Antibiotic use prior to seeking medical care in patients with persistent fever: a cross-sectional study in four low- and middle-income countries.

Abstract Objectives Community-level antibiotic use contributes to antimicrobial resistance, but is rarely monitored as part of efforts to optimize antibiotic use in low- and middle-income countries (LMIC). We investigated antibiotic use in the 4 weeks before study inclusion for persistent fever. Methods The NIDIAG-Fever study investigated etiologies of infections in patients ≥5 years old with fever >1 week in six healthcare facilities in Cambodia, Democratic Republic of the Congo (DRC), Nepal, and Sudan. In the present nested cross-sectional study, we describe prevalence and choice of antibiotics before and at study inclusion, applying the Access/Watch/Reserve (AWaRe) classification of the WHO List of Essential Medicines. Factors associated with prior antibiotic use were analysed. Results Of 1939 participants, 428 (22.1%) reported the prior use of ≥1 antibiotic, ranging from 6.3% (24/382, Cambodia) to 35.5% (207/583, Nepal). Of 545 reported antibiotics, most frequent were Watch group antibiotics (351/545, 64.4%), ranging from 23.6% (DRC)-82.1% (Nepal). Parenteral administration ranged from 5.9%-69.6% between study sites. Antibiotic use was most frequent among young patients (5-17 years; Risk ratio 1.42, 95%CI 1.19-1.71) and men (RR 1.29; 95%CI 1.09-1.53). No association was found with specific symptoms. Of 555 antibiotics started before, 275 (49.5%) were discontinued at study inclusion. Conclusions Watch antibiotics were frequently used, and discontinued upon study inclusion. The antibiotic use frequency and choice varied importantly between LMIC. Local antibiotic use data are essential to guide efforts to optimize antibiotic use in LMIC, should not be restricted to hospitals, and need to take local healthcare utilization into account.