Drivers influencing antibiotics use in pediatric wards across five public hospitals in Zanzibar: a WHO multiple point prevalence survey.

Background: Strengthening antimicrobial stewardship (AMS) programs is a major public health strategy to reduce inappropriate antibiotic use (AMU) and averting antibiotic resistance (AMR). Evidence on AMU and AMS program implementation is widely documented in Tanzania mainland, consistent with previous studies done and other low-and middle-income countries. However, there is limited information on AMU and AMS programs to guide the implementation of the Zanzibar Action Plan on AMR. The objective of this study was to determine the prevalence of AMU, identify factors associated with AMU, and to assess the performance of AMS programs in pediatric wards across hospitals in Zanzibar. Methods: This repeated cross-sectional study employed the World Health Organization Point Prevalence Survey (WHO-PPS) tool at two time points (February to April 2024 and December 2024 to May 2025), complemented by a one-time WHO-Health Care Facility Core Element Indicators Tool conducted in April 2024 to assess AMS performance. The WHO-PPS study population was children ≤13 years admitted to pediatric wards in five public hospitals in Zanzibar. Healthcare providers and AMS team members reported on Core Element Indicators. The WHO-PPS data were analyzed using descriptive statistics and multivariate modified Poisson regression, while AMS performance was computed as percentage scores per hospital. Results: Of 943 paediatric patients, 826 (87.6%) received at least one antibiotic. Gentamicin, ampicillin, and ceftriaxone were the most commonly prescribed antibiotics. Watch-category antibiotics accounted for the majority of prescriptions (53.8%), followed by Access (45.8%) and Reserve (0.4%). Community-acquired infections were the predominant indication for antibiotic use, 60.4%, with pneumonia and sepsis being the most common diagnoses. Bacteriological culture testing was performed in only 10.9% of patients, while adherence to national treatment guidelines was 77.8%. Significant predictors of AMU included hospital tier (regional: aPR 1.39, 95%CI 1.30-1.50; and district level: aPR 1.35, 95%CI 1.26-1.46); and higher disease severity shown by ultimately fatal McCabe score, aPR 1.20, 95%CI: 1.07-1.33). The AMS program performance was below the 50% functionality threshold, with low scores observed in leadership, accountability, monitoring and surveillance, and reporting and feedback, alongside limited progress in the establishment of DTC/IPC/AMC committees and implementation of AMS actions. Conclusions: Antibiotic use among admitted children was markedly prevalent, notably by the Watch category of antibiotics, and limited reliance on bacteriological culture and suboptimal AMS program performance across hospitals in Zanzibar. These findings highlight important opportunities to strengthen AMS programs and diagnostic practices. Future research should evaluate the appropriateness of antibiotic prescribing and explore barriers to effective AMS implementation across hospitals in Zanzibar.