Evaluating the appropriateness of laboratory testing and antimicrobial use in South African children hospitalized for community-acquired infections

INTRODUCTION: Community acquired infection (CAI) is the leading indication for paediatric hospitalization in South Africa. METHODS: We conducted secondary data analysis of prospective, consecutive paediatric admissions to Tygerberg Hospital (May 2015-November 2015). Clinical characteristics, admission diagnosis, appropriateness of diagnostic tests, use of antimicrobial prescriptions, hospital outcome and costs were analyzed. RESULTS: CAI episodes were documented in (364/451; 81%) children admitted to the general paediatric ward; median age 4.8 months (Interquartile range, IQR, 1.5–17.5) and weight 5.4kg (IQR, 3.6–9.0). Male gender predominated (210/364; 58%), and Human Immunodeficiency Virus infection prevalence was 6.0% (22/364). Common CAI types included respiratory tract infections (197; 54%), gastroenteritis (51; 14%), and bloodstream infections (33; 9%). Pre-hospital antibiotics (ceftriaxone) were given to 152/364 (42%). Of 274 blood cultures and 140 cerebrospinal fluid samples submitted, 5% and 2% respectively yielded a pathogen. Common CAI antibiotic treatment regimens included: ampicillin alone (53%); ampicillin plus gentamicin (25%) and ampicillin plus cefotaxime (20%). Respiratory syncytial virus (RSV) was found in 39% of the children investigated for pneumonia. Most antibiotic prescriptions (323/364; 89%) complied with national guidelines and were appropriately adjusted based on the patient’s clinical condition and laboratory findings. The overall estimated cost of CAI episode management ZAR 22,535 (≈1423 USD) per CAI admission episode. Unfavourable outcomes were uncommon (1% died, 4% required re-admission within 30 days of discharge). CONCLUSION: CAI is the most frequent reason for hospitalization and drives antimicrobial use. Improved diagnostic stewardship is needed to prevent inappropriate antimicrobial prescriptions. Clinical outcome of paediatric CAI episodes was generally favourable.