Antibiotic Prescribing Patterns Among Outpatients Using the WHO AWaRe Classification in Health Facilities in Tete and Sofala, Mozambique

Antibiotic Prescribing Patterns Among Outpatients Using the WHO AWaRe Classification in Health Facilities in Tete and Sofala, Mozambique | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Antibiotic Prescribing Patterns Among Outpatients Using the WHO AWaRe Classification in Health Facilities in Tete and Sofala, Mozambique Nelson Domingos Cote, Mussagy Miraz Pinto Issufo, Álvaro da Costa Rosa Alberto, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9291164/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 10 You are reading this latest preprint version Abstract Background Antibiotic overuse is a major driver of antimicrobial resistance (AMR), a global public health concern, particularly in sub-Saharan Africa where a high burden of infectious diseases and predominantly empirical diagnosis contribute to inappropriate use. The World Health Organization (WHO) AWaRe (Access, Watch, Reserve) classification supports rational prescribing by enabling the monitoring of antibiotic use patterns. However, data on AWaRe-based antibiotic use in Mozambique, especially in outpatient settings, remain limited. This study aimed to evaluate antibiotic prescribing patterns among outpatients using the WHO AWaRe classification in health facilities in Tete and Sofala, Mozambique. Methods Secondary data from outpatient prescriptions at two health facilities in Mozambique, Health Center No. 3 in Tete Province and Caia District Hospital in Sofala Province, were analyzed. Patients of all ages attended between November 2025 and January 2026 with at least one antibiotic prescribed were included (n = 387). Antibiotic prescribing patterns were evaluated using the WHO AWaRe classification and WHO/INRUD prescribing indicators. Results Among the 387 prescriptions included, a total of 435 antibiotics were prescribed. Most patients received one antibiotic (89.4%), while 6.7% received two and 3.9% received three or more. Cotrimoxazole was the most frequently prescribed antibiotic (42.8%), followed by amoxicillin (20.2%) and metronidazole (11.3%). According to the AWaRe classification, 85.7% of antibiotics belonged to the Access group and 12.4% to the Watch group, with no prescriptions from the Reserve group. All antibiotics were prescribed by their generic names and were included in the essential medicines list. Total antibiotic consumption was 121.91 DDD/1,000 inhabitants/day, with amoxicillin (50.22) and ciprofloxacin (23.59) showing the highest utilization rates. Conclusion Antibiotic prescribing among outpatients in this study met the WHO target for the Access group, indicating overall alignment with recommended practices. However, the use of Watch antibiotics, particularly macrolides, highlights the need to strengthen antimicrobial stewardship efforts to ensure more rational use. The implementation of WHO recommendations, including the AWaRe classification, together with improved adherence to clinical guidelines and targeted training of healthcare providers, is essential to optimize prescribing practices in outpatient settings. Antibiotic prescribing Outpatients Antimicrobial stewardship WHO AWaRe classification Mozambique Figures Figure 1 Introduction Excessive and inappropriate use of antibiotics is a major driver of antimicrobial resistance (AMR), which is widely recognized as a global public health challenge [ 1 ]. AMR affects not only human health but also animal health, agriculture, and the environment [ 2 , 3 ]. Recent estimates indicate that millions of deaths are associated with bacterial resistance, representing an even greater concern in Sub-Saharan Africa (SSA), where the coexistence of a high burden of infectious diseases, limited diagnostic capacity, and reliance on empirical prescribing practices increases the likelihood of inappropriate antibiotic use [ 4 ]. In this context, strategies that promote rational prescribing are essential to curb the progression of resistance [ 1 ]. To guide clinical decision-making and improve prescribing quality, the World Health Organization (WHO) developed the AWaRe classification, which categorizes antibiotics into three groups: Access, Watch, and Reserve [ 5 ]. Antibiotics in the Access group are recommended as first- or second-line treatments for common infections and should be widely available. The Watch group includes antibiotics with a higher potential to drive resistance and therefore requires closer monitoring. The Reserve group consists of last-resort agents, intended for use only in specific situations to preserve their effectiveness. This classification, together with the WHO Model List of Essential Medicines, provides a practical framework for optimizing antimicrobial use [ 5 ]. Monitoring antibiotic consumption based on the AWaRe classification allows the identification of inappropriate prescribing patterns and supports antimicrobial stewardship interventions [ 5 ]. The WHO recommends that at least 60% of total national antibiotic consumption should come from the Access group, aiming to reduce selective pressure that contributes to the emergence of resistant microorganisms [ 5 , 6 ]. Although some countries have made progress in implementing these recommendations, substantial regional variations in antibiotic prescribing and consumption patterns persist [ 7 ]. These differences are driven by multiple factors, including medicine availability, the local epidemiological profile of infections, access to laboratory diagnostics to guide treatment decisions, and the level of training of healthcare professionals [ 1 , 8 ]. In Mozambique, despite several studies assessing antibiotic use [ 9 – 12 ], there is limited evidence evaluating prescribing practices using the AWaRe classification alongside WHO/INRUD indicators [ 13 ], particularly in outpatient settings within tertiary hospitals. To address this gap, this study aimed to assess antibiotic prescribing patterns among outpatients using the WHO AWaRe classification (Access, Watch, and Reserve) in tertiary hospitals in Tete and Sofala, Mozambique. Methods Study design, population, and sample size A cross-sectional study was conducted using secondary data obtained from medical records and prescription forms. The study focused on outpatients attending Health Center No. 3 in Tete City, Tete Province, Mozambique, and Caia District Hospital in Sofala Province, Mozambique. The health center is a primary care facility responsible for outpatient services, including general consultations, management of acute and chronic conditions, and medication dispensing. The district hospital is a secondary-level facility providing both outpatient and inpatient care, including specialized consultations and the management of more complex cases. The study was carried out between November 2025 and January 2026. During this period, a total of 387 outpatients, including both children and adults, received at least one antibiotic prescription and were included in the study. Data collection and variables The WHO AWaRe classification and WHO/INRUD prescribing indicators were used to assess antibiotic prescribing practices. Data were collected under the supervision of the principal investigator using a structured data collection tool that included patient-related and antibiotic-related information. Prescriptions with illegible handwriting that prevented clear identification of the prescribed antibiotic, as well as those containing only medical supplies, were excluded from the analysis. Statistical analysis Statistical analyses were performed using R software (R Foundation for Statistical Computing, Vienna, Austria), version 4.5.1 for Windows, within the RStudio environment. Descriptive statistics, including frequencies, percentages, means, medians, and standard deviations (SD), were used to summarize the data. Results Sociodemographic characteristics As shown in Table 1 , a total of 387 individuals were included in the study. There was a slight predominance of male participants (51%) compared to females (49%). The median age was 15 years. Regarding the place of care, most patients attended Health Center No. 3 (323; 83%), while 64 (17%) attended Caia District Hospital. In terms of diagnostic approach, clinical diagnosis was the most common (356; 93%), whereas laboratory-confirmed diagnosis was less frequent (28; 7%). Concerning antiretroviral therapy (ART), the majority of participants were not receiving treatment (357; 92%), and only 30 (8%) were on ART. Information on disease type was available for 77 participants, among whom 57 (74%) had infectious diseases and 20 (26%) had non-infectious conditions. Table 1 Sociodemographic characteristics Characteristics N (%) Age Children (0–11 years) 151 (39.0) Adolescents (12–17 years) 47 (12.1) Adults (18–59 years) 155 (40.1) 60 years and over 4 (1.0) Not specified 30 (7.8) Sex Female 190 (49.1) Male 197 (50.9) Name of the health centre Health Centre No. 3 323 (83.5) Caia District Hospital 64 (16.5) Type of diagnosis Clinical 359 (92.8) Clinical and laboratory 28 (7.2) Antiretroviral therapy (ART) No 357 (92.2) Yes 30 (7.8) Diagnostic Infectious disease 49 (12.7) Non-infectious disease 29 (7.5) Not specified 309 (79.8) Number of antibiotics prescribed 1 353 (91.2) 2 20 (5.2) 3 14 (3.6) Routes of administration Oral 385 (99.5) Parenteral 2 (0.5) Duration of tratment < 5 26 (6.7) 5–10 361 (93.3) Antibiotic prescribing patterns According to Table 1 , most patients received a single antibiotic (261; 87%). The prescription of two