Utility of the WHO AWaRe classification in monitoring antibiotics use trends at select tertiary hospitals in Uganda: Evaluation of 2020-2023 Point Prevalence Surveys

Introduction: Irrational use of antibiotics is a major driver of antimicrobial resistance (AMR). The WHO AWaRe classification was introduced as a tool to support antibiotic stewardship efforts to optimize antibiotic use and control AMR. We evaluated antibiotic use trends at nine tertiary hospitals in Uganda, classified according to the AWaRe classification. Methods: We evaluated the Point Prevalence Surveys (PPS) data, collected at nine regional referral hospitals (RRH); Arua, Gulu, Jinja, Kabale, Lira, Masaka, Mbale, Mbarara and Soroti, from Oct 2020 to Dec 2023. Data were collected at each facility from five wards; gynaecology, maternity, medical, paediatric and surgical, using the modified WHO PPS tool. The antibiotics prescribed were categorized according to the 2023 WHO AWaRe classification. Data were analyzed descriptively using frequencies and percentages, and linear regression analysis using R software version 4.3.1. Results: Over the evaluation period, 12 PPS were conducted and a total of 15,934 antibiotics were prescribed. Overall, the prevalence of antibiotic use was 60.1 per 100 admissions (8879/14,769). Access antibiotics were the most frequently used antibiotics 47.7% (7,605/15,934), followed by Watch 44.4% (7075/15,934), with less of the Reserve 0.08% (12/15,934). Up to 7.8% of the antibiotics used were unclassified combination drugs. Notably, medical ward used more Watch antibiotics 62% (1740/2806), compared to gynaecology, maternity, paediatric and surgical wards, whose use were 43.7% (791/1812), 42.2% (1425/3375), 39.2% (1555/3970), and 39.4% (1564/3971) respectively. Prescription of Reserve antibiotics was 1.8% (7/379), on the surgical ward in the 11th PPS.Over the evaluation period, there was an 18% (R-squared: 0.183, slope: 0.147, p-value: 0.165) increase, and a 64% (R-squared: 0.641, slope: -0.417, p-value: 0.002) decrease in the use of Access and Watch antibiotics respectively. There was no notable change in the Reserve antibiotics use trend (R-squared: 0.331, slope: 0.022, p-value: 0.051). Discussion: Similar to findings in Zambia (Mudenda, 2024), prescription of Access antibiotics was below the WHO AWaRe classification recommended threshold of 60%. The observed effect from the stewardship interventions needs to be strengthened and scaled up to preserve our endangered antibiotics. Conclusion: Overall, antibiotic use prevalence was 61%, with a notably high use of Watch antibiotics on the surgical ward. However, there was an overall decrease in use of the Watch antibiotics over the evaluation period. Adoption of the WHO AWaRe classification to guide stewardship can help to promote the rational use of antibiotics, addressing one of the major drivers of AMR. Control of AMR can contribute to reducing the burden of infectious diseases more so in limited resource settings.