ORIGINAL  
Niger J Paed 2014; 41 (3):234 –238  
Onubogu UC  
Anochie IC  
Empiric antibiotic prescription  
among febrile under-five Children  
in the University of Port Harcourt  
Teaching Hospital, Rivers State,  
Nigeria.  
DOI:http://dx.doi.org/10.4314/njp.v41i3,16  
Accepted: 6th April 2014  
Abstract: Background: More than  
7% of febrile infants and young  
studied. Two hundred and eighty  
three (78.2%) febrile children re-  
ceived empiric antibiotic prescrip-  
tions. The most frequent antibiotic  
prescribed was amoxicillin 80  
(28.3%). Children aged 1-  
12months received the highest  
number of prescriptions 113  
(80.7%). There was no significant  
relationship between age, tempera-  
ture level, weight for age, number  
of symptoms and frequency of  
antibiotic prescription (p>0.05).  
Upper respiratory tract infection  
(83.7 %) and diarrhea (55.9%)  
were significantly associated with  
empiric antibiotic prescription  
(P=0.05 and 0.002 respectively).  
9
Onubogu UC (  
Anochie IC  
)
children have self-limiting viral  
infection and therefore, would not  
require antibiotics. Over prescrip-  
tion of antibiotics increases antibi-  
otics exposure and development of  
resistance among patients. There is  
need to evaluate empiric antibiotic  
prescription in order to limit its use  
to only febrile children with bacte-  
rial infection.  
Aim and Objectives: The aim of  
this study was to determine the  
prevalence of empiric antibiotic  
prescription among febrile under-  
five, post neonatal children pre-  
senting in the children outpatient  
clinic of the University of Port  
Harcourt teaching hospital.  
Method: Febrile Children aged 29  
days to <60 months who presented  
in the outpatient clinic were re-  
cruited from September 2010 to  
January 2011. Their weight, bio-  
data, symptoms, Physician’s diag-  
nosis, and names of antibiotic pre-  
scribed were entered into a prede-  
termined proforma and analysed.  
Result: A total of 362 children with  
male to female ratio of 1.03:1 were  
Department of Paediatrics,  
Braithwaite Memorial Specialist  
Hospital, Port Harcourt, Rivers State.  
Email: utchayonubogu@yahoo.co.uk  
Conclusion:  
Empiric antibiotic  
prescription for febrile under-five  
children is a common practice in  
UPTH. Physicians should there-  
fore reduce the frequency of anti-  
biotics prescription in febrile chil-  
dren unless there is clinical  
evidence of bacterial infection.  
Key words: Empiric Antibiotics,  
Fever, post neonatal under-five,  
Nigeria  
5
Introduction  
signs, stiff neck or any sign of severe malaria . The  
National institute for health and clinical excellence  
(NICE) guide lines for management of febrile children  
in the United Kingdom recommends empiric antibiotic  
be given to children with suspected serious bacterial  
Acute febrile illness among infants or young children is  
a common clinical scenario, accounting for up to 30% of  
paediatric clinic consultation . More than 97% of non-  
1
6
toxic but febrile infants and young children have self-  
limiting viral infection therefore would not require anti-  
infection. Considering that the prevalence of bacterial  
infections among febrile children in ambulatory clinic  
setting is 1.1% in the United States of America, few  
febrile children7would actually require empiric antibiot-  
ics prescription .  
2
biotics . In Uganda, antibiotic was prescribed empiri-  
cally to 59.5% of febrile, under-five children while in  
Netherland, it was prescribed to 26.5% of febrile chil-  
dren aged 1month to 6years .  
3
,4  
It is important to monitor antibiotic usage in order to  
8
The Integrated management for childhood illnesses  
protect their efficacy . This is because improper antibi-  
(
Malaria endemic areas recommended use of antibiotics  
when any of the following is present: General danger  
IMCI) guideline for management of febrile children in  
otic usage, increases antibiotic exposure among humans  
and animals. This directly increases antibiotic resistance  
by promoting emergence of resistant bacteria strains.  
9
,10  
2
35  
If this continues unchecked it would ultimately cause  
increased mortality from treatable diseases. In manage-  
ment of the febrile child, there is a need to evaluate  
empiric antibiotic treatment in order to limit its use to  
Empiric antibiotic prescription.  
Their nutritional status was determined using the Gomez  
classification .  
