Evaluating the appropriateness of prescribing antibiotics among persons with HIV (PWH) in an Urban HIV outpatient clinic in Uganda

BACKGROUND: Sub-Saharan Africa (SSA) faces a high burden of antimicrobial resistance (AMR). Inappropriate antibiotic use is the major driver of AMR. Populations at high risk for infections, such as persons living with HIV (PWH), are more likely to experience AMR. However, data on the appropriateness of antibiotic prescribing in outpatient settings for PWH are limited. METHODS: We conducted a retrospective review of antibiotic prescriptions from 1st January 2016 to 31st December 2022 in an HIV tertiary care outpatient clinic in Uganda. We extracted data from patients' records and assessed appropriateness using a customized tool. Data were abstracted across three points of care: the general clinic, the urgent care unit, and the TB clinic for presumptive TB patients. Prescriptions were considered appropriate if they had a documented indication, the right drug, dose, frequency, and duration, when evaluated against national guidelines and the national formulary in some instances. Appropriateness was measured in proportions, and differences in patient characteristics were analyzed. Factors associated with inappropriate antibiotic prescriptions were assessed using a modified Poisson regression model. RESULTS: We reviewed the medical records of 1367 participants, with a median age of 49 years (IQR: 42-57), and the majority, 944 (69.1%), were female. In total, the participants contributed 1823 antibiotic prescriptions, of which 1605 (88%) were inappropriate. Of the 1605 inappropriate prescriptions, 842 (52.5%) were due to absence of an indication, 539 (33.5%) to nonadherence to the guidelines, and 224 (14%) didn't have a suspected or confirmed infection. The urgent care unit had the highest proportion of inappropriate antibiotic use (82.4%), p = 0.02. Fluoroquinolones 14/124 (11.3%), macrolides 22/189 (11.6%), and cephalosporins 56/479 (11.7%) were the least appropriately prescribed classes of antibiotics. The male participants had a 17% lower prevalence of inappropriate prescriptions compared to females [adjusted PR 0.83 (95% CI: 0.75-0.92)]. CONCLUSION: We found a high level of inappropriate antibiotic use among PWH in outpatient care. Notably, more than half of the prescriptions lacked a documented indication, highlighting poor documentation practices.