Audit of Antibiotic Prescribing Practices for Pediatric Pneumonia in the Outpatient Department: Focus on Amoxicillin and Azithromycin

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This audit evaluated outpatient prescribing patterns, implemented targeted interventions, and assessed post-audit improvements in guideline-based prescribing. Methods A two-cycle clinical audit was conducted at the Children’s Hospital, Sukkur, Pakistan. Children under 15 years presenting with cough and/or difficulty breathing and age-specific tachypnea were evaluated during pre-audit (n = 132) and post-audit (n = 153) cycles. Educational sessions emphasized WHO AWaRe and IMNCI guidelines recommending amoxicillin as first-line therapy. Data were collected on demographics, clinical features, antibiotic type, dose, and appropriateness. Results Overall antibiotic prescribing remained high (116/132 [87.9%] pre-audit vs 135/153 [88.2%] post-audit). Appropriateness improved markedly: amoxicillin prescriptions rose from 26/132 (19.7%) to 119/153 (77.8%), with guideline-concordant use increasing from 5/132 (3.8%) to 96/153 (62.7%). Azithromycin use fell from 66/132 (50.0%) to 5/153 (3.3%), with guideline-concordant use increasing from 20/66 (30.3%) to 4/5 (80.0%). Clinical documentation and adherence to pneumonia criteria improved significantly. Follow-up rates remained low (15%), though most returning patients demonstrated clinical improvement. Conclusion Structured audit and feedback markedly improved guideline-adherent antibiotic prescribing for pediatric pneumonia, increasing appropriate amoxicillin use and reducing inappropriate macrolide prescriptions. Short, focused interventions in LMIC outpatient settings can effectively improve antimicrobial stewardship. Pediatric pneumonia antibiotic prescribing antimicrobial stewardship azithromycin amoxicillin clinical audit Pakistan Figures Figure 1 Figure 2 Introduction Pneumonia is an acute infection of the lung parenchyma and remains the leading infectious cause of morbidity and mortality in children under five years of age worldwide, responsible for nearly one in six childhood deaths annually (1). The burden is especially severe in low- and middle-income countries (LMICs), including Pakistan, where limited access to healthcare and guideline-discordant antibiotic use contribute to poor outcomes (2). In children, the World Health Organization (WHO) and Integrated Management of Neonatal and Childhood Illness (IMNCI) guidelines define pneumonia by cough and/or difficulty breathing with age-specific tachypnea, and in severe cases, chest indrawing or general danger signs (3,4). Within the context of these guidelines, the presence of tachypnea in a child with cough or difficulty breathing is considered diagnostic of non-severe pneumonia in the absence of chest indrawing or danger signs (3,4). Amoxicillin remains the recommended first-line antibiotic, supporting its judicious use in CAP, while azithromycin should be reserved for select situations. However, incorporation of these principles remains suboptimal in many LMIC outpatient departments (3–7). Despite these recommendations, guideline-discordant antibiotic prescribing for childhood pneumonia remains common in outpatient settings, contributing to antimicrobial resistance (AMR) and unnecessary healthcare expenditure. The WHO’s AWaRe classification (2022) emphasizes amoxicillin as an “Access” antibiotic, promoting its rational use while restricting macrolides such as azithromycin to targeted indications (6–7). Clinical audits are proven quality improvement tools that assess practice against standards, provide structured feedback, and monitor change. Study objective This audit aimed to evaluate outpatient antibiotic prescribing patterns for pediatric pneumonia, implement a targeted educational intervention, and assess post-audit improvements in guideline-based prescribing. Hypothesis We hypothesized that structured audit and feedback would increase the appropriateness of antibiotic prescriptions—particularly amoxicillin—without significantly altering overall prescription rates in children presenting with non-severe pneumonia. Methodology This two-cycle clinical audit was conducted in the Pediatric Outpatient Department (OPD) of the Children’s Hospital, Sukkur. All children aged under 15 years presenting with cough and/or difficulty breathing within the context of these guidelines, with age-specific tachypnea as defined by IMNCI, were included. Children with severe pneumonia (chest indrawing or any general danger signs requiring hospital admission) were excluded. Receipt of an antibiotic prescription was not required for inclusion; all eligible patients were assessed for appropriateness of antibiotic prescribing according to WHO AWaRe and IMNCI standards. The pre-audit cycle was conducted from 27 June to 26 July 2025, followed by the intervention and educational reinforcement phase from 27 July to 26 August 2025, and the post-audit cycle from 27 August to 26 September 2025. Structured training sessions were conducted twice weekly for attendings, registrars, medical officers, and pharmacists, focusing on rational antibiotic use, documentation, and adherence to AWaRe principles. Daily prescription monitoring through the Hospital Information Management System (HIMS) provided immediate feedback for guideline-discordant prescriptions. Weekly reinforcement meetings summarized trends and highlighted areas for improvement. Data were anonymized prior to extraction and analysis. Only patient-level variables relevant to the audit (demographics, clinical features, antibiotics prescribed, doses, duration, and follow-up) were collected. Ethical approval was obtained from the Institutional Review Board (IRB), which waived written consent, as this was a quality improvement audit using routinely collected anonymized data. Ethical Approval and Consent to Participate This audit was approved by the Institutional Review Board (IRB) of the Children’s Hospital, Sukkur, under reference number SICHN/EX-006/2025. The audit involved retrospective review and analysis of anonymized outpatient medical records of children with non-severe pneumonia. As this was a non-interventional quality improvement audit using routinely collected data, the IRB waived the requirement for written informed consent. All records were de-identified before analysis to ensure confidentiality and privacy. For minors whose data were included, parental or guardian consent was not applicable due to the retrospective and anonymized nature of the study. The audit adhered to the principles of the Declaration of Helsinki (2013 revision) and complied with the PLOS ONE Human Participants Research Policy for ethical standards in human subject research. Results A total of 285 children were included in the audit, comprising 132 in the pre-audit cycle and 153 in the post-audit cycle. Demographic characteristics were comparable between cycles. Males accounted for 81/132 (61.4%) of the pre-audit group and 93/153 (60.8%) of the post-audit group. Most children were under five years of age, representing 252/285 (88.4%) of the overall study population. Presenting complaints and clinical findings From the pre-audit to post-audit period, fever (115/132 [87.1%] vs 149/153 [97.4%]; p < 0.01) and cough (121/132 [91.7%] vs 126/153 [82.4%]; p = 0.02) were increasingly documented, along with shortness of breath (5/132 [3.8%] vs 13/153 [8.5%]; p = 0.05). Other symptoms, including vomiting, abdominal pain, and runny nose, were infrequently recorded. Pertinent negatives were coded as “not documented” if absent from the record. On examination, Crepitations were recorded in 87/132 (65.9%) pre-audit and 141/153 (92.2%) post-audit; wheezing 31/132 (23.5%) vs 46/153 (30.1%). Tonsillar hypertrophy and throat erythema decreased post-audit (23/132 [17.4%] → 3/153 [2.0%]; 23/132 [17.4%] → 7/153 [4.6%], respectively). Tachypnea, defined according to IMNCI criteria, was observed in 11/132 (8.3%) children pre-audit and 13/153 (8.5%) post-audit. Children with severe tachypnea requiring referral or oxygen therapy were