Evaluation of Antimicrobial Use in Children and Adults at a National Referral Hospital in Guatemala
Authors: Morris Lee E , Schweiger Jennifer A , Raffler Rebecca , Posadas Sofia , Forrester Jeanne B 
Published: January 2025

Abstract

Corresponding Author: Lee Morris, 1000 Blythe Blvd, PO Box 32861, Charlotte NC 28203, 919-260-8623, Lee.morris@atriumhealth.org
Alternative Corresponding Author: Jennifer Schwieger, 1000 Blythe Blvd, Charlotte, NC 28203, 704-381-6331, Jennifer.schwieger@atriumhealth.org
Funding Source: Heineman-Robicsek Foundation
No conflicts of interest.

Background
Latin America has high rates of antimicrobial resistance among hospitalized patients, including neonates and children, and many barriers to antimicrobial stewardship implementation. Understanding local patterns of antimicrobial utilization is an essential component of antimicrobial stewardship efforts. Inappropriate antimicrobial prescribing is described in some low-resource settings, but data are lacking in Central America, particularly Guatemala. This study evaluated antimicrobial utilization at a tertiary hospital in Guatemala to identify targets for antimicrobial stewardship interventions.

Methods
This single-center point prevalence study evaluated antimicrobial utilization for all patients admitted to the Hospital of Escuintla, Guatemala. Demographic, microbiologic, and antimicrobial use data were assessed for all hospitalized patients from 1/23/2023 to 1/25/2023. Overall prevalence of antimicrobial use, indications and appropriateness of antimicrobials prescribed, and rate of appropriate culture attainment were analyzed for all patients and by patient care unit.

Results
Over the 3-day period, a total of 178 patients and 169 antimicrobial prescriptions were evaluated. Seventy-two percent of pediatric (N=41/57) and 60% of adult patients (N=73/121) were administered at least one antimicrobial (overall 64% of patients received antimicrobials). Antimicrobial utilization differed between adult and pediatric units (Figure 1). The most frequently utilized antimicrobials in pediatric patients were piperacillin-tazobactam (67%), amikacin (39%), ampicillin-sulbactam (28%) and metronidazole (28%). Broad spectrum antimicrobial use in pediatric units was largely driven by the neonatal intensive care unit (NICU) in which piperacillin-tazobactam accounted for 44% of antimicrobial prescriptions. The most frequent antimicrobial indications in pediatric units were pulmonary (30%), sepsis (20%) and abdominal (15%). In contrast, musculoskeletal (17%) and surgical prophylaxis (15%) were the most frequent indications in adults. Approximately half of all antimicrobial use was deemed inappropriate by reviewers. Rates of inappropriateness were similar between pediatric (53%) and adult (52%) patients (Table 1). The most common reasons an antimicrobial was classified as inappropriate were incorrect dose (41%), spectrum too narrow (22%), spectrum too broad (17%), prolonged duration (17%), and antibiotic not indicated (17%). More specifically, among patients in the pediatric intensive care unit (PICU) and pediatric progressive care unit, antibiotic not indicated was the most common reason for inappropriate use (41%). NICU inappropriate use was most often due to spectrum being too broad (80%), while spectrum too narrow was most common in non-ICU pediatric patients (50%). Finally, 60% of patients had cultures obtained appropriately (74% of pediatric and 42% of adult patients).

Conclusion
Rates of overall antimicrobial prescribing and inappropriate antimicrobial use were high amongst hospitalized adult and pediatric patients. These findings will be used to inform development of targeted antimicrobial stewardship interventions, such as dissemination of dosing information, treatment algorithms for common infections and surgical prophylaxis guidance, that may improve prescribing. Application of this point prevalence approach should be considered for other Guatemalan healthcare institutions to identify opportunities to optimize the use of antimicrobials.

Figure 1. Inpatient Antimicrobial Utilization at a Tertiary Hospital in Guatemala (N=169)
AMK, amikacin; AMX, amoxicillin; AMP, ampicillin; SAM, ampicillin/sulbactam; AZM, azithromycin; CFR, cefadroxil; CFZ, cefazolin; CFM, cefixime; CTX, cefotaxime; CAZ, ceftazidime; CRO, ceftriaxone; CIP, ciprofloxacin; CLI, clindamycin; DCX, dicloxacillin; FLC, fluconazole; FOF, fosfomycin; GEN, gentamicin; LVX, levofloxacin; MEM, meropenem; MTZ, metronidazole; PEN, penicillin; TZP, piperacillin/tazobactam; RIF, rifampin; SXT, sulfamethoxazole/trimethoprim; TGC, tigecycline; VAN, vancomycin
Table 1. Antimicrobial Evaluation