antibiotics occurred in 22 cases (7%), and three antibiotics in 16 cases (5%). Regarding the route of administration, oral delivery predominated (385; 99%). As illustrated in Fig. 1 , cotrimoxazole was the most frequently prescribed antibiotic (42.8%), followed by amoxicillin (20.0%). Metronidazole accounted for 11.3%, while erythromycin and ciprofloxacin each represented 7.1%. In terms of pharmacological classes (Fig. 1 ), the combination of sulfonamide + trimethoprim was the most commonly used (43.0%; n = 186), followed by penicillins (24.0%; n = 105). Macrolides accounted for 12.0%, and nitroimidazoles for 11.0%. Distribution of prescribed antibiotics by age group, health facility, and prescriber Table 2 shows that antibiotics were most frequently prescribed to adults (41.4%) and children aged 0–11 years (36.3%). Cotrimoxazole was predominantly prescribed among adolescents aged 12–17 years (65.3%) and children aged 0–11 years (45.6%). Amoxicillin was more frequently prescribed in children aged 0–11 years (23.4%) and adults (18.3%). Erythromycin was prescribed in 10.1% of cases among children. According to S. Table 1 , cotrimoxazole was the most prescribed antibiotic in both health facilities, with a higher proportion at Health Center No. 3 (48.9%) compared to Caia District Hospital (16.9%). In contrast, amoxicillin was more frequently prescribed at Caia District Hospital (18.8%) than at Health Center No. 3 (6%). Table 2 Distribution of prescribed antibiotics by age Antibiotics ATC code Age 0–11 years N = 158 12–17 years N = 49 18–59 years N = 180 Above 60 years N = 4 Not specified N = 44 Overall N = 435 Amoxicillin J01CA04 37 (23.4) 8 (16.3) 33 (18.3) 1 (25.0) 9 (20.5) 88 (20.2) Azithromycin J01FA10 5 (3.2) 1 (2.0) 12 (6.7) 0 (0.0) 5 (11.4) 23 (5.3) Benzathine Penicillin J01CE08 1 (0.6) 0 (0.0) 2 (1.1) 0 (0.0) 0 (0.0) 3 (0.7) Ciprofloxacin J01MA02 8 (5.1) 3 (6.1) 18 (10.0) 1 (25.0) 1 (2.3) 31 (7.1) Cotrimoxazole J01EE01 72 (45.6) 32 (65.3) 69 (38.3) 0 (0.0) 13 (29.5) 186 (42.8) Erythromycin J01FA01 16 (10.1) 1 (2.0) 10 (5.6) 1 (25.0) 3 (6.8) 31 (7.1) Griseofulvin D01BA01 3 (1.9) 1 (2.0) 1 (0.6) 0 (0.0) 0 (0.0) 5 (1.1) Metronidazole P01AB01 9 (5.7) 3 (6.1) 29 (16.1) 0 (0.0) 8 (18.2) 49 (11.3) Nystatin A07AA01 1 (0.6) 0 (0.0) 1 (0.6) 0 (0.0) 1 (2.3) 3 (0.7) Phenoxymethylpenicillin J01CE02 4 (2.5) 0 (0.0) 5 (2.8) 1 (25.0) 4 (9.1) 14 (3.2) Tetracycline J01A A01 2 (1.3) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 2 (0.5) As presented in S. Table 2 , which describes antibiotic distribution by professional category, most prescriptions were issued by general medical technicians (71.5%), followed by physicians (20.0%) and general nurses (9.4%). Cotrimoxazole was most frequently prescribed by medical technicians (46.3%) and nurses (36.6%), while amoxicillin was more commonly prescribed by physicians (29.9%). Defined daily dose (DDD) of prescribed antibiotics The total antibiotic consumption was 121.91 DDD per 1,000 inhabitants per day, corresponding to a total DDD (DDDT) of 1,121.405. Amoxicillin showed the highest utilization rate (50.22 DDD/1,000/day), followed by ciprofloxacin (23.59), cotrimoxazole (13.58), erythromycin (11.32), and azithromycin (8.75). Moderate levels of consumption were observed for phenoxymethylpenicillin (5.71) and benzathine penicillin (5.48). In contrast, metronidazole (2.80) and tetracycline (0.46) had the lowest utilization rates (Table 3 ). Table 3 Defined daily dose (DDD) of prescribed antibiotics Antibiotics ATC Code DDD (g) DDDT DDD/1,000/day Amoxicillin J01CA04 1 462 50.22 Azithromycin J01FA10 0.5 80.5 8.75 Benzathine Penicillin J01CE08 3.6 50.4 5.48 Ciprofloxacin J01MA02 1 217 23.59 Cotrimoxazole J01EE01 0.5 124.92 13.58 Erythromycin J01FA01 2 104.16 11.32 Metronidazole P01AB01 1.5 25.725 2.8 Phenoxymethylpenicillin J01CE02 2 52.5 5.71 Tetracycline J01AA01 1 4.2 0.46 Total 1.121.405 121.91 Note : ATC: Anatomical Therapeutic Chemical classification system; DDD (g): Defined Daily Dose in grams, as established by the WHO; DDDT: Total number of defined daily doses consumed during the study period; DDD/1,000 inhabitants/day: Defined daily doses per 1,000 inhabitants per day, indicating the intensity of antibiotic consumption. Antibiotic prescription according to WHO AWaRe classification As shown in Table 4 , 85 .7% of the prescribed antibiotics belonged to the Access group, while 12.4% were classified in the Watch group. No antibiotics from the Reserve group were prescribed. Within the Access group, cotrimoxazole (49.9%), amoxicillin (23.6%), and metronidazole (13.1%) were the most frequently used. In the Watch group, ciprofloxacin (57.4%) and azithromycin (42.6%) predominated. Table 4 Categorization of antibiotics according to AWaRe classification by the WHO Antibiotics ATC code Access Watch Unclassified Overall (N = 373) (N = 54) (N = 8) (N = 435) Amoxicillin J01CA04 88 (23.6) 0 (0.0) 0 (0.0) 88 (20.2) Azithromycin J01FA10 0 (0.0) 23 (42.6) 0 (0.0) 23 (5.3) Benzathine Penicillin J01CE08 3 (0.8) 0 (0.0) 0 (0.0) 3 (0.7) Ciprofloxacin J01MA02 0 (0.0) 31 (57.4) 0 (0.0) 31 (7.1) Cotrimoxazole J01EE01 186 (49.9) 0 (0.0) 0 (0.0) 186 (42.8) Erythromycin J01FA01 31 (8.3) 0 (0.0) 0 (0.0) 31 (7.1) Griseofulvin D01BA01 0 (0.0) 0 (0.0) 5 (62.5) 5 (1.1) Metronidazole P01AB01 49 (13.1) 0 (0.0) 0 (0.0) 49 (11.3) Nystatin A07AA01 0 (0.0) 0 (0.0) 3 (37.5) 3 (0.7) Phenoxymethylpenicillin J01CE02 14 (3.8) 0 (0.0) 0 (0.0) 14 (3.2) Tetracycline J01A A01 2 (0.5) 0 (0.0) 0 (0.0) 2 (0.5) WHO/INRUD Standard Prescribing Indicators According to Table 5 , all antibiotics were prescribed by their generic names (100%), fully meeting the WHO-recommended standard. Likewise, all prescribed antibiotics were listed in the Essential Medicines List (100%), in complete alignment with established guidelines. Only 0.5% of patients received antibiotics in injectable form. Table 5 WHO/INRUD Standard Prescribing Indicators Drug use indicators N (%) WHO optimal values (%)[ 26 ] Average number of antibiotics per prescription 1.12 (SD: 0.426) Antibiotics prescribed by generic name 435 (100) 100 Antibiotics prescribed from the essential medicines list 435 (100) 100 Antibiotics prescribed in injectable form 2 (0.5) 13.4–24.1 Discussion This study represents one of the first analyses conducted in Mozambique to evaluate outpatient antibiotic prescribing patterns using the WHO AWaRe classification, focusing on health facilities in the provinces of Tete and Sofala. A higher proportion of prescriptions was observed among children and adolescents, which may reflect the increased burden of infectious diseases in these age groups and their frequent use of outpatient services. Amoxicillin and cotrimoxazole were the most commonly prescribed antibiotics, a pattern consistent with findings from other studies conducted in SSA [ 14 – 17 ], where these agents form the backbone of primary healthcare treatment. In settings characterized by a high burden of infectious diseases and limited access to diagnostic tools, empirical prescribing is common practice [ 1 ]. This likely explains the high proportion of clinically diagnosed cases observed in this study. Although these antibiotics predominated, other studies have reported different prescribing patterns, in which antibiotics such as ciprofloxacin ranked among the most frequently used after amoxicillin [ 15 , 18 ]. This variation may reflect differences in local prescribing practices, availability of medicines, and adherence to treatment guidelines across settings. The predominance of general medical technicians in issuing most prescriptions may reflect the structure of the Mozambican health system, where these professionals play a central role in primary healthcare delivery. In this context, investing in continuous professional training on rational prescribing, along with the adoption of tools that support appropriate antibiotic use [ 19 ], such as the AWaRe classification, may contribute to strengthening efforts to combat antimicrobial resistance. Regarding the AWaRe classification, the findings of this study demonstrate a predominance of antibiotics from the Access group (85.7%), aligning with the WHO recommendation that at least 60% of total antibiotic consumption should come from this category [ 6 ]. The proportion of prescriptions from the Watch group was 12.4%. Although this proportion is relatively lower compared with findings from other studies [ 16 , 20 ], antibiotics in this group are recommended only for specific indications and require careful monitoring due to their higher potential to drive AMR [ 6 ]. Their use should ideally be guided by laboratory diagnostics; however, in settings with limited diagnostic capacity, prescribing may occur empirically. Such practices can compromise the quality of care and contribute to the emergence and spread of AMR. Regarding the WHO/INRUD prescribing indicators, all evaluated prescriptions were consistent with recommended standards. The average number of antibiotics per prescription was within acceptable limits, all antibiotics were prescribed by their generic names, were included in the essential medicines list, and were administered predominantly via the appropriate route, with limited use of injectable formulations [ 21 ]. These findings suggest good adherence to key prescribing principles and reflect rational practices in terms of medicine selection and prescription writing. Prescribing by generic name and adherence to the essential medicines list are particularly important in resource-limited settings, as they promote cost-effectiveness and improve access to treatment. In terms of