Outpatient antibiotic prescribing for acute respiratory infections in children: an observational study in Nepal

BACKGROUND: Diagnostic challenges in children impact antibiotic decisions in low- and middle-income countries, contributing to the burden of antimicrobial resistance. This study assessed antibiotic use practices for childhood acute respiratory infections (ARI) in outpatient settings then compared findings between public and private facilities. METHODS: A cross-sectional observational study was conducted in two paediatric hospitals of Nepal (one public, one private) between January and July 2022. The standard checklist for ARI case management, adapted from the World Health Organization quality assessment and improvement tool, was applied to observe randomly selected doctor-patient consultations in disguised form with prior consent and ethics approval. Descriptive statistics were used to determine differences between the two facilities. RESULTS: Of 104 outpatient consultations assessed in two sites (52 cases each), the majority (76%) of ARI diagnoses complied with the national protocol for ARI management, and this practice was better in the private than the public facility (85% vs 67%, p=0.039). Antibiotics were prescribed in 64% of children (67/104), with no difference between facilities (p=0.838). Of these, just 9% of cases (6/67) were prescribed the first-line antibiotic (amoxicillin). The provider's decision to prescribe an antibiotic or not was inappropriate in 54% children (56/104), while among those who were prescribed an antibiotic, 81% (54/67) were prescribed the incorrect antibiotic. CONCLUSION: This study reports high rates of inappropriate antibiotic decisions and prescriptions for paediatric ARI in both public and private facilities, suggesting larger studies are needed to gauge the scope and need of antibiotic stewardship programmes targeted to the providers.