Improving Paediatric Antibiotic Prescribing in a Tertiary Referral Hospital in Ghana: A Multimodal Antibiotic Stewardship Quality Improvement Initiative

Abstract Corresponding Author Joycelyn Dame, MD, Department of Child Health, University of Ghana Medical School, College of Health Sciences, Accra, Ghana, (+233) 24 425 1126. jassimeng-dame@ug.edu.gh Funding This work was funded by Pfizer through the Stanford African Scholars in Global Health Program. Conflict(s) of Interest Joycelyn Dame, no conflict; Lourdes Eguiguren, no conflict; Naa Okaikor Addison, no conflict; Evelyn Amoah, no conflict; Helena Owusu, no conflict; Hayden T. Schwenk, no conflict. Background A global point prevalence survey in 2019 showed a high prevalence (76.3%) of antibiotic use in the paediatric medical wards of Korle Bu Teaching Hospital, Ghana, where the prevalence of multidrug-resistant organisms was substantial (70%). We evaluated a multimodal paediatric antimicrobial stewardship (AMS) intervention to increase the appropriateness of antibiotic prescribing by 20% over 12 months. Methods We implemented a quality improvement initiative comprising weekly audit-and-feedback of antibiotic orders, a train-the-trainer AMS educational workshop, and prospectively collected blood, urine, CSF, and joint aspirate culture data to develop the hospital’s first paediatric antibiogram. A multidisciplinary team assessed appropriateness of antibiotics by indication, agent, dose, route, and duration. The primary outcome was the proportion of antibiotic orders deemed appropriate. We used a pre- and post-workshop survey to evaluate AMS knowledge and perceptions. Results At baseline (September 2025), 44% of antibiotic prescriptions were appropriate. By March 2026, 294 audits covering 437 antibiotic orders were completed, and the appropriateness of prescribing had increased to 74%. Of 180 recommendations, 165 (91.7%) were accepted. Ceftriaxone, meropenem, and cefotaxime were the most frequently audited agents, and the most common reason for inappropriateness was “no indication.” Twenty-one staff members completed the stewardship training, with improved knowledge and confidence. Preliminary culture data showed a high burden of resistant gram-negative pathogens, including multidrug-resistant Klebsiella pneumoniae and Acinetobacter baumannii. Conclusions A multidisciplinary AMS intervention was feasible, well-accepted, and associated with substantial improvement in paediatric antibiotic prescribing at a resource-limited tertiary hospital. This pragmatic model may be scalable across low- and middle-income countries.