Overuse of antibiotics in maternity and neonatal wards, a descriptive report from public hospitals in Dar es Salaam, Tanzania

Overuse of antibiotics is a major challenge worldwide and undermines measures to control antimicrobial resistance (AMR). Failure to control AMR is leading to an increase in mortality, prolonged hospital stays, worsening of clinical conditions and increase in the cost for treatments [1‐3]. AMR and specifically, resistance to antibiotic agents for treating bacterial infections, is a major problem in many African countries [4‐6]. In Tanzania, an AMR surveillance platform has recently been implemented, but the extent of the burden of AMR currently remains unknown [7, 8]. Overuse (too much use), misuse (wrong use) or high consumption (use of large quantities) of antimicrobial drugs are closely related concepts. Collectively, these are major drivers of antimicrobial resistance [3, 9].

There are multiple reports of high levels of unnecessary prescriptions of antibiotics for both postnatal women, following either cesarean section (CS) or vaginal delivery, and neonates [10‐13]. In Sub-Saharan Africa (SSA), although the risk of perinatal infections is high for both mothers and neonates, limited data exists on the use of antibiotics in these groups [14].

Similarly, in Tanzania there are few formal studies of prescribing practices for antibiotics during the postpartum and neonatal period, where maternal and neonatal sepsis are estimated to be responsible for 13% and 20% mortality respectively [15, 16]. As part of a pilot study investigating impacts of an environmental hygiene intervention in Tanzanian hospitals, we aimed to describe antibiotic use in women who recently gave birth and their newborns in three hospitals in Dar es Salaam, Tanzania.

We performed repeated rounds of PPS for antibiotic use in the maternity and neonatal departments of three busy public sector hospitals in urban Tanzania. We found high levels of antibiotic use in women following vaginal delivery or caesarean section. Around 95% of surveyed women who had CS were receiving antibiotics, and among these, 95% were receiving them for post-operative surgical prophylaxis lasting more than one day. The high use was observed in all three hospitals and in all surveys. Prescription of antibiotics in post-natal wards varied widely between hospitals: while Hospital 1 prescribed antibiotics in about 60% of women, Hospitals 2 and 3 only prescribed 11% and 1.4% respectively. The most common reasons for antibiotic prescription were medical or surgical prophylaxis in all hospitals. Similarly, we observed high use of antibiotics, at around 90%, in neonatal wards, with the vast majority being used for medical prophylaxis or without a clear indication. This near-universal prescription of antibiotics after CS is a common clinical practice in low income countries [21‐23], despite the absence of evidence or recommendations to support it. By contrast, in high income countries, the irrational use of antibiotics after CS and in maternity wards is reported to have dropped markedly over recent years [10]. This variation in practice may be explained by the onset of antibiotic stewardship programs in many hospitals in high-income countries [24]. In hospitals with limited resources, prescribing post-operative prophylactic antibiotics is likely to be influenced by concerns about high local rates of SSI, in turn attributable to weak measures for infection prevention and poor hygiene in surgical environments [25]. However, to the best of our knowledge there is no evidence that post-operative antibiotic prophylaxis helps to prevent surgical site infections. In Tanzania, infection prevention and control (IPC) data from health facilities indicates low adherence to IPC guidelines among health care workers [25, 26]. In this study, antibiotics were prescribed to one quarter of women with vaginal delivery, with substantial variation between the facilities. The highest use was reported in Hospital 1 (62.5%), most commonly for prophylaxis, whereas antibiotic use was relatively low for women following vaginal delivery in Hospital 2 (11.1%) and Hospital 3 (1.4%). We believe this wide variation between hospitals is likely to reflect differences in prescribing practices between the facilities or individual health care workers, rather than differences in infection rates, though we cannot conclusively confirm this. In other low-income settings, high use of antibiotics in women with vaginal delivery has been reported in India and Vietnam, and in a WHO study combined data from Africa, Asia and the Americas [12, 23, 26].While the study in India reported the lack of local guidelines at the time of the study as a possible factor underlying the high antibiotic prescribing rate, it was not clear whether the Vietnamese and WHO studies were in facilities with availability of guidelines for management. On the other hand, studies from Sweden and USA have reported a low use of antibiotics after vaginal delivery, reflecting the well-established nature of antibiotic stewardship programs in these countries [10, 23, 28].

In this study, we expected to see a difference in antibiotic use between the CS and vaginal delivery because CS carries higher risk of infection. Prophylactic antibiotics are recommended in CS but they should be given pre-rather than post-operatively. Irrational overuse of antibiotics is likely to ultimately lead to severe illness and death in mothers and newborns as a result of increasing levels of antibiotic resistance in low-income countries [3]. More than 90% of the admitted neonates were given antibiotics during this survey, typically as medical prophylaxis or without a clearly recorded indication. The wards were staffed by pediatricians and general practitioners, and it is possible that prescribing practice would be different among specialist neonatologists. However, specialists are rare for regional hospitals in Tanzania, so we believe our findings would be generalizable to other hospitals in Tanzania. Similarly, high use of antibiotics in neonates has been reported in one study in India where around 90% of the admitted neonates were given antibiotics [27]. Use of antibiotics in high-income countries is reported to have dropped significantly in the past years among neonates [28]. Early neonatal antibiotic exposure may be associated with morbidities such as allergy, obesity, gastrointestinal disorders and acquisition of carriage of antibiotic resistant bacteria, though the underlying evidence is weak [29‐31].

There was an extremely high prevalence of antibiotic prescribing for prophylaxis in maternal and neonatal units in hospitals in Dar es Salaam, Tanzania. Better infection control policies, local and national guidelines, and antimicrobial stewardship programs need to be implemented to avoid unnecessary prescription of the antibiotics and promotion of antibiotic resistance.