Antibacterial Utilization for Febrile Illnesses and Laboratory-confirmed Bloodstream Infections in Northern Tanzania

Antibacterial management of febrile patients in low-resource settings is challenging and adherence to treatment guidelines is variable. We describe antibacterial use in febrile patients, use of effective therapy for laboratory-confirmed bloodstream infections, and adherence to published guidelines for common febrile illnesses among patients enrolled in prospective hospital-based fever surveillance studies in Moshi, Tanzania.

We compared data from two hospital-based prospective cohort studies, Cohort 1 (2011–2014) and Cohort 2 (2016–2019), that enrolled febrile infants, children, and adults. A study team member administered a standardized questionnaire, performed a physical examination, and collected blood cultures on all participants. Ceftriaxone, ciprofloxacin, amoxicillin-clavulanate, or azithromycin were categorized as broad-spectrum antibacterials based on published frameworks and local antimicrobial availability. Participants with laboratory-confirmed bloodstream infections were categorized as receiving effective or ineffective antibacterials based on culture and susceptibility data. Antimicrobials prescribed for preliminary or final diagnosis of pneumonia, urinary tract infection, or presumed sepsis were compared with syndrome-specific recommendations from the World Health Organization (WHO) and the Tanzania Standard Treatment Guidelines. We used descriptive statistics and logistic regression to describe factors associated with antibacterial use.

We analyzed data from 2175 participants. The median age of participants in Cohort 1 was 29 (IQR: 5-41) and 22 in Cohort 2 (IQR: 2-45). Among all participants, 50% were female. There were 430 (42.0%) and 501 (45.1%) participants who reported use of antibacterials prior to admission in Cohort 1 and Cohort 2, respectively. There were 989 (91.4%) participants who received antibacterials during admission for febrile illness in Cohort 1 versus 1060 (93.6%) in Cohort 2 (p < 0.001); 548 (52.5%) in Cohort 1 and 682 (60.2%) in Cohort 2 (p < 0.001) received broad-spectrum therapy. Inpatient use of ceftriaxone, metronidazole, and ampicillin increased between the two cohorts (ceftriaxone p = < 0.001; metronidazole p = 0.02; ampicillin p = < 0.001). Laboratory-confirmed bacteremia was found in 38 (3.6%) participants in Cohort 1 and 47 (4.2%) participants in Cohort 2. Complete data to determine appropriateness of antibacterial prescription were available for 81 (95.3%) of 85 participants and 52 (63.0%) participants were prescribed effective therapy. Guideline-consistent therapy for pneumonia, urinary tract infection, and sepsis increased over time.

Receipt of antibacterials prior to and after hospital admission were high and use of broad-spectrum medications was common. A large proportion of participants with culture-confirmed bloodstream infections were treated with ineffective antibacterials but consistency of antibacterial prescribing with WHO and Tanzanian treatment guidelines improved over time. Our results highlight the need for improved diagnostics for febrile illness, data on local antimicrobial resistance patterns, institution-specific clinical guidelines, and provider education to improve prescribing practices and rational use of antimicrobials in Tanzania.