antibiotic consumption, this study identified a total of 121.91 DDD per 1,000 inhabitants per day, indicating a high level of use in the outpatient setting, likely associated with a substantial burden of infectious diseases and the frequent reliance on empirical prescribing. When compared with findings from other settings, these values are considerably higher than those reported in Ethiopia (5.31 DDD per 100 outpatient visits per day) [ 22 ], Tanzania (39.05 DDD per 1,000 inhabitants per day) [ 23 ], and Slovenia (59.8 DDD per 1,000 inhabitants per day) [ 24 ], where antibiotics such as penicillins, ciprofloxacin, and doxycycline were among the most commonly used. In the present study, amoxicillin showed the highest utilization rate, followed by ciprofloxacin and cotrimoxazole, suggesting that these agents form the core of treatment in the study setting. This pattern is partly expected, as amoxicillin belongs to the Access group and is widely recommended as a first-line treatment for common infections. However, the substantial use of ciprofloxacin, a Watch group antibiotic, warrants attention due to its higher potential to drive antimicrobial resistance. The differences observed across studies may be explained by several factors, including the relatively short data collection period in the present study, potential seasonal variations in infection patterns, and differences in prevention and control strategies [ 22 ]. In the context of the growing threat of antimicrobial resistance, strengthening antimicrobial stewardship strategies within healthcare facilities is essential. The systematic integration of the AWaRe classification into local treatment protocols, the implementation of regular prescription audits, and investment in laboratory infrastructure to support diagnostic confirmation are key measures [ 1 ]. In addition, targeted educational interventions for prescribers may help reduce inappropriate practices related to antibiotic selection, dosing, and treatment intervals. This study has some limitations. As a cross-sectional study based on clinical records and prescription data, it is subject to potential omissions or inconsistencies in documentation. The inclusion of only two healthcare facilities limits the generalizability of the findings to other regions or settings within the country. Furthermore, the lack of microbiological data precluded the assessment of treatment appropriateness based on etiological confirmation. Despite these limitations, the study provides relevant insights into outpatient prescribing patterns and serves as an important foundation for future, more comprehensive research in Mozambique, while also contributing to efforts aimed at promoting the rational use of antibiotics. Conclusion Antibiotic prescribing in this outpatient setting was generally consistent with WHO recommendations, as reflected by the universal use of generic names and full adherence to the Essential Medicines List. Most prescriptions involved antibiotics from the Access group, aligning with global efforts to promote rational antibiotic use. Despite these positive findings, the results highlight the need to strengthen diagnostic capacity and reinforce antimicrobial stewardship strategies to further optimize prescribing practices and reduce the risk of AMR. Additionally, these findings emphasize the importance of conducting more comprehensive future studies to better understand prescribing patterns and inform evidence-based interventions. Declarations Acknowledgements The authors would like to thank the Scientific Committee of Zambeze University, Faculty of Health Sciences, for approving this research project. They also express their gratitude to the health facilities where the data were collected for their support and collaboration. Ethical Consideration and consent to participate Prior to data collection, scientific approval to conduct the study was obtained from the Faculty of Health Sciences at Zambeze University in Tete, as well as from the participating health facilities. The study was conducted under official authorization (TF – VNo2/2025CCAP) and in accordance with the ethical principles outlined in the Declaration of Helsinki [25]. Clinical trial number Not applicable. Consent for publication Not applicable. Availability of data and materials The datasets generated and/or analyzed during the current study are available from the corresponding author upon reasonable request. Competing interests The authors declare that there are no competing interests. Funding This research did not receive any specific funding from public, commercial, or non-profit organizations. Authors’ contributions All authors contributed to the study conception and critically reviewed the manuscript prior to submission. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9291164","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":634893696,"identity":"3e632f64-3351-4536-b569-dfb9408adc8e","order_by":0,"name":"Nelson Domingos Cote","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABEklEQVRIiWNgGAWjYFAC5gYYi/EBQwGEPgAR4MGhhRGqhY2B2YDBAGyIAdFa2CRgWhjwaTFnb2z+8HEHgzy/fPOxih8Gh/P4GZgZD3youZc4v4H32AcsWix7DrZJzjzDYDizjS3tZo/B4WLJBmaGgzOOFSc2NvAlz8CixeBGYhszbxtDgsExHrMbPAaHEzcc4D9wmLchIbGZgccYm8MM7j9s/gzRwv+t8A9YCzMDWEsbLi03GBukobawMfMga+nBpeVMItAvbRJAv6QZS8sYpCfObAb7JcF4BjNfMlYtxw8f/vCxzUaen/nww49vKqwT+9mbmT98qEmQnd/eexhrKEOABBKbGYMxCkbBKBgFo4BUAADVVWB4ZtkpgwAAAABJRU5ErkJggg==","orcid":"","institution":"Universidade Zambeze","correspondingAuthor":true,"prefix":"","firstName":"Nelson","middleName":"Domingos","lastName":"Cote","suffix":""},{"id":634893697,"identity":"e6b52bc0-5d8b-41b8-a73c-755fce5aa489","order_by":1,"name":"Mussagy Miraz Pinto Issufo","email":"","orcid":"","institution":"Universidade Zambeze","correspondingAuthor":false,"prefix":"","firstName":"Mussagy","middleName":"Miraz Pinto","lastName":"Issufo","suffix":""},{"id":634893699,"identity":"a5314f42-7213-4c5e-a91a-e7988d667aef","order_by":2,"name":"Álvaro da Costa Rosa Alberto","email":"","orcid":"","institution":"Universidade Zambeze","correspondingAuthor":false,"prefix":"","firstName":"Álvaro","middleName":"da Costa Rosa","lastName":"Alberto","suffix":""},{"id":634893700,"identity":"9c1d970d-832a-4e93-8474-bfb8a68ef0a3","order_by":3,"name":"Samito Simões Sebastião","email":"","orcid":"","institution":"Universidade Zambeze","correspondingAuthor":false,"prefix":"","firstName":"Samito","middleName":"Simões","lastName":"Sebastião","suffix":""},{"id":634893701,"identity":"1dfc1f37-05e0-42a7-b622-47d1e1d4555f","order_by":4,"name":"Delfina Augusto Virgílio","email":"","orcid":"","institution":"Universidade Zambeze","correspondingAuthor":false,"prefix":"","firstName":"Delfina","middleName":"Augusto","lastName":"Virgílio","suffix":""},{"id":634893702,"identity":"7ad87871-2c51-40fb-abcc-c380c648f776","order_by":5,"name":"Ramim Lorenço Xavi","email":"","orcid":"","institution":"Universidade Zambeze","correspondingAuthor":false,"prefix":"","firstName":"Ramim","middleName":"Lorenço","lastName":"Xavi","suffix":""},{"id":634893703,"identity":"e91607cd-c4df-4c28-a663-72c048851c86","order_by":6,"name":"Sancho Pedro Xavier","email":"","orcid":"","institution":"Universidade de São Paulo","correspondingAuthor":false,"prefix":"","firstName":"Sancho","middleName":"Pedro","lastName":"Xavier","suffix":""}],"badges":[],"createdAt":"2026-04-01 11:24:04","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9291164/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9291164/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108973799,"identity":"ce09f9a3-5f28-487e-87a0-172ef96987e4","added_by":"auto","created_at":"2026-05-11 10:44:13","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":95917,"visible":true,"origin":"","legend":"\u003cp\u003eDistribution of prescribed antibiotics by individual agent (A) and by pharmacological group (B).\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-9291164/v1/6ac2d810c2de3580ab47fae3.png"},{"id":108973907,"identity":"c4205987-a437-4a63-86ff-a3c68e229d4b","added_by":"auto","created_at":"2026-05-11 10:44:50","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":452803,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9291164/v1/3efef8a3-3d46-4a6b-ab44-2e835172b0d2.pdf"},{"id":108973848,"identity":"5d2d194d-38db-4c66-8fb5-ce06a944f78f","added_by":"auto","created_at":"2026-05-11 10:44:19","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":17785,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryMaterial.docx","url":"https://assets-eu.researchsquare.com/files/rs-9291164/v1/2e238086e0b7b99b23661614.