excluded, accounting for the relatively low proportion of tachypneic patients. Antibiotic prescribing patterns Overall antibiotic prescribing remained high and unchanged between cycles, occurring in 116/132 (87.9%) children pre-audit and 135/153 (88.2%) post-audit (p = 0.94). Age-stratified analysis showed that antibiotic prescribing was highest among infants younger than 12 months (55/60 [91.7%] pre-audit vs. 44/52 [84.6%] post-audit), followed by children aged 13–60 months (46/57 [80.7%] vs. 65/75 [86.7%]) and those older than 60 months (6/15 [40.0%] vs. 26/26 [100.0%]). Amoxicillin prescribing Amoxicillin prescriptions increased markedly following the intervention, rising from 26/132 (19.7%) pre-audit to 119/153 (77.8%) post-audit (p < 0.001). Appropriate amoxicillin prescribing improved substantially from 1/26 (3.8% of amoxicillin prescriptions) to 96/119 (80.7%). Azithromycin prescribing Azithromycin use declined sharply after the intervention, decreasing from 66/132 (50.0%) pre-audit to 5/153 (3.3%) post-audit (p < 0.001). Appropriate azithromycin use increased from 20/66 (30.3% of azithromycin prescriptions) to 4/5 (80.0%). Overall prescribing appropriateness Across all antibiotics, overall appropriate prescribing increased from 21/116 (18.1% of antibiotic prescriptions) pre-audit to 116/135 (85.9%) post-audit, demonstrating substantial improvement in guideline adherence. Follow-up and clinical outcomes Follow-up attendance increased modestly from 15/132 (11.4%) pre-audit to 23/153 (15.0%) post-audit. Among those who returned for review, clinical improvement was observed in 11/15 (73.3%) pre-audit and 18/23 (78.3%) post-audit. Tachypnea remained strongly associated with hospital admission, occurring in 7/11 (63.6%) tachypneic children pre-audit and 9/12 (75.0%) post-audit among those requiring referral, indicating consistent recognition of disease severity. Summary of post-audit changes Overall antibiotic use remained unchanged; however, the intervention resulted in marked improvement in prescribing quality. There was a substantial shift toward guideline-recommended amoxicillin use, a significant reduction in unnecessary macrolide prescribing, and improved clinical documentation and diagnostic accuracy. Discussion This audit demonstrated that structured educational feedback based on WHO AWaRe and IMNCI guidelines can significantly improve rational antibiotic prescribing for pediatric pneumonia in outpatient settings. Following the intervention, appropriate amoxicillin prescribing increased from 1/26 (3.8% of prescriptions) pre-audit to 96/119 (80.7%) post-audit, while appropriate azithromycin use increased from 20/66 (30.3%) to 4/5 (80.0%). These findings reflect a tangible shift toward evidence-based practice and highlight the effectiveness of short, focused educational interventions. Our results are consistent with international data showing that amoxicillin remains the most effective first-line therapy for non-severe community-acquired pneumonia (CAP) in children (3,5,11). Similar interventions in India reported guideline adherence increases from 37% to over 80% within months of audit and feedback implementation (12). In Nepal, stewardship initiatives targeting outpatient respiratory infections demonstrated substantial reductions in unnecessary macrolide use and improved prescription appropriateness following educational campaigns and AWaRe adoption (13). These regional findings underscore that low-cost, structured educational interventions can have a profound impact on outpatient antibiotic prescribing patterns in LMICs. In Pakistan, multicenter data consistently highlight irrational antibiotic prescribing as a major driver of antimicrobial resistance. A point-prevalence survey in Punjab reported that 82% of hospitalized pediatric pneumonia patients received antibiotics, with over half from the WHO “Watch” category (14). Another multicenter study documented frequent prescribing errors and inappropriate antibiotic use in pediatric respiratory infections (15). Our audit complements these findings: although overall antibiotic use remained high (116/132 [87.9%] pre-audit vs. 135/153 [88.2%] post-audit), rational prescribing increased substantially, with appropriate amoxicillin prescriptions rising from 1/26 (3.8%) to 96/119 (80.7%). Age-stratified analysis showed the greatest gains among infants under 12 months and children aged 13–60 months, indicating that targeted education improved prescribing practices in the most vulnerable populations. Evidence from randomized controlled trials in Pakistan supports the effectiveness of short-course oral amoxicillin therapy for non-severe pneumonia. In a multicenter trial involving 2,000 children aged 2–59 months, Bari et al. reported no significant difference in treatment failure between 3-day and 5-day amoxicillin regimens, reinforcing its role as an effective first-line agent (16). Treatment failure was more likely among younger children, those with poor adherence, and those with higher respiratory rates—factors consistent with our outpatient cohort. Persistent high antibiotic use despite improved appropriateness mirrors a common pattern in LMICs, where diagnostic limitations, clinical uncertainty, and parental expectations drive overprescribing (15–17). Our intervention improved the choice and documentation of antibiotics but did not significantly reduce the overall prescribing rate. Future audit cycles could incorporate point-of-care testing, CRP measurements, or chest radiography to refine antibiotic indications further. Post-intervention, documentation quality improved substantially, reflecting greater clinician awareness and adherence to guideline-based diagnostic criteria. Crepitations were documented more frequently (87/132 [65.9%] pre-audit vs. 141/153 [92.2%] post-audit) and shortness of breath recognition increased (5/132 [3.8%] vs. 13/153 [8.5%]), indicating more precise clinical assessment. These improvements align with evidence from East Africa, where audits demonstrated that enhanced documentation was strongly associated with more appropriate prescribing (18). Follow-up attendance remained low, increasing modestly from 15/132 (11.4%) to 23/153 (15.0%), similar to national trends (14,19). Among returning patients, clinical improvement was observed in 11/15 (73.3%) pre-audit and 18/23 (78.3%) post-audit, suggesting that appropriate antibiotic selection translated into favorable short-term outcomes. Strengthening follow-up systems through reminders, telemedicine, or caregiver education may further improve outcomes and monitoring. Overall, this audit demonstrates that modest, structured educational feedback can drive substantial behavioral change among outpatient prescribers, even in resource-limited settings. Improvements in antibiotic appropriateness, documentation, and diagnostic focus were evident across all age groups, highlighting the value of low-cost interventions in LMIC pediatric care. Limitations This audit was limited to a single tertiary-care center, which may restrict the generalizability of results. The short post-audit duration may not capture long-term behavioral changes. Lack of microbiological testing and selective inclusion of laboratory or radiological findings limited diagnostic precision. Data on treatment adherence and parental understanding were not collected, which could have offered further insight into outcomes. Despite these limitations, the audit provides robust evidence that structured feedback can improve prescribing quality in real-world outpatient settings. Conclusion This audit demonstrated that targeted educational interventions, guided by WHO AWaRe and IMNCI standards, can markedly improve rational antibiotic prescribing for pediatric pneumonia in outpatient care. The same clinicians participated across both cycles, ensuring reliability of findings. Although overall antibiotic use remained high, a strong shift toward appropriate amoxicillin use and reduced macrolide misuse highlights the effectiveness of stewardship-based feedback. Future multi-center audits across Sindh could validate these results