Prevalence and Predictors of Antibiotic Prescription Among Patients Hospitalized with Viral Lower Respiratory Tract Infections in Southern Province, Sri Lanka

Abstract

Background: Antimicrobial overprescription has been associated with antimicrobial resistance, and is common for lower respiratory tract infections (LRTI) as viral and bacterial infections generally present with similar clinical features. The aim of this study was to identify the prevalence and predictors of antibiotic prescription among children and adults hospitalized with viral LRTI. Methods: A prospective cohort study was conducted among patients hospitalized with viral LRTI in a tertiary care hospital in Southern Province, Sri Lanka from April 2018 to October 2021. Consecutive patients ≥1 year old who met a case definition for LRTI were enrolled. Patients’ demographic, clinical, and laboratory data were recorded. A nasopharyngeal sample and blood sample were collected from all patients for multiplex polymerase chain reaction (PCR) testing for respiratory pathogens and procalcitonin (PCT) detection, respectively. Among patients with viral RTI, demographic and clinical features associated with antibiotic prescription were identified using Chi Square and t-tests, as appropriate. Significant variables (p<0.05) on bivariable analyses were included in a multivariable logistic regression model to identify features associated with antibiotic prescription. The potential impact of procalcitonin testing on antibiotic prescription was simulated using standard PCT cut-offs. Analyses were conducted separately for children (<18 years) and adults using R Statistical Software (R Core Team 2022). Results: A total of 1217 patients were enrolled during the study period; of these, 438 (36.0%) had one or more respiratory viruses detected. Of 438 patients, 48.4% were male and 30.8% were children; the median age was 4 years (IQR 2-7) for children and 61 years (IQR 48-70) for adults. The most commonly detected viruses were influenza A (39.3%), human rhinovirus/ enterovirus (HRV/HEV; 28.3%), and respiratory syncytial virus A (RSV A; 10.3%). Overall, 114 (84.4%) children and 266 (87.8%) adults with respiratory viruses were treated with antibiotics during hospitalization. On multivariable modeling for children, neutrophil percentage (median 63.8% vs 47.3%, p=0.03) was positively associated with antibiotic prescription. Among adults, headache (60.6% vs 35.1%, p=0.003), presence of crepitations/crackles on exam (55.3% vs 21.6%, p<0.001), rhonchi/wheezing on exam (42.9% vs 18.9%, p=0.005), and presence of opacities on chest x-ray (27.4% vs 8.1%, p=0.01) were associated with antibiotic prescription. Access to PCT test results could have potentially decreased inappropriate antibiotic prescription in this study by 83.3%. Conclusions: A high percentage of viral detection and high prevalence of antibiotic prescription were observed among a large inpatient cohort with LRTI. Our results suggest that improved access to point-of-care biomarker testing may improve antimicrobial stewardship for LRTI in this low-resource setting.