Patterns of antibiotic use for acute febrile illness in resource-limited settings: a multicenter study in DR Congo, Kenya and Uganda

Introduction:
In East Africa and beyond, uncertainty regarding the underlying aetiology of febrile illnesses may result in inappropriate treatment. In our study, we aimed at enhancing our understanding of antibiotic use patterns, prescribing practices and factors influencing antibiotic use in this region by exploring the pathways of care for acute febrile illnesses in three countries in East Africa.

Methods:
Between October 2021 and February 2024, acute febrile patients were enrolled in six health facilities in the eastern Democratic Republic of the Congo (DRC), Kenya, and Uganda. Our cross-sectional study assessed sociodemographic and clinical data along with initial diagnosis and antibiotic treatment record, collected at the initial outpatient and enrolment visit.

Results:
A total of 4,806 subjects were enrolled: 1,370 in DRC, 1,468 Kenya, 1,968 Uganda. About a quarter of the total population (23.3%) reported having already sought care before enrolment, most frequently in DRC (36.6%) at pharmacies (83.9%), and in Uganda (27.9%) at hospital (84.1%). Fifty percent of the DRC study population reported antibiotics use before enrolment, much higher than Kenya (3.3%) and Uganda (11.2%). Undifferentiated febrile illness was suspected in 37.5% of cases. At enrolment, in all countries, antibiotics were prescribed for 72.9% of cases (DRC 87.2% > Kenya 68.9% > Uganda 65.8%), with a non-negligible prescription of watch antibiotics (33.0%), prevalent in DRC (62.2%). In Kenya and Uganda, access antibiotics prevailed (80.9 and 67.1%, respectively). Prescription of watch antibiotics for undifferentiated febrile illnesses was strongly associated with a positive Widal test and access to hospital.

Conclusion:
Different patterns of access to care and antibiotic use for acute febrile illness were observed among countries. DRC had the highest level of pharmacy attendance prior to accessing the formal healthcare sector, as well as the highest reported use of antibiotics before formal care. It also showed the highest proportion of watch antibiotic use within the formal healthcare sector, even among patients without a confirmed diagnosis. Urgent targeted action is needed through effective and sustainable antimicrobial stewardship programs targeting both the formal and informal health sectors.