and establish a sustainable antimicrobial stewardship framework. Integrating diagnostics, routine audits, and public education will be essential for achieving Pakistan’s national goals in combating antimicrobial resistance. Abbreviations AMR Antimicrobial resistance AWaRe Access, Watch, Reserve classification of antibiotics CAP Community—acquired pneumonia HIMS Hospital Information Management System IMNCI Integrated Management of Neonatal and Childhood Illness IRB Institutional Review Board LMICs Low—and middle—income countries OPD Outpatient Department WHO World Health Organization Declarations Clinical Trial Registration This study was a clinical audit and not an interventional clinical trial. Clinical trial number: not applicable. Ethics approval and consent to participate This study was approved by the Institutional Review Board (IRB) of Children’s Hospital Sukkur (Reference: SICHN/EX-006/2025). The audit involved retrospective analysis of anonymized outpatient medical records. As this was a non-interventional quality improvement audit using routinely collected data, the requirement for written informed consent was waived by the IRB. All methods were carried out in accordance with the Declaration of Helsinki. Consent for Publication: Not applicable. Funding: This study received no external funding. Author Contributions: WA conceived the audit, designed the methodology, analyzed data, and drafted the manuscript. IA, SA, SN, BB, MKK, HN, HM, and FB assisted in data collection, review, and educational implementation. All authors reviewed and approved the final version. Conflict of Interest: None declared. References Dayib AA, Ali HN, Miad AA, Daud FI. Determinants of Community-acquired Pneumonia Among Under-five Children at Selected Public Hospitals in Jigjiga Town, Ethiopia, 2024. A Facility-based Unmatched Case-control Study. Zhang ZQ, Li JY, Wang H, Fu CY, Li YL, Guo Q, Bao YW, Wu J, Liao JC, Song YQ, Li DX. Global, regional and national burden of respiratory infections among children and adolescents under 19 years of age from 1990 to 2021 and projected trends to 2040. The Egyptian Journal of Bronchology. 2025 Jul 11;19(1):66. Walker CLF, Rudan I, Liu L, Nair H, Theodoratou E, Bhutta ZA, et al. Global burden of childhood pneumonia and diarrhoea. Lancet. 2013;381(9875):1405–16. World Health Organization. Department of Child, Adolescent Health. Handbook IMCI: integrated management of childhood illness. World Health Organization; 2005. World Health Organization. Revised WHO classification and treatment of pneumonia in children at health facilities: evidence summaries. InRevised WHO classification and treatment of pneumonia in children at health facilities: evidence summaries 2014. World Health Organization. WHO AWaRe Antibiotic Book: Practical guidance on the use of antibiotics. Geneva: World Health Organization; 2022. Suhag ZH, Pal A, Naeem M, Ahmed I, Khuwaja NA, Khakwani S, Mujtaba A, Qazi SA, Nisar YB. Outcome and management of children with chest indrawing pneumonia at primary health care settings in Pakistan: an observational cohort study. Journal of Global Health. 2025 Mar 28;15:04096. Iftikhar S, Sarwar MR, Saqib A, Sarfraz M, Shoaib QU. Antibiotic prescribing practices and errors among hospitalized pediatric patients suffering from acute respiratory tract infections: a multicenter, cross-sectional study in Pakistan. Medicina. 2019 Feb 11;55(2):44. Klein EY, Van Boeckel TP, Martinez EM, Pant S, Gandra S, Levin SA, Goossens H, Laxminarayan R. Global increase and geographic convergence in antibiotic consumption between 2000 and 2015. Proceedings of the National Academy of Sciences. 2018 Apr 10;115(15):E3463-70. Holmes AH, Moore LS, Sundsfjord A, Steinbakk M, Regmi S, Karkey A, Guerin PJ, Piddock LJ. Understanding the mechanisms and drivers of antimicrobial resistance. The Lancet. 2016 Jan 9;387(10014):176-87. Lee CF, Cowling BJ, Feng S, Aso H, Wu P, Fukuda K, Seto WH. Impact of antibiotic stewardship programmes in Asia: a systematic review and meta-analysis. Journal of Antimicrobial Chemotherapy. 2018 Apr 1;73(4):844-51. Farooqui HH, Mehta A, Selvaraj S. Outpatient antibiotic prescription rate and pattern in the private sector in India: evidence from medical audit data. PloS one. 2019 Nov 13;14(11):e0224848. Khanal S, Acharya U, Trotter AB, Tripathi P, Koirala S, Pahari B, Acharya SP. Challenges and opportunities in the implementation of an antimicrobial stewardship program in Nepal. Antimicrobial Stewardship & Healthcare Epidemiology. 2023 Jan;3(1):e58. Sheikh S, Saleem Z, Afzal S, Qamar MU, Raza AA, Haider Naqvi SZ, Al-Rawi MB, Godman B. Identifying targets for antibiotic stewardship interventions in pediatric patients in Punjab, Pakistan: point prevalence surveys using AWaRe guidance. Frontiers in Pediatrics. 2025 Jan 10;12:1469766. Iftikhar S, Sarwar MR, Saqib A, Sarfraz M, Shoaib QU. Antibiotic prescribing practices and errors among hospitalized pediatric patients suffering from acute respiratory tract infections: a multicenter, cross-sectional study in Pakistan. Medicina. 2019 Feb 11;55(2):44. Pneumonia Study Group. Clinical efficacy of 3 days versus 5 days of oral amoxicillin for treatment of childhood pneumonia: a multicentre double-blind trial. The Lancet. 2002 Sep 14;360(9336):835-41. Holmes AH, Moore LS, Sundsfjord A, Steinbakk M, Regmi S, Karkey A, Guerin PJ, Piddock LJ. Understanding the mechanisms and drivers of antimicrobial resistance. The Lancet. 2016 Jan 9;387(10014):176-87. Manirakiza A, Maru SM, Nyamu DG, Bizimana T, Nimpagaritse M. Antimicrobial prescribing patterns among pediatric outpatient encounters in primary healthcare centers in Bujumbura Mairie, Burundi. BMC Primary Care. 2025 Aug 1;26(1):236. Bari A, Sadruddin S, Khan A, Ullah A, Lehri IA, Macleod WB, Fox MP, Thea DM, Qazi SA. Cluster Randomized Trial of Community Case Management of Severe Pneumonia with Oral Amoxicillin in Children 2-59 Months of Age in Haripur District, Pakistan. Lancet. 2011 Nov 10;378(9805):1796. Tables Table 1 Baseline characteristics and clinical features of children presenting with non-severe pneumonia before and after the audit Variable Pre-Audit (n = 132) Post-Audit (n = 153) Male 81/132 (61.4%) 93/153 (60.8%) Female 51/132 (38.6%) 60/153 (39.2%) < 12 months 60/132 (45.5%) 52/153 (34.0%) 13–60 months 57/132 (43.2%) 75/153 (49.0%) 60 months 15/132 (11.4%) 26/153 (17.0%) Fever 115/132 (87.1%) 149/153 (97.4%) Cough 121/132 (91.7%) 126/153 (82.4%) Shortness of breath 5 /132(3.8%) 13/153 (8.5%) Vomiting 7/132 (5.3%) 4/153 (2.6%) Abdominal pain 9/132 (6.8%) 1/153 (0.7%) Runny nose 4/132 (3.0%) 1/153 (0.7%) Note: Fever and cough were the predominant presenting complaints in both audit cycles. Most patients were under five years of age. Table 2 Examination findings among children with non-severe pneumonia before and after the audit Examination FindingPre-Audit (n = 132) Post-Audit (n = 153) Crepitation 87/132 (65.9%) 141/153 (92.2%) Wheeze 31/132 (23.5%) 46/153 (30.1%) Chest clear 8/132 (6.1%) 3/153 (2.0%) Tonsillar hypertrophy 23/132 (17.4%) 3/153 (2.0%) Throat erythema 23/132 (17.4%) 7/153 (4.6%) Runny nose 11/132 (8.3%) 13/153 (8.5%) Note: Crepitation were the most frequent finding, showing a marked increase post-audit, reflecting improved clinical documentation and diagnostic accuracy. Table 3 Age-wise Antibiotic Use Age Group Pre-Audit Total (n) Antibiotic Given Post-audit Total (n) Antibiotic Given < 12 months 60 55/60 (91.7%) 52 44/52 (84.6%) 13–60 months 57 46/57 (80.7%) 75 65/75 (86.7%) 60 months 15 6/15 (40.0%) 26 26/26 (100.0%) Inappropriate prescribing was most common in < 12 months during pre-audit, with notable improvement post-audit. Table 4 Antibiotic prescribing patterns and appropriateness before and after the audit Parameter Pre-Audit (n = 132) Post-Audit (n = 153) p-value Any antibiotic prescribed 116/132 (87.9%) 135/153 (88.2%) 0.94 Amoxicillin prescribed 26/132 (19.7%) 119/153 (77.8%) < 0.001 Amoxicillin appropriate 1/26 (3.8%) 96/119 (80.7%) < 0.001 Azithromycin prescribed 66/132 (50.0%) 5/153 (3.3%) < 0.001 Azithromycin appropriate 20/66 (30.3%) 4/5 (80.0%) 0.0002 Note: Age-stratified prescribing improved across all groups. Follow-up rates modestly increased from 15/132 (11.4%) to 23/153 (15.0%), with most returning patients showing clinical improvement. Tachypnea remained closely associated with hospital referral among the follow-up subset (χ² test, p < 0.05). Additional Declarations No competing interests reported. 