Background <p>Inappropriate use of antibiotics is a major driver of antimicrobial resistance and can lead to adverse healthcare outcomes. Treatment guidelines promote rational prescribing and help minimize healthcare costs. We aimed to assess adherence to the national pediatric treatment guideline for pneumonia among healthcare providers at a major rural hospital in Rwanda.</p> Methods <p>A retrospective chart review was conducted to audit clinical records of children aged 2–59 months hospitalized with pneumonia between January 2022 to January 2024. Data on the classifications of pneumonia, prescribed medications, and adherence to the treatment protocol were extracted and analyzed. The local guideline’s classifications of pneumonia are in classes of stage based on severity of the disease. The World Health Organization/International Network of Rational Use of Drugs (WHO/INRUD) indicator parameters on adherence were used to summarize and present the results.</p> Results <p>Clinical records from 308 patients generated by 30 doctors met the inclusion criteria. Only 42 (14%) of cases were correctly classified. While 558/781 (71%) prescriptions matched pneumonia signs and symptoms and were aligned with the guideline, adherence to the requirement for complete correct specification of the treatment regimen was 0/558 (0%). The route of administration, dose, frequency, and treatment duration were correct in only 366/558 (66%), 335/558 (60%), 251/558 (45%), and 67/558 (12%) of cases respectively. Once the medications were prescribed, 541/558 (97%) were administered according to the prescription.</p> Conclusion <p>Adherence to pneumonia treatment guideline was suboptimal, with major deficiencies in disease classification and treatment regimen implementation. The introduction of an antibiotic stewardship program to provide support through improved training and monitoring of antibiotic prescribing practices is warranted.</p> Clinical trial <p>Not applicable.</p>