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Antibiotic Prescribing Patterns Among Outpatients Using the WHO AWaRe Classification in Health Facilities in Tete and Sofala, Mozambique","fulltext":[{"header":"Introduction","content":"\u003cp\u003eExcessive and inappropriate use of antibiotics is a major driver of antimicrobial resistance (AMR), which is widely recognized as a global public health challenge [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. AMR affects not only human health but also animal health, agriculture, and the environment [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Recent estimates indicate that millions of deaths are associated with bacterial resistance, representing an even greater concern in Sub-Saharan Africa (SSA), where the coexistence of a high burden of infectious diseases, limited diagnostic capacity, and reliance on empirical prescribing practices increases the likelihood of inappropriate antibiotic use [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. In this context, strategies that promote rational prescribing are essential to curb the progression of resistance [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTo guide clinical decision-making and improve prescribing quality, the World Health Organization (WHO) developed the AWaRe classification, which categorizes antibiotics into three groups: Access, Watch, and Reserve [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Antibiotics in the Access group are recommended as first- or second-line treatments for common infections and should be widely available. The Watch group includes antibiotics with a higher potential to drive resistance and therefore requires closer monitoring. The Reserve group consists of last-resort agents, intended for use only in specific situations to preserve their effectiveness. This classification, together with the WHO Model List of Essential Medicines, provides a practical framework for optimizing antimicrobial use [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMonitoring antibiotic consumption based on the AWaRe classification allows the identification of inappropriate prescribing patterns and supports antimicrobial stewardship interventions [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The WHO recommends that at least 60% of total national antibiotic consumption should come from the Access group, aiming to reduce selective pressure that contributes to the emergence of resistant microorganisms [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough some countries have made progress in implementing these recommendations, substantial regional variations in antibiotic prescribing and consumption patterns persist [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. These differences are driven by multiple factors, including medicine availability, the local epidemiological profile of infections, access to laboratory diagnostics to guide treatment decisions, and the level of training of healthcare professionals [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn Mozambique, despite several studies assessing antibiotic use [\u003cspan additionalcitationids=\"CR10 CR11\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], there is limited evidence evaluating prescribing practices using the AWaRe classification alongside WHO/INRUD indicators [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], particularly in outpatient settings within tertiary hospitals. To address this gap, this study aimed to assess antibiotic prescribing patterns among outpatients using the WHO AWaRe classification (Access, Watch, and Reserve) in tertiary hospitals in Tete and Sofala, Mozambique.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design, population, and sample size\u003c/h2\u003e \u003cp\u003eA cross-sectional study was conducted using secondary data obtained from medical records and prescription forms. The study focused on outpatients attending Health Center No. 3 in Tete City, Tete Province, Mozambique, and Caia District Hospital in Sofala Province, Mozambique. The health center is a primary care facility responsible for outpatient services, including general consultations, management of acute and chronic conditions, and medication dispensing. The district hospital is a secondary-level facility providing both outpatient and inpatient care, including specialized consultations and the management of more complex cases.\u003c/p\u003e \u003cp\u003eThe study was carried out between November 2025 and January 2026. During this period, a total of 387 outpatients, including both children and adults, received at least one antibiotic prescription and were included in the study.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eData collection and variables\u003c/h3\u003e\n\u003cp\u003eThe WHO AWaRe classification and WHO/INRUD prescribing indicators were used to assess antibiotic prescribing practices. Data were collected under the supervision of the principal investigator using a structured data collection tool that included patient-related and antibiotic-related information. Prescriptions with illegible handwriting that prevented clear identification of the prescribed antibiotic, as well as those containing only medical supplies, were excluded from the analysis.\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eStatistical analyses were performed using R software (R Foundation for Statistical Computing, Vienna, Austria), version 4.5.1 for Windows, within the RStudio environment. Descriptive statistics, including frequencies, percentages, means, medians, and standard deviations (SD), were used to summarize the data.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eSociodemographic characteristics\u003c/h2\u003e \u003cp\u003eAs shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, a total of 387 individuals were included in the study. There was a slight predominance of male participants (51%) compared to females (49%). The median age was 15 years. Regarding the place of care, most patients attended Health Center No. 3 (323; 83%), while 64 (17%) attended Caia District Hospital. In terms of diagnostic approach, clinical diagnosis was the most common (356; 93%), whereas laboratory-confirmed diagnosis was less frequent (28; 7%). Concerning antiretroviral therapy (ART), the majority of participants were not receiving treatment (357; 92%), and only 30 (8%) were on ART. Information on disease type was available for 77 participants, among whom 57 (74%) had infectious diseases and 20 (26%) had non-infectious conditions.\u003c/p\u003e \u003cp\u003e \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 \u003cp\u003eSociodemographic characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChildren (0\u0026ndash;11 years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e151 (39.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdolescents (12\u0026ndash;17 years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e47 (12.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdults (18\u0026ndash;59 years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e155 (40.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e60 years and over\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4 (1.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot specified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e30 (7.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e190 (49.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e197 (50.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eName of the health centre\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealth Centre No. 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e323 (83.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCaia District Hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e64 (16.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eType of diagnosis\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e359 (92.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical and laboratory\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e28 (7.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAntiretroviral therapy (ART)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e357 (92.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e30 (7.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDiagnostic\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInfectious disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e49 (12.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-infectious disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e29 (7.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot specified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e309 (79.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNumber of antibiotics prescribed\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e353 (91.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e20 (5.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14 (3.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRoutes of administration\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e385 (99.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParenteral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2 (0.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDuration of tratment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e26 (6.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u0026ndash;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e361 (93.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eAntibiotic prescribing patterns\u003c/h2\u003e \u003cp\u003eAccording to Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, most patients received a single antibiotic (261; 87%). The prescription of two antibiotics occurred in 22 cases (7%), and three antibiotics in 16 cases (5%). Regarding the route of administration, oral delivery predominated (385; 99%). As illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, cotrimoxazole was the most frequently prescribed antibiotic (42.8%), followed by amoxicillin (20.0%). Metronidazole accounted for 11.3%, while erythromycin and ciprofloxacin each represented 7.1%. In terms of pharmacological classes (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), the combination of sulfonamide\u0026thinsp;+\u0026thinsp;trimethoprim was the most commonly used (43.0%; n\u0026thinsp;=\u0026thinsp;186), followed by penicillins (24.0%; n\u0026thinsp;=\u0026thinsp;105). Macrolides accounted for 12.0%, and nitroimidazoles for 11.0%.