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10:23:35","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8879141/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8879141/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":103577407,"identity":"5c34d0cf-9898-43c9-a930-b5055a654154","added_by":"auto","created_at":"2026-02-27 09:27:55","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":44329,"visible":true,"origin":"","legend":"\u003cp\u003eAudit and Intervention Timeline.\u003c/p\u003e\n\u003cp\u003eThe timeline shows three phases:\u003c/p\u003e\n\u003cp\u003e- Pre-audit (27 June – 26 July 2025): retrospective review of outpatient records, no feedback.\u003c/p\u003e\n\u003cp\u003e- Intervention (27 July – 26 August 2025): structured training sessions twice weekly, daily prospective prescription review with real-time feedback, and weekly reinforcement meetings.\u003c/p\u003e\n\u003cp\u003e- Post-audit (27 August – 26 September 2025): data collection to assess improvements, with brief reminders only.\u003c/p\u003e\n\u003cp\u003eKey activities and staff involvement are indicated.\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8879141/v1/04c986460cfd497107c9fd60.jpeg"},{"id":103577431,"identity":"cb28d0ed-831c-4e30-8665-16feccf66ece","added_by":"auto","created_at":"2026-02-27 09:28:00","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":105403,"visible":true,"origin":"","legend":"\u003cp\u003ePost-Audit Appropriateness of Antibiotic Prescribing.\u003c/p\u003e\n\u003cp\u003eBar chart comparing the proportion of appropriate prescriptions for amoxicillin and azithromycin in the post-audit cycle. Appropriateness increased to 80.7% for amoxicillin and 80.0% for azithromycin, reflecting improved adherence to WHO-based treatment guidelines.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8879141/v1/b8c37293f3ddca0cade8553d.jpeg"},{"id":103577519,"identity":"aae1e5db-5371-4e32-b322-1ca11b4569e8","added_by":"auto","created_at":"2026-02-27 09:28:17","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":766442,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8879141/v1/03c24906-da71-4149-8b4d-98796f17633b.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Audit of Antibiotic Prescribing Practices for Pediatric Pneumonia in the Outpatient Department: Focus on Amoxicillin and Azithromycin","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePneumonia is an acute infection of the lung parenchyma and remains the leading infectious cause of morbidity and mortality in children under five years of age worldwide, responsible for nearly one in six childhood deaths annually (1). The burden is especially severe in low- and middle-income countries (LMICs), including Pakistan, where limited access to healthcare and guideline-discordant antibiotic use contribute to poor outcomes (2). In children, the World Health Organization (WHO) and Integrated Management of Neonatal and Childhood Illness (IMNCI) guidelines define pneumonia by cough and/or difficulty breathing with age-specific tachypnea, and in severe cases, chest indrawing or general danger signs (3,4). Within the context of these guidelines, the presence of tachypnea in a child with cough or difficulty breathing is considered diagnostic of non-severe pneumonia in the absence of chest indrawing or danger signs (3,4). Amoxicillin remains the recommended first-line antibiotic, supporting its judicious use in CAP, while azithromycin should be reserved for select situations. However, incorporation of these principles remains suboptimal in many LMIC outpatient departments (3\u0026ndash;7). Despite these recommendations, guideline-discordant antibiotic prescribing for childhood pneumonia remains common in outpatient settings, contributing to antimicrobial resistance (AMR) and unnecessary healthcare expenditure. The WHO\u0026rsquo;s AWaRe classification (2022) emphasizes amoxicillin as an \u0026ldquo;Access\u0026rdquo; antibiotic, promoting its rational use while restricting macrolides such as azithromycin to targeted indications (6\u0026ndash;7). Clinical audits are proven quality improvement tools that assess practice against standards, provide structured feedback, and monitor change.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eStudy objective\u003c/strong\u003e \u003cp\u003eThis audit aimed to evaluate outpatient antibiotic prescribing patterns for pediatric pneumonia, implement a targeted educational intervention, and assess post-audit improvements in guideline-based prescribing.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eHypothesis\u003c/strong\u003e \u003cp\u003eWe hypothesized that structured audit and feedback would increase the appropriateness of antibiotic prescriptions\u0026mdash;particularly amoxicillin\u0026mdash;without significantly altering overall prescription rates in children presenting with non-severe pneumonia.\u003c/p\u003e \u003c/p\u003e"},{"header":"Methodology","content":"\u003cp\u003eThis two-cycle clinical audit was conducted in the Pediatric Outpatient Department (OPD) of the Children\u0026rsquo;s Hospital, Sukkur. All children aged under 15 years presenting with cough and/or difficulty breathing within the context of these guidelines, with age-specific tachypnea as defined by IMNCI, were included. Children with severe pneumonia (chest indrawing or any general danger signs requiring hospital admission) were excluded. Receipt of an antibiotic prescription was not required for inclusion; all eligible patients were assessed for appropriateness of antibiotic prescribing according to WHO AWaRe and IMNCI standards.\u003c/p\u003e \u003cp\u003eThe pre-audit cycle was conducted from 27 June to 26 July 2025, followed by the intervention and educational reinforcement phase from 27 July to 26 August 2025, and the post-audit cycle from 27 August to 26 September 2025. Structured training sessions were conducted twice weekly for attendings, registrars, medical officers, and pharmacists, focusing on rational antibiotic use, documentation, and adherence to AWaRe principles. Daily prescription monitoring through the Hospital Information Management System (HIMS) provided immediate feedback for guideline-discordant prescriptions. Weekly reinforcement meetings summarized trends and highlighted areas for improvement.\u003c/p\u003e \u003cp\u003eData were anonymized prior to extraction and analysis. Only patient-level variables relevant to the audit (demographics, clinical features, antibiotics prescribed, doses, duration, and follow-up) were collected. Ethical approval was obtained from the Institutional Review Board (IRB), which waived written consent, as this was a quality improvement audit using routinely collected anonymized data.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eEthical Approval and Consent to Participate\u003c/strong\u003e \u003cp\u003eThis audit was approved by the Institutional Review Board (IRB) of the Children\u0026rsquo;s Hospital, Sukkur, under reference number SICHN/EX-006/2025. The audit involved retrospective review and analysis of anonymized outpatient medical records of children with non-severe pneumonia. As this was a non-interventional quality improvement audit using routinely collected data, the IRB waived the requirement for written informed consent.\u003c/p\u003e \u003c/p\u003e \u003cp\u003eAll records were de-identified before analysis to ensure confidentiality and privacy. For minors whose data were included, parental or guardian consent was not applicable due to the retrospective and anonymized nature of the study. The audit adhered to the principles of the Declaration of Helsinki (2013 revision) and complied with the PLOS ONE Human Participants Research Policy for ethical standards in human subject research.