Significantly lower rates of antibiotic prescribing for hospital acquired infections in low income settings than high income settings in the GARPEC study
Authors: Aislinn Cook1, Rebecca Lundin2, Yingfen Hsia1, Julia Bielicki1, Mike Sharland1
1 St. George’s University of London, London, United Kingdom 
2 PENTA Foundation, Padua, Italy

Background:
	There is very limited data on neonatal and paediatric hospital-acquired infection (HAI) rates globally. Future interventional studies of infection prevention and control will require baseline data on hospital structures and prescribing for HAI. This study aims to describe the characteristics of centres participating in the Global Antimicrobial Resistance, Prescribing and Efficacy among Neonates and Children (GARPEC) project, and prescribing patterns for HAI. 

Methods: 
	GARPEC recruited a global convenience sample of 83 hospitals treating paediatric and neonatal infections. Hospital data including bed counts, presence of Neonatal Intensive Care Unit (NICU) and Paediatric Intensive Care Unit (PICU) wards and annual admissions were collected.  Antibiotic (ATC code J01) prescription data were collected through four point prevalence surveys (PPS) between February 2016 and February 2017.  

Results:
	63.9% (53/83) of centres provided both hospital data and prescribing data representing 5 WHO regions. Most facilities were paediatric and neonatal units within larger hospitals. PICU/NICU size and annual admissions were comparable between high income countries (HIC), upper middle income countries (UMIC) and low/middle income countries (LMIC). HIC and LMIC reported more NICU admissions per year than UMIC (Table 1). 33.7% (719/2134) of paediatric prescriptions in HIC (n=25) were for HAI versus 21.5% (685/3180) in UMIC (n=19) and only 1.7% (5/288) in LMIC (n=9). 41.1% (196/477) of neonatal treatment indications in HIC were for HAI compared to 18.9% (184/975) in UMIC and 34.9% (73/209) in LMIC. 

Conclusion: 
	In these centres, HAI accounted for a higher percentage of prescriptions in HIC than UMIC and LMIC. Previous limited data has suggested that rates of HAI are higher in LMIC, suggesting possible under-diagnosis and treatment of HAI in LMIC or more frequent use of combination therapy in HIC in the GARPEC study. The difference between settings is particularly great for paediatric HAI prescriptions compared to neonatal HAI prescriptions. Given the sampling bias of the GARPEC facilities, future studies are needed to validate these findings in other settings, perhaps conducting combined HAI and antibiotic PPS.

Significantly lower rates of antibiotic prescribing for hospital acquired infections in low income settings than high income settings in the GARPEC study