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eDistribution of prescribed antibiotics by age group, health facility, and prescriber\u003c/h3\u003e\n\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows that antibiotics were most frequently prescribed to adults (41.4%) and children aged 0\u0026ndash;11 years (36.3%). Cotrimoxazole was predominantly prescribed among adolescents aged 12\u0026ndash;17 years (65.3%) and children aged 0\u0026ndash;11 years (45.6%). Amoxicillin was more frequently prescribed in children aged 0\u0026ndash;11 years (23.4%) and adults (18.3%). Erythromycin was prescribed in 10.1% of cases among children. According to \u003cb\u003eS.\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, cotrimoxazole was the most prescribed antibiotic in both health facilities, with a higher proportion at Health Center No. 3 (48.9%) compared to Caia District Hospital (16.9%). In contrast, amoxicillin was more frequently prescribed at Caia District Hospital (18.8%) than at Health Center No. 3 (6%).\u003c/p\u003e \u003cp\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 \u003cp\u003eDistribution of prescribed antibiotics by age\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" 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 \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAntibiotics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eATC code\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"6\" nameend=\"c8\" namest=\"c3\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0\u0026ndash;11 years N\u0026thinsp;=\u0026thinsp;158\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e12\u0026ndash;17 years N\u0026thinsp;=\u0026thinsp;49\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e18\u0026ndash;59 years N\u0026thinsp;=\u0026thinsp;180\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003eAbove 60 years N\u0026thinsp;=\u0026thinsp;4\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003eNot specified N\u0026thinsp;=\u0026thinsp;44\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003eOverall N\u0026thinsp;=\u0026thinsp;435\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAmoxicillin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJ01CA04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e37 (23.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8 (16.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e33 (18.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1 (25.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e9 (20.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e88 (20.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAzithromycin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJ01FA10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5 (3.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1 (2.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e12 (6.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e5 (11.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e23 (5.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBenzathine Penicillin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJ01CE08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1 (0.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2 (1.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e3 (0.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCiprofloxacin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJ01MA02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8 (5.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3 (6.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e18 (10.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1 (25.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1 (2.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e31 (7.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCotrimoxazole\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJ01EE01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e72 (45.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e32 (65.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e69 (38.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e13 (29.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e186 (42.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eErythromycin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJ01FA01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16 (10.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1 (2.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e10 (5.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1 (25.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e3 (6.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e31 (7.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGriseofulvin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eD01BA01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3 (1.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1 (2.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1 (0.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e5 (1.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMetronidazole\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eP01AB01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9 (5.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3 (6.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e29 (16.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e8 (18.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e49 (11.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNystatin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eA07AA01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1 (0.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1 (0.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1 (2.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e3 (0.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhenoxymethylpenicillin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJ01CE02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4 (2.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5 (2.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1 (25.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e4 (9.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e14 (3.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTetracycline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJ01A A01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2 (1.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e2 (0.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAs presented in \u003cb\u003eS.\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, which describes antibiotic distribution by professional category, most prescriptions were issued by general medical technicians (71.5%), followed by physicians (20.0%) and general nurses (9.4%). Cotrimoxazole was most frequently prescribed by medical technicians (46.3%) and nurses (36.6%), while amoxicillin was more commonly prescribed by physicians (29.9%).\u003c/p\u003e\n\u003ch3\u003eDefined daily dose (DDD) of prescribed antibiotics\u003c/h3\u003e\n\u003cp\u003eThe total antibiotic consumption was 121.91 DDD per 1,000 inhabitants per day, corresponding to a total DDD (DDDT) of 1,121.405. Amoxicillin showed the highest utilization rate (50.22 DDD/1,000/day), followed by ciprofloxacin (23.59), cotrimoxazole (13.58), erythromycin (11.32), and azithromycin (8.75). Moderate levels of consumption were observed for phenoxymethylpenicillin (5.71) and benzathine penicillin (5.48). In contrast, metronidazole (2.80) and tetracycline (0.46) had the lowest utilization rates (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\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 \u003cp\u003eDefined daily dose (DDD) of prescribed antibiotics\u003c/p\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=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" 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 \u003cp\u003eAntibiotics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eATC Code\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDDD (g)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDDDT\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDDD/1,000/day\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAmoxicillin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJ01CA04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e462\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e50.22\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAzithromycin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJ01FA10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e80.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e8.75\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBenzathine Penicillin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJ01CE08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5.48\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCiprofloxacin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJ01MA02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e217\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e23.59\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCotrimoxazole\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJ01EE01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e124.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e13.58\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eErythromycin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJ01FA01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e104.