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 285 children were included in the audit, comprising 132 in the pre-audit cycle and 153 in the post-audit cycle. Demographic characteristics were comparable between cycles. Males accounted for 81/132 (61.4%) of the pre-audit group and 93/153 (60.8%) of the post-audit group. Most children were under five years of age, representing 252/285 (88.4%) of the overall study population.\u003c/p\u003e \u003cp\u003ePresenting complaints and clinical findings\u003c/p\u003e \u003cp\u003eFrom the pre-audit to post-audit period, fever (115/132 [87.1%] vs 149/153 [97.4%]; p\u0026thinsp;\u0026lt;\u0026thinsp;0.01) and cough (121/132 [91.7%] vs 126/153 [82.4%]; p\u0026thinsp;=\u0026thinsp;0.02) were increasingly documented, along with shortness of breath (5/132 [3.8%] vs 13/153 [8.5%]; p\u0026thinsp;=\u0026thinsp;0.05). Other symptoms, including vomiting, abdominal pain, and runny nose, were infrequently recorded. Pertinent negatives were coded as \u0026ldquo;not documented\u0026rdquo; if absent from the record.\u003c/p\u003e \u003cp\u003eOn examination, Crepitations were recorded in 87/132 (65.9%) pre-audit and 141/153 (92.2%) post-audit; wheezing 31/132 (23.5%) vs 46/153 (30.1%). Tonsillar hypertrophy and throat erythema decreased post-audit (23/132 [17.4%] \u0026rarr; 3/153 [2.0%]; 23/132 [17.4%] \u0026rarr; 7/153 [4.6%], respectively).\u003c/p\u003e \u003cp\u003eTachypnea, defined according to IMNCI criteria, was observed in 11/132 (8.3%) children pre-audit and 13/153 (8.5%) post-audit. Children with severe tachypnea requiring referral or oxygen therapy were excluded, accounting for the relatively low proportion of tachypneic patients.\u003c/p\u003e \u003cp\u003eAntibiotic prescribing patterns\u003c/p\u003e \u003cp\u003eOverall antibiotic prescribing remained high and unchanged between cycles, occurring in 116/132 (87.9%) children pre-audit and 135/153 (88.2%) post-audit (p\u0026thinsp;=\u0026thinsp;0.94).\u003c/p\u003e \u003cp\u003eAge-stratified analysis showed that antibiotic prescribing was highest among infants younger than 12 months (55/60 [91.7%] pre-audit vs. 44/52 [84.6%] post-audit), followed by children aged 13\u0026ndash;60 months (46/57 [80.7%] vs. 65/75 [86.7%]) and those older than 60 months (6/15 [40.0%] vs. 26/26 [100.0%]).\u003c/p\u003e \u003cp\u003eAmoxicillin prescribing\u003c/p\u003e \u003cp\u003eAmoxicillin prescriptions increased markedly following the intervention, rising from 26/132 (19.7%) pre-audit to 119/153 (77.8%) post-audit (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003eAppropriate amoxicillin prescribing improved substantially from 1/26 (3.8% of amoxicillin prescriptions) to 96/119 (80.7%).\u003c/p\u003e \u003cp\u003eAzithromycin prescribing\u003c/p\u003e \u003cp\u003eAzithromycin use declined sharply after the intervention, decreasing from 66/132 (50.0%) pre-audit to 5/153 (3.3%) post-audit (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003eAppropriate azithromycin use increased from 20/66 (30.3% of azithromycin prescriptions) to 4/5 (80.0%).\u003c/p\u003e \u003cp\u003eOverall prescribing appropriateness\u003c/p\u003e \u003cp\u003eAcross all antibiotics, overall appropriate prescribing increased from 21/116 (18.1% of antibiotic prescriptions) pre-audit to 116/135 (85.9%) post-audit, demonstrating substantial improvement in guideline adherence.\u003c/p\u003e \u003cp\u003eFollow-up and clinical outcomes\u003c/p\u003e \u003cp\u003eFollow-up attendance increased modestly from 15/132 (11.4%) pre-audit to 23/153 (15.0%) post-audit. Among those who returned for review, clinical improvement was observed in 11/15 (73.3%) pre-audit and 18/23 (78.3%) post-audit.\u003c/p\u003e \u003cp\u003eTachypnea remained strongly associated with hospital admission, occurring in 7/11 (63.6%) tachypneic children pre-audit and 9/12 (75.0%) post-audit among those requiring referral, indicating consistent recognition of disease severity.\u003c/p\u003e \u003cp\u003eSummary of post-audit changes\u003c/p\u003e \u003cp\u003eOverall antibiotic use remained unchanged; however, the intervention resulted in marked improvement in prescribing quality. There was a substantial shift toward guideline-recommended amoxicillin use, a significant reduction in unnecessary macrolide prescribing, and improved clinical documentation and diagnostic accuracy.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis audit demonstrated that structured educational feedback based on WHO AWaRe and IMNCI guidelines can significantly improve rational antibiotic prescribing for pediatric pneumonia in outpatient settings. Following the intervention, appropriate amoxicillin prescribing increased from 1/26 (3.8% of prescriptions) pre-audit to 96/119 (80.7%) post-audit, while appropriate azithromycin use increased from 20/66 (30.3%) to 4/5 (80.0%). These findings reflect a tangible shift toward evidence-based practice and highlight the effectiveness of short, focused educational interventions.\u003c/p\u003e \u003cp\u003eOur results are consistent with international data showing that amoxicillin remains the most effective first-line therapy for non-severe community-acquired pneumonia (CAP) in children (3,5,11). Similar interventions in India reported guideline adherence increases from 37% to over 80% within months of audit and feedback implementation (12). In Nepal, stewardship initiatives targeting outpatient respiratory infections demonstrated substantial reductions in unnecessary macrolide use and improved prescription appropriateness following educational campaigns and AWaRe adoption (13). These regional findings underscore that low-cost, structured educational interventions can have a profound impact on outpatient antibiotic prescribing patterns in LMICs.\u003c/p\u003e \u003cp\u003eIn Pakistan, multicenter data consistently highlight irrational antibiotic prescribing as a major driver of antimicrobial resistance. A point-prevalence survey in Punjab reported that 82% of hospitalized pediatric pneumonia patients received antibiotics, with over half from the WHO \u0026ldquo;Watch\u0026rdquo; category (14). Another multicenter study documented frequent prescribing errors and inappropriate antibiotic use in pediatric respiratory infections (15). Our audit complements these findings: although overall antibiotic use remained high (116/132 [87.9%] pre-audit vs. 135/153 [88.2%] post-audit), rational prescribing increased substantially, with appropriate amoxicillin prescriptions rising from 1/26 (3.8%) to 96/119 (80.7%). Age-stratified analysis showed the greatest gains among infants under 12 months and children aged 13\u0026ndash;60 months, indicating that targeted education improved prescribing practices in the most vulnerable populations.\u003c/p\u003e \u003cp\u003eEvidence from randomized controlled trials in Pakistan supports the effectiveness of short-course oral amoxicillin therapy for non-severe pneumonia. In a multicenter trial involving 2,000 children aged 2\u0026ndash;59 months, Bari et al. reported no significant difference in treatment failure between 3-day and 5-day amoxicillin regimens, reinforcing its role as an effective first-line agent (16). Treatment failure was more likely among younger children, those with poor adherence, and those with higher respiratory rates\u0026mdash;factors consistent with our outpatient cohort.\u003c/p\u003e \u003cp\u003ePersistent high antibiotic use despite improved appropriateness mirrors a common pattern in LMICs, where diagnostic limitations, clinical uncertainty, and parental expectations drive overprescribing (15\u0026ndash;17). Our intervention improved the choice and documentation of antibiotics but did not significantly reduce the overall prescribing rate. Future audit cycles could incorporate point-of-care testing, CRP measurements, or chest radiography to refine antibiotic indications further.