1
3
1
1
only children at risk of bacterial infection .  
Statistical analysis was done using EP Info version 3.5.  
Chi- squared test and Fishers Exact test were used to test  
for significant associations between proportions. Com-  
parison of means was done with the student’s t test. A p  
value of 0.05 or less was considered statistically signifi-  
cant  
The aim of this study was to determine the prevalence of  
empiric antibiotic prescription among febrile under-five,  
post neonatal age children presenting in the children  
outpatient clinic of the University of Port Harcourt  
teaching hospital. We also set out to identify the factors  
on which physicians base their decision to prescribe  
empiric antibiotics and to identify the pattern of antibiot-  
ics prescription. It is hoped that consideration of find-  
ings from this study may lead to better founded and con-  
sequently, diminished empiric antibiotic prescriptions.  
This will ultimately help to protect available antibiotics  
from the emergence of resistant bacteria strains, threat-  
ening to render them ineffective.  
Result  
Three hundred and sixty two children who met the in-  
clusion criteria were enrolled into the study. There were  
184 (50.8%) males and 178 (49.2%) females, giving a  
male to female (M:F) ratio of 1.03: 1. They were aged 1  
to < 60 months (mean 21.1 ± 15.4 months). The mean  
age of the male subjects was 20.8 ± 15.07 months, while  
that of the females was 21.4 ± 15.8 months (p=0.15).  
The median age for all the subjects was 18 months and  
the modal age was 24months. Two hundred and fifty  
eight (71.3%) children were aged ≤ 24months. The  
mean temperature of the study population was 38.2 ±  
Subjects and Methods  
This was a prospective study that was carried out in the  
Children’s outpatient clinic (CHOP) of the University of  
Port Harcourt Teaching Hospital (UPTH) between  
o
o
0.6 C (range 37.5 - 40.8 C). One hundred and ninety  
children had axillary temperatures within the range of  
o
o
September 2010 and January 2011. The University of  
Port Harcourt Teaching hospital is a tertiary hospital  
located in Southern part of Nigeria. The children outpa-  
tient clinic runs both general and specialist paediatric  
services. The general paediatric clinic is covered mostly  
by Resident doctors and House officers with access to  
review cases with the Consultant Paediatrician. Ethical  
clearance for the study was obtained from the Ethics  
Committee of the University of Port Harcourt Teaching  
Hospital. Written informed consent was obtained from  
parents or guardian. The minimum sample size of 362  
was calculated using a bacteraemia prevalence rate of  
37.5 - 38 C. Seven had temperature >40 C( Table 1).  
Table 1: Temperature and age distribution of the study population  
o
Temp ( C)  
Age in months (%)  
Total (%)  
1-12  
>12-24  
>24-36  
>36-  
>48-  
<60  
4
8
3
7.5-38.0  
85(44.7)  
31(35.6)  
54(28.4)  
29(33.3)  
31(16.3)  
12(13.8)  
10  
10(5.3)  
190(100)  
87(100)  
(5.3)  
>38.0-38.5  
5(5.7)  
10  
(11.5)  
>
>
38.5-39.0  
39.0-39.5  
>39.5-40.0  
>40.0  
13(34.2)  
9(30.0)  
2(20.0)  
0(0)  
16(42.1)  
11(36.7)  
5(50.0)  
3(42.9)  
6(15.8)  
8(26.7)  
0(0)  
1(2.6)  
1(3.3)  
0(0)  
1
2(5.3)  
1(3.3)  
3(30.0)  
2(28.6)  
38(100)  
30(100)  
10(100)  
7(100)  
1(14.3)  
(14.3)  
3
8.2% among febrile infants in a children emergency  
Total (%)  
140  
118  
58(16.0)  
18  
28(7.7)  
362(100)  
12  
ward in Nigeria . All the children that presented to the  
clinic and met the inclusion criteria within the study  
period were consecutively recruited. The criteria for  
inclusion into the study was age one month to < 5years,  
and axillary temperature ≥ 37.5°C. Children that had  
initially received antibiotic were excluded. The tem-  
perature and weight of all the children were measured  
and recorded in a structured data collection form. Each  
child was given a code prior to their scheduled consulta-  
tion by the physician. In order not to influence the pa-  
tients’ prescription, the attending physicians were not  
informed that their prescriptions were being recorded.  
