Assessing antibacterial use practices among in-patients in hospitals in Uganda

Abstract Background Inappropriate antibacterial use is a major driver of antimicrobial resistance (AMR), particularly in low- and middle-income countries where surveillance remains limited. Although Uganda has implemented antimicrobial stewardship (AMS) initiatives, evidence on inpatient antibacterial prescribing across hospital levels is limited. This study assessed antibacterial prescribing practices, adherence to national treatment guidelines, and factors associated with adherence to treatment guidelines among hospitalized patients in Uganda. Methods A cross-sectional analytical study was conducted using inpatient Point Prevalence Survey data submitted to the Ministry of Health National Health Data Warehouse between January and December 2025. Data from 9,871 antibacterial prescriptions across 79 hospitals, including general, regional referral, national referral, and specialized hospitals, were analyzed. Guideline adherence was assessed against national treatment guidelines. Pearson’s chi-square test examined associations at bivariate level, while LASSO regression was used for variable selection followed by multivariable logistic regression. Results Adults accounted for most of the prescriptions 57.5% (5,671). Community-acquired infections were the leading indication 43.2% (4,263), while 20.4% (2,014) of prescriptions had no documented indication. Culture samples were obtained in only 2.2% of encounters. Cephalosporins 46.8% (4,622) were the most frequently prescribed antibacterials and Ceftriaxone had the highest consumption (43.75 DDDs/100 bed-days). Watch antibacterials accounted for 51.4% (5,071) of prescriptions compared with 41.6% (4,107) for Access antibacterials. Overall, 41.3% (4,076) of prescriptions complied with national guidelines. Generic prescribing (AOR 1.54, 95% CI 1.41–1.69, p < 0.001), peripheral vascular catheterization (AOR 1.80, 95% CI 1.65–1.96, p < 0.001), urinary catheterization (AOR 1.38, 95% CI 1.19–1.60, p < 0.001), and intravenous-to-oral switching (AOR 1.77, 95% CI 1.54–2.04, p < 0.001) were independently associated with higher odds of guideline compliance. Regional referral hospitals (AOR 0.79, 95% CI 0.71–0.87, p < 0.001) and specialized institutes (AOR 0.40, 95% CI 0.27–0.60, p < 0.001) had lower adherence than general hospitals. Conclusion Inpatient antibacterial prescribing in Uganda is characterized by limited microbiological testing, substantial use of broad-spectrum Watch antibacterials, incomplete indication documentation, and suboptimal guideline compliance. Strengthening AMS through improved diagnostics, prescription audit and feedback, generic prescribing, appropriate Access antibacterial use, better documentation, and timely intravenous-to-oral switching could improve antibacterial use and reduce AMR.