\u003c/p\u003e \u003cp\u003ePost-intervention, documentation quality improved substantially, reflecting greater clinician awareness and adherence to guideline-based diagnostic criteria. Crepitations were documented more frequently (87/132 [65.9%] pre-audit vs. 141/153 [92.2%] post-audit) and shortness of breath recognition increased (5/132 [3.8%] vs. 13/153 [8.5%]), indicating more precise clinical assessment. These improvements align with evidence from East Africa, where audits demonstrated that enhanced documentation was strongly associated with more appropriate prescribing (18).\u003c/p\u003e \u003cp\u003eFollow-up attendance remained low, increasing modestly from 15/132 (11.4%) to 23/153 (15.0%), similar to national trends (14,19). Among returning patients, clinical improvement was observed in 11/15 (73.3%) pre-audit and 18/23 (78.3%) post-audit, suggesting that appropriate antibiotic selection translated into favorable short-term outcomes. Strengthening follow-up systems through reminders, telemedicine, or caregiver education may further improve outcomes and monitoring.\u003c/p\u003e \u003cp\u003eOverall, this audit demonstrates that modest, structured educational feedback can drive substantial behavioral change among outpatient prescribers, even in resource-limited settings. Improvements in antibiotic appropriateness, documentation, and diagnostic focus were evident across all age groups, highlighting the value of low-cost interventions in LMIC pediatric care.\u003c/p\u003e\n\u003ch3\u003eLimitations\u003c/h3\u003e\n\u003cp\u003eThis audit was limited to a single tertiary-care center, which may restrict the generalizability of results. The short post-audit duration may not capture long-term behavioral changes. Lack of microbiological testing and selective inclusion of laboratory or radiological findings limited diagnostic precision. Data on treatment adherence and parental understanding were not collected, which could have offered further insight into outcomes. Despite these limitations, the audit provides robust evidence that structured feedback can improve prescribing quality in real-world outpatient settings.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis audit demonstrated that targeted educational interventions, guided by WHO AWaRe and IMNCI standards, can markedly improve rational antibiotic prescribing for pediatric pneumonia in outpatient care. The same clinicians participated across both cycles, ensuring reliability of findings. Although overall antibiotic use remained high, a strong shift toward appropriate amoxicillin use and reduced macrolide misuse highlights the effectiveness of stewardship-based feedback.\u003c/p\u003e \u003cp\u003eFuture multi-center audits across Sindh could validate these results and establish a sustainable antimicrobial stewardship framework. Integrating diagnostics, routine audits, and public education will be essential for achieving Pakistan\u0026rsquo;s national goals in combating antimicrobial resistance.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAMR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAntimicrobial resistance\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAWaRe\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAccess, Watch, Reserve classification of antibiotics\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCAP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCommunity\u0026mdash;acquired pneumonia\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHIMS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHospital Information Management System\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIMNCI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eIntegrated Management of Neonatal and Childhood Illness\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIRB\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInstitutional Review Board\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLMICs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eLow\u0026mdash;and middle\u0026mdash;income countries\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eOPD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eOutpatient Department\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eWHO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWorld Health Organization\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eClinical Trial Registration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was a clinical audit and not an interventional clinical trial.\u003c/p\u003e\n\u003cp\u003eClinical trial number: not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Institutional Review Board (IRB) of Children\u0026rsquo;s Hospital Sukkur (Reference: SICHN/EX-006/2025).\u003c/p\u003e\n\u003cp\u003eThe audit involved retrospective analysis of anonymized outpatient medical records. As this was a non-interventional quality improvement audit using routinely collected data, the requirement for written informed consent was waived by the IRB.\u003c/p\u003e\n\u003cp\u003eAll methods were carried out in accordance with the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study received no external funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWA conceived the audit, designed the methodology, analyzed data, and drafted the manuscript. IA, SA, SN, BB, MKK, HN, HM, and FB assisted in data collection, review, and educational implementation. All authors reviewed and approved the final version.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone declared.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eDayib AA, Ali HN, Miad AA, Daud FI. Determinants of Community-acquired Pneumonia Among Under-five Children at Selected Public Hospitals in Jigjiga Town, Ethiopia, 2024. A Facility-based Unmatched Case-control Study.\u003c/li\u003e\n\u003cli\u003eZhang ZQ, Li JY, Wang H, Fu CY, Li YL, Guo Q, Bao YW, Wu J, Liao JC, Song YQ, Li DX. Global, regional and national burden of respiratory infections among children and adolescents under 19 years of age from 1990 to 2021 and projected trends to 2040. The Egyptian Journal of Bronchology. 2025 Jul 11;19(1):66.\u003c/li\u003e\n\u003cli\u003eWalker CLF, Rudan I, Liu L, Nair H, Theodoratou E, Bhutta ZA, et al. Global burden of childhood pneumonia and diarrhoea. Lancet. 2013;381(9875):1405\u0026ndash;16.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Department of Child, Adolescent Health. Handbook IMCI: integrated management of childhood illness. World Health Organization; 2005.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Revised WHO classification and treatment of pneumonia in children at health facilities: evidence summaries. InRevised WHO classification and treatment of pneumonia in children at health facilities: evidence summaries 2014.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. WHO AWaRe Antibiotic Book: Practical guidance on the use of antibiotics. Geneva: World Health Organization; 2022.\u003c/li\u003e\n\u003cli\u003eSuhag ZH, Pal A, Naeem M, Ahmed I, Khuwaja NA, Khakwani S, Mujtaba A, Qazi SA, Nisar YB. Outcome and management of children with chest indrawing pneumonia at primary health care settings in Pakistan: an observational cohort study. Journal of Global Health. 2025 Mar 28;15:04096.\u003c/li\u003e\n\u003cli\u003eIftikhar S, Sarwar MR, Saqib A, Sarfraz M, Shoaib QU. Antibiotic prescribing practices and errors among hospitalized pediatric patients suffering from acute respiratory tract infections: a multicenter, cross-sectional study in Pakistan. Medicina. 2019 Feb 11;55(2):44.\u003c/li\u003e\n\u003cli\u003eKlein EY, Van Boeckel TP, Martinez EM, Pant S, Gandra S, Levin SA, Goossens H, Laxminarayan R. Global increase and geographic convergence in antibiotic consumption between 2000 and 2015. Proceedings of the National Academy of Sciences. 2018 Apr 10;115(15):E3463-70.\u003c/li\u003e\n\u003cli\u003eHolmes AH, Moore LS, Sundsfjord A, Steinbakk M, Regmi S, Karkey A, Guerin PJ, Piddock LJ. Understanding the mechanisms and drivers of antimicrobial resistance. The Lancet. 2016 Jan 9;387(10014):176-87.\u003c/li\u003e\n\u003cli\u003eLee CF, Cowling BJ, Feng S, Aso H, Wu P, Fukuda K, Seto WH. Impact of antibiotic stewardship programmes in Asia: a systematic review and meta-analysis. Journal of Antimicrobial Chemotherapy. 2018 Apr 1;73(4):844-51.