days; children who received two antibiotics were likely to spend as much as four weeks in the hospital. What our study concludes is that antibiotics use is significantly high, and preventive efforts should be targeted at eliminating diseases through health education and health promotion.
Limitation
This study was a retrospective study, it limited the possibility of identifying other factors that may have contributed to the high rate of antibiotic use.
References
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Acknowledgements
We acknowledge the efforts of Ukwuru Science Management team and Ukwuru Science Study Group in bringing this study to reality.
Funding
Funding was provided by Ukwuru Science.
Author Information
Edmund Ikpechi, Ukwuru is the research director at Ukwuru Science Lagos. He works with a number of private organisations and individuals, consulting on public health and biomedical science research. He is also a Management Consultant and holds a Honorary Doctor of Business Administration (DBA) for his expertise in business practices.
Onyinye Lydia, Okeke (Medical Doctor) is the Medical Director at Ukwuru Science. She works with several healthcare institutions and private professionals as a consultant. She also works as a Medical Doctor at Rhowil Total Care Hospital Lagos.
Corresponding Author
Edmund Ikpechi, Ukwuru
Competing Interests
There are no competing interests for this study.
Rights
The publication is open for public use; credits must be provided by acknowledging the authors of the study.
Cite as
Ukwuru, E.I. and Okeke, L.O. (2024). A Multi-Level Study Of A Pediatric Population Attending A Teaching Hospital In South-South Nigeria (MuSPePATHS). Part 3: Prevalence Of Antibiotics Use Among the Children. Ukwuru Public Health, 24(1): 1-15.
Received: 1 August 2024
Accepted: 1 October 2024
Published: 10 October, 2024
Keywords: Children, antibiotics, combination therapy, infectious disease