Antimicrobial Prescribing and Guideline Adherence Among Febrile Inpatients in Rural Sierra Leone: The Masanga Fever Study (MaFeStu) Prospective Observational Study.

Abstract

Background: Antimicrobial resistance is increasing in sub-Saharan Africa, yet detailed data on prescribing practices remain limited. We characterise antimicrobial compounds prescribed as initial therapy at admission, assess their concordance with treatment guidelines, and examine antimicrobial compounds prescribed during hospitalisation. Methods: We conducted a one-year prospective observational study of febrile inpatients (>=5 months) at Masanga Teaching Hospital, Sierra Leone (September 2023-September 2024). Clinical data, diagnoses, and antimicrobial prescriptions were recorded. Antimicrobial compounds initiated at admission were stratified by indication and WHO AWaRe classification and assessed for concordance with hospital protocol and WHO guidance using predefined decision rules. Secondary analyses summarised antimicrobial compounds prescribed during hospitalisation, including treatment changes such as oral step-down and culture-directed therapy. Findings: Among 689 febrile inpatients, 70.7% (487/689) received one or more antimicrobial compounds at admission. In total, 882 antimicrobial compounds were prescribed, of which 65.0% (573/882) were WHO Access and 35.0% (309/882) Watch category antimicrobials. Ceftriaxone was the most frequently prescribed compound at admission (30.4%, 268/882). Lower respiratory tract infection, sepsis, and skin and soft tissue infections accounted for the largest share of compounds prescribed overall and within the Watch category. In total, 73.7% (650/882) of prescribed compounds were concordant with the hospital protocol compared with 55.7% (491/882) under WHO guidance. Discordance under both protocols was largely driven by compounds prescribed for sepsis, pneumonia, and uncomplicated malaria. During hospitalisation, 4.9% (58/1183) of antimicrobial compounds prescribed reflected oral step-down therapy and 6.2% (73/1183) were culture-directed. Interpretation: Most antimicrobial compounds were from the WHO Access category and were largely concordant with hospital guidance and, to a lesser extent, with WHO guidance. The observed prescribing patterns suggest that strengthening diagnostic capacity, refining treatment guidelines, improving health worker familiarity with guidance, and ensuring adequate antimicrobial availability could improve adherence, reduce WHO Watch category use, and strengthen antimicrobial stewardship in resource-limited settings. Funding statement. Copyright © 2026, The Authors. All rights reserved.