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e11.32\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMetronidazole\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eP01AB01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25.725\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhenoxymethylpenicillin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJ01CE02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e52.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5.71\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTetracycline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJ01AA01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.46\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.121.405\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e121.91\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cb\u003eNote\u003c/b\u003e: ATC: Anatomical Therapeutic Chemical classification system; DDD (g): Defined Daily Dose in grams, as established by the WHO; DDDT: Total number of defined daily doses consumed during the study period; DDD/1,000 inhabitants/day: Defined daily doses per 1,000 inhabitants per day, indicating the intensity of antibiotic consumption.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eAntibiotic prescription according to WHO AWaRe classification\u003c/h2\u003e \u003cp\u003eAs shown in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e, \u003cb\u003e85\u003c/b\u003e.7% of the prescribed antibiotics belonged to the Access group, while 12.4% were classified in the Watch group. No antibiotics from the Reserve group were prescribed. Within the Access group, cotrimoxazole (49.9%), amoxicillin (23.6%), and metronidazole (13.1%) were the most frequently used. In the Watch group, ciprofloxacin (57.4%) and azithromycin (42.6%) predominated.\u003c/p\u003e \u003cp\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 \u003cp\u003eCategorization of antibiotics according to AWaRe classification by the WHO\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" 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 \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAntibiotics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eATC code\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAccess\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWatch\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eUnclassified\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eOverall\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;373)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;54)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;8)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;435)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAmoxicillin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJ01CA04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e88 (23.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e88 (20.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAzithromycin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJ01FA10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e23 (42.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e23 (5.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBenzathine Penicillin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJ01CE08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3 (0.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3 (0.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCiprofloxacin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJ01MA02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e31 (57.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e31 (7.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCotrimoxazole\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJ01EE01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e186 (49.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e186 (42.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eErythromycin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJ01FA01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e31 (8.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e31 (7.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGriseofulvin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eD01BA01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5 (62.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e5 (1.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMetronidazole\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eP01AB01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e49 (13.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e49 (11.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNystatin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eA07AA01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3 (37.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3 (0.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhenoxymethylpenicillin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJ01CE02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14 (3.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e14 (3.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTetracycline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJ01A A01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2 (0.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2 (0.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eWHO/INRUD Standard Prescribing Indicators\u003c/h2\u003e \u003cp\u003eAccording to Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e, all antibiotics were prescribed by their generic names (100%), fully meeting the WHO-recommended standard. Likewise, all prescribed antibiotics were listed in the Essential Medicines List (100%), in complete alignment with established guidelines. Only 0.5% of patients received antibiotics in injectable form.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eWHO/INRUD Standard Prescribing Indicators\u003c/p\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=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDrug use indicators\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWHO optimal values (%)[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAverage number of antibiotics per prescription\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.12 (SD: 0.426)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAntibiotics prescribed by generic name\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e435 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAntibiotics prescribed from the essential medicines list\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e435 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAntibiotics prescribed in injectable form\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (0.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.4\u0026ndash;24.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study represents one of the first analyses conducted in Mozambique to evaluate outpatient antibiotic prescribing patterns using the WHO AWaRe classification, focusing on health facilities in the provinces of Tete and Sofala. A higher proportion of prescriptions was observed among children and adolescents, which may reflect the increased burden of infectious diseases in these age groups and their frequent use of outpatient services.\u003c/p\u003e \u003cp\u003eAmoxicillin and cotrimoxazole were the most commonly prescribed antibiotics, a pattern consistent with findings from other studies conducted in SSA [\u003cspan additionalcitationids=\"CR15 CR16\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], where these agents form the backbone of primary healthcare treatment. In settings characterized by a high burden of infectious diseases and limited access to diagnostic tools, empirical prescribing is common practice [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. This likely explains the high proportion of clinically diagnosed cases observed in this study. Although these antibiotics predominated, other studies have reported different prescribing patterns, in which antibiotics such as ciprofloxacin ranked among the most frequently used after amoxicillin [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. This variation may reflect differences in local prescribing practices, availability of medicines, and adherence to treatment guidelines across settings.\u003c/p\u003e \u003cp\u003eThe predominance of general medical technicians in issuing most prescriptions may reflect the structure of the Mozambican health system, where these professionals play a central role in primary healthcare delivery. In this context, investing in continuous professional training on rational prescribing, along with the adoption of tools that support appropriate antibiotic use [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], such as the AWaRe classification, may contribute to strengthening efforts to combat antimicrobial resistance.\u003c/p\u003e \u003cp\u003eRegarding the AWaRe classification, the findings of this study demonstrate a predominance of antibiotics from the Access group (85.7%), aligning with the WHO recommendation that at least 60% of total antibiotic consumption should come from this category [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The proportion of prescriptions from the Watch group was 12.4%. Although this proportion is relatively lower compared with findings from other studies [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], antibiotics in this group are recommended only for specific indications and require careful monitoring due to their higher potential to drive AMR [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Their use should ideally be guided by laboratory diagnostics; however, in settings with limited diagnostic capacity, prescribing may occur empirically. Such practices can compromise the quality of care and contribute to the emergence and spread of AMR.