After being attended by the physician, they were seen in  
a separate room where data was collected by interview-  
ing the caregivers. Sociodermographic information  
regarding age, sex, address was obtained. Clinical infor-  
mation including the number of symptoms the subject  
presented with, Physician’s diagnosis, number and  
names of antibiotic prescribed if any was obtained from  
the patient files. The questionnaire was filled by the in-  
vestigator. Any antibiotic prescribed prior to laboratory  
evidence of any bacterial infection was defined as  
(38.7)  
(32.6)  
(5.0)  
Two hundred and sixty seven (n7d3.8%) children had  
st  
rd  
normal nutritional status. 1 , 2 and 3 degree malnutri-  
tion was seen in 72(19.9%), 21(5.8%) and 2(0.6%)  
respectively. The mean weight of the study population  
was 11.2 ± 4.5kg. Two hundred and eighty three  
(
78.2%) febrile children received prescription for em-  
piric antibiotics from the consulting physician. The most  
frequent antibiotic prescribed was amoxicillin in 28.3%  
of children (Fig 1). Antibiotics prescribed less than five  
times were grouped under others and they include am-  
picllox, ceftazidime, ceftriaxone, cephalexin, ciproflox-  
acin, erythromycin, septrin, ampicillin/ sulbactam and  
chloramphenicol. Most children 257(90.8%) received  
one antibiotic while two antibiotics were prescribed in  
2
5(8.8%) and 3 in a single prescription.  
2
36  
Fig 1: Names of Empiric antibiotics and frequency  
Table 4: Nutritional status and empiric antibiotic prescription  
9
8
7
6
5
4
3
2
1
0
0
0
0
0
0
0
0
0
0
8
0
Nutritional status  
Gomez)  
Empiric  
antibiotic  
Yes(%)  
Empiric  
antibiotic  
No(%)  
Total  
6
9
6
6
(
2
6
1
9
11  
Normal  
210(78.7)  
54(75.0)  
18(85.7)  
1(50.0)  
57(21.3)  
18(25.0)  
3(14.3)  
267(100)  
72(100)  
21(100)  
2(100)  
7
5
st  
1 degree malnutrition  
nd  
2
3
degree malnutrition  
degree malnutrition  
rd  
1(50.0)  
Total  
283(78.2)  
79(21.8)  
2(100)  
2
χ =2.0, df=3, P=0.55  
Children aged 1-12months received the highest number  
of prescriptions (80.7%) and frequency of antibiotic  
prescription decreased with age (Table 2). Although the  
difference was not statistically significant (P=0.76).  
Table 5: Number of symptoms excluding fever and antibiotic  
prescription  
No of symp-  
Empiric anti-  
Empiric anti-  
biotic  
No(%)  
Total  
toms excluding biotic  
Table 2: Age distribution of children given empiric antibiotics  
fever  
Yes(%)  
Age  
Empiric  
Empiric  
antibiotics  
No (%)  
Total  
0
1
2
3
4
≥5  
Total  
16(72.7)  
55(76.4)  
108(77.1)  
70(83.3)  
29(76.3)  
5(83.3)  
6(27.3)  
17(23.6)  
32(22.9)  
14(16.7)  
9(23.7)  
1(16.7)  
79(21.8)  
22(100)  
72(100)  
140(100)  
84(100)  
38(100)  
6(100)  
(months) antibiotics  
Yes (%)  
1
-12  
113(80.7)  
93(78.8)  
44(75.9)  
13(72.2)  
20(71.4)  
283(78.2)  
27(19.3)  
25(21.2)  
14(24.1)  
5(27.8)  
8(28.6)  
79(21.8)  
140(100)  
118(100)  
58(100)  
18(100)  
28(100)  
362(100)  
>
>
>
>
12-24  
24-36  
36-48  
48-<60  
283(78.2)  
362(100)  
2
Total  
χ =2.08, df=5, P=0.83  
2
χ =1.86 df=4 P=0.76  
Febrile Children who had upper respiratory tract infec-  
tion (URTI) presenting only as either cough or catarrh or  
both were given empiric antibiotic prescription in 83.7%  
of their consultations. Those who had diarrhoea received  
prescription for empiric antibiotics in 55.9% of their  
consultations (Table 6). Diagnosis that occurred in less  
than 9%(32) of the study population was not evaluated  
because of the small sample size. URTI and diarrhoea  
were significantly associated with increased antibiotic  
prescription (P=0.05 and 0.002 respectively).  