\u003c/li\u003e\n\u003cli\u003eFarooqui HH, Mehta A, Selvaraj S. Outpatient antibiotic prescription rate and pattern in the private sector in India: evidence from medical audit data. PloS one. 2019 Nov 13;14(11):e0224848.\u003c/li\u003e\n\u003cli\u003eKhanal S, Acharya U, Trotter AB, Tripathi P, Koirala S, Pahari B, Acharya SP. Challenges and opportunities in the implementation of an antimicrobial stewardship program in Nepal. Antimicrobial Stewardship \u0026amp; Healthcare Epidemiology. 2023 Jan;3(1):e58.\u003c/li\u003e\n\u003cli\u003eSheikh S, Saleem Z, Afzal S, Qamar MU, Raza AA, Haider Naqvi SZ, Al-Rawi MB, Godman B. Identifying targets for antibiotic stewardship interventions in pediatric patients in Punjab, Pakistan: point prevalence surveys using AWaRe guidance. Frontiers in Pediatrics. 2025 Jan 10;12:1469766.\u003c/li\u003e\n\u003cli\u003eIftikhar S, Sarwar MR, Saqib A, Sarfraz M, Shoaib QU. Antibiotic prescribing practices and errors among hospitalized pediatric patients suffering from acute respiratory tract infections: a multicenter, cross-sectional study in Pakistan. Medicina. 2019 Feb 11;55(2):44.\u003c/li\u003e\n\u003cli\u003ePneumonia Study Group. Clinical efficacy of 3 days versus 5 days of oral amoxicillin for treatment of childhood pneumonia: a multicentre double-blind trial. The Lancet. 2002 Sep 14;360(9336):835-41.\u003c/li\u003e\n\u003cli\u003eHolmes AH, Moore LS, Sundsfjord A, Steinbakk M, Regmi S, Karkey A, Guerin PJ, Piddock LJ. Understanding the mechanisms and drivers of antimicrobial resistance. The Lancet. 2016 Jan 9;387(10014):176-87.\u003c/li\u003e\n\u003cli\u003eManirakiza A, Maru SM, Nyamu DG, Bizimana T, Nimpagaritse M. Antimicrobial prescribing patterns among pediatric outpatient encounters in primary healthcare centers in Bujumbura Mairie, Burundi. BMC Primary Care. 2025 Aug 1;26(1):236.\u003c/li\u003e\n\u003cli\u003eBari A, Sadruddin S, Khan A, Ullah A, Lehri IA, Macleod WB, Fox MP, Thea DM, Qazi SA. Cluster Randomized Trial of Community Case Management of Severe Pneumonia with Oral Amoxicillin in Children 2-59 Months of Age in Haripur District, Pakistan. Lancet. 2011 Nov 10;378(9805):1796.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":" \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cdiv class=\"SimplePara\"\u003eBaseline characteristics and clinical features of children presenting with non-severe pneumonia before and after the audit\u003c/div\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eVariable\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003ePre-Audit (n\u0026thinsp;=\u0026thinsp;132)\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003ePost-Audit (n\u0026thinsp;=\u0026thinsp;153)\u003c/div\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eMale\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e81/132 (61.4%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e93/153 (60.8%)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eFemale\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e51/132 (38.6%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e60/153 (39.2%)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u0026lt;\u0026thinsp;12 months\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e60/132 (45.5%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e52/153 (34.0%)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e13\u0026ndash;60 months\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e57/132 (43.2%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e75/153 (49.0%)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e60 months\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e15/132 (11.4%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e26/153 (17.0%)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eFever\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e115/132 (87.1%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e149/153 (97.4%)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eCough\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e121/132 (91.7%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e126/153 (82.4%)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eShortness of breath\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e5 /132(3.8%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e13/153 (8.5%)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eVomiting\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e7/132 (5.3%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e4/153 (2.6%)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eAbdominal pain\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e9/132 (6.8%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e1/153 (0.7%)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eRunny nose\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e4/132 (3.0%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e1/153 (0.7%)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eNote: Fever and cough were the predominant presenting complaints in both audit cycles. Most patients were under five years of age.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003cbr/\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cdiv class=\"SimplePara\"\u003eExamination findings among children with non-severe pneumonia before and after the audit\u003c/div\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eExamination\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eFindingPre-Audit (n\u0026thinsp;=\u0026thinsp;132)\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003ePost-Audit (n\u0026thinsp;=\u0026thinsp;153)\u003c/div\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eCrepitation\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e87/132 (65.9%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e141/153 (92.2%)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eWheeze\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e31/132 (23.5%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e46/153 (30.1%)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eChest clear\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e8/132 (6.1%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e3/153 (2.0%)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eTonsillar hypertrophy\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e23/132 (17.4%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e3/153 (2.0%)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eThroat erythema\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e23/132 (17.4%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e7/153 (4.6%)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eRunny nose\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e11/132 (8.3%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e13/153 (8.5%)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eNote: Crepitation were the most frequent finding, showing a marked increase post-audit, reflecting improved clinical documentation and diagnostic accuracy.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003cbr/\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cdiv class=\"SimplePara\"\u003eAge-wise Antibiotic Use\u003c/div\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eAge Group\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003ePre-Audit\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003eTotal (n)\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003eAntibiotic Given\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003ePost-audit\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003eTotal (n)\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003eAntibiotic Given\u003c/div\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u0026lt;\u0026thinsp;12 months\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e60\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e55/60 (91.7%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e52\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e44/52 (84.6%)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e13\u0026ndash;60 months\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e57\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e46/57 (80.7%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e75\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e65/75 (86.7%)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e60 months\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e15\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e6/15 (40.0%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e26\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e26/26 (100.0%)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eInappropriate prescribing was most common in \u0026lt;\u0026thinsp;12 months during pre-audit, with notable improvement post-audit.