\u003c/p\u003e \u003cp\u003eRegarding the WHO/INRUD prescribing indicators, all evaluated prescriptions were consistent with recommended standards. The average number of antibiotics per prescription was within acceptable limits, all antibiotics were prescribed by their generic names, were included in the essential medicines list, and were administered predominantly via the appropriate route, with limited use of injectable formulations [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. These findings suggest good adherence to key prescribing principles and reflect rational practices in terms of medicine selection and prescription writing. Prescribing by generic name and adherence to the essential medicines list are particularly important in resource-limited settings, as they promote cost-effectiveness and improve access to treatment.\u003c/p\u003e \u003cp\u003eIn terms of antibiotic consumption, this study identified a total of 121.91 DDD per 1,000 inhabitants per day, indicating a high level of use in the outpatient setting, likely associated with a substantial burden of infectious diseases and the frequent reliance on empirical prescribing. When compared with findings from other settings, these values are considerably higher than those reported in Ethiopia (5.31 DDD per 100 outpatient visits per day) [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], Tanzania (39.05 DDD per 1,000 inhabitants per day) [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], and Slovenia (59.8 DDD per 1,000 inhabitants per day) [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], where antibiotics such as penicillins, ciprofloxacin, and doxycycline were among the most commonly used. In the present study, amoxicillin showed the highest utilization rate, followed by ciprofloxacin and cotrimoxazole, suggesting that these agents form the core of treatment in the study setting. This pattern is partly expected, as amoxicillin belongs to the Access group and is widely recommended as a first-line treatment for common infections. However, the substantial use of ciprofloxacin, a Watch group antibiotic, warrants attention due to its higher potential to drive antimicrobial resistance. The differences observed across studies may be explained by several factors, including the relatively short data collection period in the present study, potential seasonal variations in infection patterns, and differences in prevention and control strategies [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn the context of the growing threat of antimicrobial resistance, strengthening antimicrobial stewardship strategies within healthcare facilities is essential. The systematic integration of the AWaRe classification into local treatment protocols, the implementation of regular prescription audits, and investment in laboratory infrastructure to support diagnostic confirmation are key measures [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In addition, targeted educational interventions for prescribers may help reduce inappropriate practices related to antibiotic selection, dosing, and treatment intervals.\u003c/p\u003e \u003cp\u003eThis study has some limitations. As a cross-sectional study based on clinical records and prescription data, it is subject to potential omissions or inconsistencies in documentation. The inclusion of only two healthcare facilities limits the generalizability of the findings to other regions or settings within the country. Furthermore, the lack of microbiological data precluded the assessment of treatment appropriateness based on etiological confirmation. Despite these limitations, the study provides relevant insights into outpatient prescribing patterns and serves as an important foundation for future, more comprehensive research in Mozambique, while also contributing to efforts aimed at promoting the rational use of antibiotics.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eAntibiotic prescribing in this outpatient setting was generally consistent with WHO recommendations, as reflected by the universal use of generic names and full adherence to the Essential Medicines List. Most prescriptions involved antibiotics from the Access group, aligning with global efforts to promote rational antibiotic use. Despite these positive findings, the results highlight the need to strengthen diagnostic capacity and reinforce antimicrobial stewardship strategies to further optimize prescribing practices and reduce the risk of AMR. Additionally, these findings emphasize the importance of conducting more comprehensive future studies to better understand prescribing patterns and inform evidence-based interventions.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank the Scientific Committee of Zambeze University, Faculty of Health Sciences, for approving this research project. They also express their gratitude to the health facilities where the data were collected for their support and collaboration.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Consideration and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePrior to data collection, scientific approval to conduct the study was obtained from the Faculty of Health Sciences at Zambeze University in Tete, as well as from the participating health facilities. The study was conducted under official authorization (TF \u0026ndash; VNo2/2025CCAP) and in accordance with the ethical principles outlined in the Declaration of Helsinki [25].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analyzed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that there are no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research did not receive any specific funding from public, commercial, or non-profit organizations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the study conception and critically reviewed the manuscript prior to submission. NDC performed the data analysis, and SPX validated the results. SPX, MMPI, ACRA, SSS, DAV, RLX, and NDC contributed to data interpretation and manuscript development. MMPI, ACRA, and SSS were responsible for data collection and data entry. All authors read and approved the final version of the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eXavier SP. An urgent call to combat antimicrobial resistance in Sub-Saharan Africa through integrated and innovative solutions. Discov Public Heal. 2025;22:673.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSingh B, Bhat A, Ravi K. Antibiotics misuse and antimicrobial resistance development in agriculture: a global challenge. Environ Heal. 2024;2:618\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNammi J, Pasala R, Andhe N, Vasam R, Poruri AD, Sherikar RR, Nammi JY. (2025) Antibiotic misuse: an in-depth examination of its global consequences and public health challenges. Cureus 17.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMurray CJL, Ikuta KS, Sharara F, Swetschinski L, Aguilar GR, Gray A, Han C, Bisignano C, Rao P, Wool E. Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis. Lancet. 2022;399:629\u0026ndash;55.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoja L, Zanichelli V, Mertz D, Gandra S, Cappello B, Cooke GS, Chuki P, Harbarth S, Pulcini C, Mendelson M. WHO\u0026rsquo;s essential medicines and AWaRe: recommendations on first-and second-choice antibiotics for empiric treatment of clinical infections. Clin Microbiol Infect. 2024;30:S1\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKlein EY, Milkowska-Shibata M, Tseng KK, Sharland M, Gandra S, Pulcini C, Laxminarayan R. Assessment of WHO antibiotic consumption and access targets in 76 countries, 2000\u0026ndash;15: an analysis of pharmaceutical sales data. Lancet Infect Dis. 2021;21:107\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrowne AJ, Chipeta MG, Haines-Woodhouse G, Kumaran EPA, Hamadani BHK, Zaraa S, Henry NJ, Deshpande A, Reiner RC, Day NPJ. Global antibiotic consumption and usage in humans, 2000\u0026ndash;18: a spatial modelling study. Lancet Planet Heal. 2021;5:e893\u0026ndash;904.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLaxminarayan R, Duse A, Wattal C, et al. Antibiotic resistance-the need for global solutions. Lancet Infect Dis. 2013;13:1057\u0026ndash;98.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSal\u0026ecirc;ncia-Ferr\u0026atilde;o J, Chissaque A, Manhique-Coutinho L, Kenga AN, Cassocera M, de Deus N. Inappropriate use of antibiotics in the management of diarrhoea in children under five years admitted with acute diarrhoea in four provinces of Mozambique 2014\u0026ndash;2019. BMC Infect Dis. 2025;25:209.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eXavier SP, Victor A, Cumaquela G, Vasco MD, Rodrigues OAS. Inappropriate use of antibiotics and its predictors in pediatric patients admitted at the Central Hospital of Nampula, Mozambique. Antimicrob Resist Infect Control. 2022;11:79.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMonteiro LGS, Cha\u0026uacute;que A, Barros MP, Ir\u0026aacute; TR. Determinants of antibiotic prescription in paediatric patients: The case of two hospitals in Maputo. Mozambique. 2017;11:109\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFaiela C, Sevene E. Antibiotic prescription for HIV-positive patients in primary health care in Mozambique: A cross-sectional study. South Afr J Infect Dis. 2022;37:340.