o
All children with temperature >39.5-40.0 C received  
empiric antibiotics (Table 3). There was however, no  
significant relationship between temperature level and  
the frequency of empiric antibiotic prescription (P=0.2)  
Table 3: Relationship between temperature and empiric  
antibiotic prescription  
Temperature range Empiric anti-  
Empiric  
antibiotic  
No(%)  
Total  
o
(
C)  
biotic  
Yes(%)  
Table 6: Clinical diagnosis and frequency of antibiotic  
prescription  
3
7.5-38.0  
143(75.3)  
71(81.6)  
31(81.6)  
24(80.0)  
10(100)  
4(57.1)  
47(24.7)  
16(18.4)  
7(18.4)  
6(20.0)  
0(0)  
190(100)  
87(100)  
38(100)  
30(100)  
10(100)  
7(100)  
>38.0-38.5  
>38.5-39.0  
>39.0-39.5  
>39.5-40.0  
>40.0  
Clinical  
Empiric antibiotic Empiric antibi-  
P value  
diagnosis  
Yes(%)  
otics  
No(%)  
URTI  
118(83.7)  
41(87.2)  
33(86.8)  
19(55.9)  
23(16.3)  
6(12.8)  
5(13.2)  
15(44.1)  
0.05  
0.1  
0.2  
3(42.9)  
Tonsillitis  
Pneumonia  
Diarrhoea  
Total  
283(78.2)  
79(21.8)  
362(100)  
2
0.002  
χ =6.4, df=5, P=0.2  
Children with second degree malnutrition received the  
highest number of prescriptions for empiric antibiotics  
(
Table 4). Only two children however had third degree  
Discussion  
malnutrition. Nutritional status was not significantly  
related with the frequency of prescriptions (P=0.55)  
An overall frequency of 78.2% for empiric antibiotic  
prescription among febrile under-five children is high.  
This high frequency of antibiotic prescription is similar  
to 72.2% reported among similar age group in Tanza-  
nia, another African country . African countries with  
developing economies could have similar challenges in  
their health sector. In such settings, challenges with  
laboratory services ranges from delay in laboratory re-  
sults to complete absence of laboratories. Results of  
laboratory investigations to confirm infection usually  
takes more than 24 hours. This necessitates a second  
Children that presented with 3 and ≥5 symptoms  
received the highest number of empiric antibiotics  
prescription (Table 5), while 72.75% of children that  
presented with fever and no other symptom where given  
empiric antibiotic prescription. The number of symp-  
toms the patient presented with was not significantly  
related to the frequency of empiric antibiotic  
prescription.  
1
4
2
37  
visit or often the patient is lost to follow up. This situa-  
tion makes the physician to opt for empiric antibiotic  
prescription. A study done in the Netherland among  
febrile children reported a lower antibiotic prescription  
shown in Table 1. Although hyperpyrexia has been  
documented to be associated with higher risk for sepsis,  
guidelines on management of febrile children recom-  
mends that, height of body temperature alone should not  
be used to identify children with high risk for bacterial  
infection bu6t,7t,h16e age of the child should also be taken  
4
rate of 26.5% . In the Netherland study a practice  
guidel5ine for the management of febrile children was  
1
used. This guideline does not recommend routine use  
into account  
.
of antibiotics in children with fever without an apparent  
source. This adherence to the guideline could have con-  
tributed to the lower frequency of antibiotic prescription.  
Also the mean temperature of the Netherlands study was  
Febrile Malnourished children could receive higher anti-  
biotic prescriptions as they have a higher risk of bacte-  
2
3
rial infectionnd . This was the case in our study as chil-  
dren with 2 degree malnutrition received the most anti-  
biotics. The number of symptoms did not significantly  
affect the rate of antibiotic prescriptions. This finding is  
not surprising as increased symptoms could have meant  
more system involvement in the on-going pathology but  
does not differentiate between viral and bacterial  
aetiology.  
o
lower than our study (37.9 vs 38.2 C respectively). The  
lower temperature could mean that the study population  
in the Netherlands study was at a lower risk of bacterial  
infection than our study population. Previous studies  
have demonstrated that high temperatures in association  
with young age increases the likelihood of bacterial in-  
6
,16  
.
