National and regional challenges of antibiotic prescribing patterns in pediatric populations across Africa: a systematic review and meta-analysis

Excessive and inappropriate use of antibiotics represents a major concern directly associated with the emergence of resistant microorganisms, posing a global public health threat. Inappropriate prescribing patterns are particularly frequent in pediatric populations, leading to significant clinical and epidemiological consequences. Improving the quality of antibiotic prescribing is a rational and necessary strategy to strengthen the AWaRe framework (Access, Watch, and Reserve), proposed by the World Health Organization (WHO) to guide rational antibiotic use. This study aimed to systematically review and conduct a meta-analysis on antibiotic prescribing patterns in pediatric patients across Africa.

We systematically searched PubMed, Embase, SciElo, Scopus, Web of Science, and the WHO Global Index Medicus on 23 May 2025. Eligible studies reported antibiotic prescribing patterns among pediatric patients in Africa, including types of prescribed antibiotics, route of administration, and AWaRe classification. Methodological quality was assessed using the National Institutes of Health (NIH) tools. Pooled prevalence estimates were calculated using random-effects meta-analysis based on the Freeman–Tukey double arcsine transformation.

The pooled prevalence of antibiotic prescribing among pediatric patients in Africa was 76.0% (95% CI, 68.0-82.0; I² = 99.8%). Approximately 78.0% received at least one antibiotic parenterally, with a mean of 1.55 antibiotics per patient (95% CI, 1.36-1.74). The highest prescribing prevalence was observed in Central Africa (85.0%), followed by Western (83.0%), while Eastern and Southern regions reported a prevalence of 64.0%. By AWaRe classification, Access antibiotics accounted for 65.0% of prescriptions, Watch for 27.0%, and Reserve for 3.0% (reported only in South Africa). The most prescribed antibiotics included amoxicillin (54.1%), amikacin (47.5%), gentamicin (41.2%), and ampicillin (38.0%) in the Access group; ceftriaxone (48.3%), cefuroxime (42.0%), and imipenem/meropenem (32.9%) in the Watch group; and ampicillin combined with cloxacillin (28.0%) in the not-recommended group.

These findings provide a descriptive overview of antibiotic prescribing patterns among pediatric patients in Africa. Given the variability across studies, the results underscore the importance of strengthening antimicrobial stewardship initiatives and promoting the rational use of antibiotics, particularly within the AWaRe framework, to support efforts aimed at mitigating antimicrobial resistance.