Antibiotic use among patients with malaria and co-existing diagnoses in tertiary hospitals in Uganda

Inappropriate antibiotic use is a major contributor to antimicrobial resistance (AMR) worldwide, especially in settings with high disease burden. This study used Point Prevalence Survey (PPS) data to determine the rate and factors associated with antibiotic use among hospitalized patients with a recorded malaria diagnosis and at least one additional recorded diagnosis in selected regional referral hospitals in Uganda. We conducted a secondary analysis of antibiotic use data from the PPS conducted between October 2020 and November 2023 at nine regional referral hospitals across Uganda. We analyzed data from 1,092 patient records in which malaria was recorded with at least one additional diagnosis. We defined non-adherence to standard treatment guidelines as any antibiotic prescription that did not comply with one or more of the 5Rs of Antimicrobial Stewardship (AMS) and used modified Poisson regression to estimate prevalence ratios (PRs) for factors associated with non-adherence to national antibiotic prescribing guidelines. We reviewed 9,008 records, among which 1,092 (12%) had malaria as part of the diagnosis. Among the 1,092, the median age was 7 (IQR:3–16), 581 (53%) were female, 738 (68%) were admitted to pediatric wards, and 464 (42%) received antibiotic prescriptions that were not adherent to national guidelines. Non-adherence to the Uganda Clinical Guidelines varied significantly, with the highest level (48%) observed in the medical ward. “Other” was the most common indication for non-adherent antibiotic prescription. Most (61%) prescribed antibiotics fell into the Watch category of the WHO AWaRe classification, and general practitioners made 923 (84.5%) of all prescriptions. Multivariable analysis indicated that medical prophylaxis (aPR = 1.81, 95% CI = 1.47–2.24), having an infectious syndrome (aPR = 2.15, 95% CI = 1.76–2.63), and other indications (aPR = 1.97, 95% CI = 1.65–2.37) were significantly associated with non-adherence to national guidelines. Nearly half of patients hospitalized with malaria and co-existing diagnoses received antibiotics outside the national prescription guidelines, often for non-specific indications, mostly by general practitioners. Targeted stewardship interventions, such as prescriber training, improved point-of-care diagnostics, routine audits and feedback, and integrating stewardship support into malaria programming, may help optimize antibiotic use and support broader AMR containment efforts in similar settings.