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003cbr/\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cdiv class=\"SimplePara\"\u003eAntibiotic prescribing patterns and appropriateness before and after the audit\u003c/div\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eParameter\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003ePre-Audit (n\u0026thinsp;=\u0026thinsp;132)\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003ePost-Audit (n\u0026thinsp;=\u0026thinsp;153)\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003ep-value\u003c/div\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eAny antibiotic prescribed\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e116/132 (87.9%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e135/153 (88.2%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.94\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eAmoxicillin prescribed\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e26/132 (19.7%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e119/153 (77.8%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u0026lt;\u0026thinsp;0.001\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eAmoxicillin appropriate\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e1/26 (3.8%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e96/119 (80.7%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u0026lt;\u0026thinsp;0.001\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eAzithromycin prescribed\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e66/132 (50.0%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e5/153 (3.3%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u0026lt;\u0026thinsp;0.001\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eAzithromycin appropriate\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e20/66 (30.3%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e4/5 (80.0%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.0002\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eNote: Age-stratified prescribing improved across all groups. Follow-up rates modestly increased from 15/132 (11.4%) to 23/153 (15.0%), with most returning patients showing clinical improvement. Tachypnea remained closely associated with hospital referral among the follow-up subset (χ\u0026sup2; test, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003cbr/\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-infectious-diseases","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"infd","sideBox":"Learn more about [BMC Infectious Diseases](http://bmcinfectdis.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/infd","title":"BMC Infectious Diseases","twitterHandle":"#bmcinfectdis","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Pediatric pneumonia, antibiotic prescribing, antimicrobial stewardship, azithromycin, amoxicillin, clinical audit, Pakistan","lastPublishedDoi":"10.21203/rs.3.rs-8879141/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8879141/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eAntibiotic overuse in childhood pneumonia drives antimicrobial resistance, especially in LMICs. This audit evaluated outpatient prescribing patterns, implemented targeted interventions, and assessed post-audit improvements in guideline-based prescribing.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA two-cycle clinical audit was conducted at the Children\u0026rsquo;s Hospital, Sukkur, Pakistan. Children under 15 years presenting with cough and/or difficulty breathing and age-specific tachypnea were evaluated during pre-audit (n\u0026thinsp;=\u0026thinsp;132) and post-audit (n\u0026thinsp;=\u0026thinsp;153) cycles. Educational sessions emphasized WHO AWaRe and IMNCI guidelines recommending amoxicillin as first-line therapy. Data were collected on demographics, clinical features, antibiotic type, dose, and appropriateness.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOverall antibiotic prescribing remained high (116/132 [87.9%] pre-audit vs 135/153 [88.2%] post-audit). Appropriateness improved markedly: amoxicillin prescriptions rose from 26/132 (19.7%) to 119/153 (77.8%), with guideline-concordant use increasing from 5/132 (3.8%) to 96/153 (62.7%). Azithromycin use fell from 66/132 (50.0%) to 5/153 (3.3%), with guideline-concordant use increasing from 20/66 (30.3%) to 4/5 (80.0%). Clinical documentation and adherence to pneumonia criteria improved significantly. Follow-up rates remained low (15%), though most returning patients demonstrated clinical improvement.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eStructured audit and feedback markedly improved guideline-adherent antibiotic prescribing for pediatric pneumonia, increasing appropriate amoxicillin use and reducing inappropriate macrolide prescriptions. Short, focused interventions in LMIC outpatient settings can effectively improve antimicrobial stewardship.\u003c/p\u003e","manuscriptTitle":"Audit of Antibiotic Prescribing Practices for Pediatric Pneumonia in the Outpatient Department: Focus on Amoxicillin and Azithromycin","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-27 09:26:04","doi":"10.21203/rs.3.rs-8879141/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-08T04:40:51+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-06T18:44:02+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-03T06:44:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"301826184620649746986442614457016394461","date":"2026-03-28T04:55:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"118431728577123813544773948494291921364","date":"2026-03-27T22:27:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"308723947211642283865789483880895939071","date":"2026-03-25T00:45:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"128299692806191628725101271968642314353","date":"2026-03-23T04:35:05+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-17T06:52:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"151234714218477834627654136220585553326","date":"2026-03-12T04:41:13+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"151872068828595853462831717666039126300","date":"2026-03-09T06:44:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"136443199664113346544346350327521547125","date":"2026-02-24T04:21:48+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-24T03:41:51+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-23T04:44:02+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-19T17:00:06+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Infectious Diseases","date":"2026-02-19T15:36:53+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-infectious-diseases","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"infd","sideBox":"Learn more about [BMC Infectious Diseases](http://bmcinfectdis.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/infd","title":"BMC Infectious Diseases","twitterHandle":"#bmcinfectdis","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1fd694ef-6005-45a1-84fa-dd19bdd97721","owner":[],"postedDate":"February 27th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-15T07:39:37+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-27 09:26:04","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8879141","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8879141","identity":"rs-8879141","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}