fection  
Amoxicillin and cefuroxime were the most frequently  
prescribed antibiotics in this study. Amoxicillin, a nar-  
row spectrum penicillin has been reported in Tanzania,  
Nigeria and America as on14e,17o,1f8 the common antibiotics  
In our study 83.7% of children who had common cold  
were prescribed antibiotics. This directly contravenes  
WHO and IMCI treatment guidelines, which discour-  
ages5,2t4he use of antibiotics in children with common  
cold . In Tanzania 68.9% of children with common  
cold were prescribed antibiotics, while in USA 29.6%  
of children received antibiotic for acu4t,e18respiratory tract  
used in paediatric practice  
. The high use of cefu-  
roxime, a broad spectrum cephalosporin in our study  
shows a growing pattern of clinicians choosing more  
expensive and broader spectrum antibiotics in their prac-  
tice. Similar trend has also been reported in USA and it  
raises serious concerns about the overuse of broad-  
spectrum antibiotics, particularly for patients for whom  
1
infections when it was not indicated . Antibiotics do  
not reduce the severity or duration of illness in viral in-  
fections. Thus their use in viral illness exposes a patient  
to the risks of side effects from a medication without  
any benefit. Antibiotics,2a4re also not recommended for  
18  
antibiotic therapy is not indicated at all . The recom-  
mended principle for rational antibiotic prescription in-  
cludes: Choosing a drug that has efficacy in treating or  
preventing the disease but leaves other bacteria in the  
body intact19a,2n0d one that is available, convenient and  
5
acute watery diarrhoea . Our study however reported  
55.9% antibiotic prescription rate in management of  
diarrheal diseases. Similar high frequency of antibiotic  
prescriptio14n,25,h26as been reported in other low income  
countries.  
inexpensive  
.
The risk of bacterial infection is higher in youn1ger chil-  
2
dren due to immaturity of the immune system. knowl-  
edge of this fact may encourage physicians to prescribe  
empiric antibiotics more often in this age group. How-  
ever, even among febrile young children there is an ur-  
gent need for classification based on risk for bacterial  
infection using clinical guidelines. In Europe and Amer-  
Conclusion  
In conclusion, empiric antibiotic prescription for febrile  
under-five children is very high in UPTH. This finding  
has also been reported in studies conducted in other low  
income countries. Such high rate of empiric antibiotic  
prescription would lead to increased development of  
resistant strain of bacteria to the present antibiotics and  
threatens the end of antibiotic era. There is a need to  
protect available antibiotics by rational prescription only  
when they are indicated. The use of available practise  
guidelines in the management of febrile children would  
help reduce inappropriate antibiotic prescription in feb-  
rile children. The campaign to protect these antibiotics  
needs to be actively brought to low income countries.  
These countries have a higher prevalence of infectious  
diseases and as such would have greater mortality  
should these drugs be rendered inactive.  
6
,15,22  
. These  
ica these guidelines are already available  
guidelines use both clinical and laboratory parameters in  
risk assessment for bacterial infection. This is based on  
the assumption that results of these laboratory tests are  
available to the physician during the index consultation.  
In a resource poor setting however, this is not the case,  
so an assessment for risk of bacterial infection in a feb-  
rile child is often made without the use of any laboratory  
results.  
The highest antibiotic prescription rate was found  
among children with temperature range of 39.5-40°C.  
The combination of young age and hyperpyrexia may  
have contributed to the 100% antibiotic prescription  
seen in this group of children. This is because in our  
study, children with temperature range of 39.5-40°C  
were much younger (70% < 24mths) while those with  
temperature >40°C were older (57% > 24mths), as  
We recommend implementation of current evidence  
based practice that advocates for prior documentation of  
evidence of bacterial infection by laboratory testing  
before antibiotic prescription for febrile children. The  
2
38  
febrile child at urgent need for empiric antibiotic should  
however receive it while laboratory testing to document  
bacterial infection is being done. We acknowledge the  
need for locally useful clinical detector/screening tools  
which could be used in the absence of sophisticated  
laboratory methods to identify the febrile child at risk of  
serious bacterial infection. There is no doubt that classi-  
fying children based on their risk assessment for bacte-  
rial infection prior to commencing antibiotics will,  
identify the small group of children that need urgent  
commencement of empiric antibiotics and at the same  
time, limit the irrational use of antibiotics. This prac-  
tice may reduce development of antibiotic resistance and  
reduce the cost of healthcare.  
Conflict of interest: None  
Funding: None  
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