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eXavier SP, da Silva AMC, Victor A. Antibiotic prescribing patterns in pediatric patients using the WHO access, watch, reserve (AWaRe) classification at a quaternary hospital in Nampula. Mozambique Sci Rep. 2024;14:22719.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIgirikwayo ZK, Migisha R, Mukaga H, Kabakyenga J. Prescription patterns of antibiotics and associated factors among outpatients diagnosed with respiratory tract infections in Jinja city, Uganda, June 2022-May 2023. BMC Pulm Med. 2024;24:446.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYimenu DK, Emam A, Elemineh E, Atalay W. Assessment of antibiotic prescribing patterns at outpatient pharmacy using world health organization prescribing indicators. J Prim Care Community Health. 2019;10:2150132719886942.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHailesilase GG, Welegebrial BG, Weres MG, Gebrewahd SA. WHO/INRUD prescribing indicators with a focus on antibiotics utilization patterns at outpatient department of Adigrat general hospital, Tigrai, Ethiopia: a retrospective cross-sectional study. Antimicrob Resist Infect Control. 2024;13:133.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang HL, Bodinayake C, Wijayaratne GB, Jayatissa P, Piyasiri DLB, Kurukulasooriya R, Sheng T, Nagahawatte A, Woods C, Tillekeratne LG. Point-prevalence survey of outpatient antibiotic prescription at a tertiary medical center in Sri Lanka: opportunities to improve prescribing practices for respiratory illnesses. BMC Infect Dis. 2021;21:97.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSummoro TS, Gidebo KD, Kanche ZZ, Woticha EW. (2015) Evaluation of trends of drug-prescribing patterns based on WHO prescribing indicators at outpatient departments of four hospitals in southern Ethiopia. Drug Des Devel Ther 4551\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFaiela C, Cambaco O, Boene H, Monnier AA, Wertheim HFL, Munguambe K, Sevene E. Knowledge and practices of healthcare professionals regarding antibiotic use in a district hospital, Southern Mozambique: a cross-sectional study. Sci Rep. 2025;15:14333.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePauwels I, Versporten A, Drapier N, Vlieghe E, Goossens H. Hospital antibiotic prescribing patterns in adult patients according to the WHO Access, Watch and Reserve classification (AWaRe): Results from a worldwide point prevalence survey in 69 countries. J Antimicrob Chemother. 2021;76:1614\u0026ndash;24.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKilipamwambu A, Bwire GM, Myemba DT, Njiro BJ, Majigo MV. WHO/INRUD core prescribing indicators and antibiotic utilization patterns among primary health care facilities in Ilala district, Tanzania. JAC-Antimicrobial Resist. 2021;3:dlab049.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMelaku T, Gashaw M, Chelkeba L, Berhane M, Bekele S, Lemi G, Wakjira T, Tesfaw G, Mekonnen Z, Ali S. (2021) Evaluation of adult outpatient antibiotics use at Jimma Medical Center (With defined daily doses for usage metrics). Infect Drug Resist 1649\u0026ndash;58.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eŠahman-Zaimović M, Vukmirović S, Tomić N, Stilinović N, Horvat O, Tomić L. Relationship between outpatient antibiotic use and the prevalence of bacterial infections in Montenegro. Vojnosanit Pregl. 2017;74:46\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eČižman M. Nationwide hospital antibiotic consumption in Slovenia. J Antimicrob Chemother. 2011;66:2189\u0026ndash;91.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Medical Association. World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA. 2013;310:2191\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAtif M, Azeem M, Sarwar MR, Shahid S, Javaid S, Ikram H, Baig U, Scahill S. (2016) WHO/INRUD prescribing indicators and prescribing trends of antibiotics in the Accident and Emergency Department of Bahawal Victoria Hospital, Pakistan. Springerplus 5:1928.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"discover-health-systems","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"dihs","sideBox":"Learn more about [Discover Health Systems](https://www.springer.com/44250)","snPcode":"44250","submissionUrl":"https://submission.nature.com/new-submission/44250/3","title":"Discover Health Systems","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Antibiotic prescribing, Outpatients, Antimicrobial stewardship, WHO AWaRe classification, Mozambique","lastPublishedDoi":"10.21203/rs.3.rs-9291164/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9291164/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eAntibiotic overuse is a major driver of antimicrobial resistance (AMR), a global public health concern, particularly in sub-Saharan Africa where a high burden of infectious diseases and predominantly empirical diagnosis contribute to inappropriate use. The World Health Organization (WHO) AWaRe (Access, Watch, Reserve) classification supports rational prescribing by enabling the monitoring of antibiotic use patterns. However, data on AWaRe-based antibiotic use in Mozambique, especially in outpatient settings, remain limited. This study aimed to evaluate antibiotic prescribing patterns among outpatients using the WHO AWaRe classification in health facilities in Tete and Sofala, Mozambique.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eSecondary data from outpatient prescriptions at two health facilities in Mozambique, Health Center No. 3 in Tete Province and Caia District Hospital in Sofala Province, were analyzed. Patients of all ages attended between November 2025 and January 2026 with at least one antibiotic prescribed were included (n\u0026thinsp;=\u0026thinsp;387). Antibiotic prescribing patterns were evaluated using the WHO AWaRe classification and WHO/INRUD prescribing indicators.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAmong the 387 prescriptions included, a total of 435 antibiotics were prescribed. Most patients received one antibiotic (89.4%), while 6.7% received two and 3.9% received three or more. Cotrimoxazole was the most frequently prescribed antibiotic (42.8%), followed by amoxicillin (20.2%) and metronidazole (11.3%). According to the AWaRe classification, 85.7% of antibiotics belonged to the Access group and 12.4% to the Watch group, with no prescriptions from the Reserve group. All antibiotics were prescribed by their generic names and were included in the essential medicines list. Total antibiotic consumption was 121.91 DDD/1,000 inhabitants/day, with amoxicillin (50.22) and ciprofloxacin (23.59) showing the highest utilization rates.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eAntibiotic prescribing among outpatients in this study met the WHO target for the Access group, indicating overall alignment with recommended practices. However, the use of Watch antibiotics, particularly macrolides, highlights the need to strengthen antimicrobial stewardship efforts to ensure more rational use. The implementation of WHO recommendations, including the AWaRe classification, together with improved adherence to clinical guidelines and targeted training of healthcare providers, is essential to optimize prescribing practices in outpatient settings.\u003c/p\u003e","manuscriptTitle":"Antibiotic Prescribing Patterns Among Outpatients Using the WHO AWaRe Classification in Health Facilities in Tete and Sofala, Mozambique","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-11 10:41:39","doi":"10.21203/rs.3.rs-9291164/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-05-14T03:30:46+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-04T18:46:06+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-02T15:32:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"277801768135950508482856855119649750314","date":"2026-04-24T10:02:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"315618161538187519582109252350920753918","date":"2026-04-23T14:34:14+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-23T14:31:04+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-04-15T01:33:43+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-02T03:00:05+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-04-02T02:59:43+00:00","index":"","fulltext":""},{"type":"submitted","content":"Discover Health Systems","date":"2026-04-01T11:13:07+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"discover-health-systems","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"dihs","sideBox":"Learn more about [Discover Health Systems](https://www.springer.com/44250)","snPcode":"44250","submissionUrl":"https://submission.nature.com/new-submission/44250/3","title":"Discover Health Systems","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a6590dd1-cb06-4691-a528-a8fd6bdf6850","owner":[],"postedDate":"May 11th, 2026","published":true,"recentEditorialEvents":[{"type":"decision","content":"Revision requested","date":"2026-05-14T03:30:46+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-04T18:46:06+00:00","index":34,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-02T15:32:52+00:00","index":32,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-05-14T03:39:03+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-11 10:41:39","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9291164","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9291164","identity":"rs-9291164","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}