PONE-D-24-28507Antibiotic consumption and utilization at a large tertiary care level hospital in Uganda: a point prevalence survey.PLOS ONE

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Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: No

Reviewer #3: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: No

Reviewer #3: Yes

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The authors did a very good job presenting thier findings in this manuscript. I must commend their efforts.

However, there are some areas that may need some clarification and refinement. These are highlighted below and in the attached manuscript

Abstract

line 35: What does OPD mean? write in full for the first use.

line 36: The authors said they used a "single-day consecutive sampling". If they selected all patients then this cannot be called sampling. I suggest you avoid the word "sampling" and just say you selected ALL inpatients.

line 36: What does IPD mean? please write in full for the first use.

Main Body

INTRODUCTION

lines 56 - 86: Your introduction provides adequate background information on antibiotic resistance of global relevance, however, not much is said about the regional relevance before talking specifically about the setting in Uganda. I encourage you to include this information.

lines 74 - 78: Your introduction needs to provide clear issues related to antibiotic consumption and utilization in Uganda or in a similar setting and also Is there is no clear explanation of why antibiotic stewardship is important in tertiary care settings in Uganda. In other words, what is the gap in literature that this study aims to fill? please add these to the introduction

line 80: Do you mean "Challenges"? "Challenges" seem to be a better word here than "importance"

METHODS

Lines 89 - 101: It is important to include information that helps to contextualize the study setting.

please include:

1. Information on the hospital's patient demographics

2. The location of the hospital in terms latitude and longitude, geographical setting (rural or urban)

3. Are there any relevant local factors that might influence antibiotic usage, such as endemic diseases, public

health infrastructure, or local antimicrobial resistance patterns?

4. There is zero detail about the hospital’s pharmacy services, laboratory capabilities, and infection control

practices?

5. How about the the availability of antibiotics in the facility? Are there any seasonal or temporal factors in the

area that could impact antibiotic usage?

all these are important to give proper context to your study and findings.

line 109: do you mean 1st of July to 30th June? Please be specific with dates

Line 124: can you clarify how you arrived at this value of 200? please briefly include the parameters used to arrive at this value.

line 125: In the actual sense you did not have anything to do with the pateints directly so i would not say "recruited". you only worked with patient records is that correct? Please stay away from using the words recruited, enrolled e.t.c

Line 124: Can you clarify how you arrived at the sampling interval of 44? There is also no mention of your sample frame? Is it that you had a long list of all the OPD patients in a sequence of how they were recorded? please briefly explain these in clear terms so the readers can understand your methodology.

Did you have any inclusion or exclusion criteria??

line 132: Please include the version of ODK as well as the reference.

Can you also give more details about this tool that you used to collect the data? was this a proforma that was adopted from the WHO PPS or you adapted this tool to suit your study? what is the validity of this tool? what is the structure of this tool? did it have a section for sociodemographic characteristics of the patient? Little is known about the tool you used. please clarify or give more details.

Line 146: How did you ensure data security? It will be a good addition to your ethical considerations

RESULT

line 156: It is incorrect to say patients were enrolled when in essence only patient records were reviewed. It is my understanding that you had absolutely no contact with patients. Patient enrollment usually refers to the process of actively recruiting and consenting individuals to participate in a study, where they are directly involved through surveys or clinical trials.

Line 158: Why are you using median and IQR instead of Mean and Standard deviation? Is there something more about the data you need to tell us?

Line 160: Please maintain consistency in presentation of your results for univariate analysis of categorocal variables. In one hand you present just the frequency and percent e.g "Females comprised 130 (61.6%)" and in another hand you present a proportion and the percent in parenthesis e.g outpatient (150/183, 160 82%) and within the same paragraph you change to just frequency and percent in parenthesis e.g "diabetes mellitus (7, 14.9%)". please chose one method and stick with it to avoid confusion

Line 164: why use the term "Baseline" here? Please clarify

Table 1: What do we mean by "OPD(%)" as a column header? This is not the same as frequency or is this another measure?? same for the second column

Table 1: Does this data fit into this column??? the column header is saying OPD(%). i dont think this is correct. please put your data properly in the correct table structure or present as prose

Line 187: Do you mean you reviewed patients or patient records???

DISCUSSION

Lines 314 - 316: rephrase this sentence. it appears to have a syntax problem. Maybe change the word "Undergoes" to "undergoing" to match the present continuous tense. "Amongst" can also be changed to "among" for a more straightforward usage.

Lines 317 - 330: In this study, there is no mention of incomplete records or data on antibiotic use was missing. considering that you used hospital records which in many settings are incomplete. How did you deal with such situations as this is usually a limitation and could lead to inaccuracies in the survey results.

Lines 333 - 334: This recommendation appears general. Tailor your recommendations to specific audiences (e.g., healthcare providers, policymakers, hospital administrators) so they know what actions they can take.

Reviewer #2: Thank you for inviting me to review this manuscript on Antibiotic consumption and utilization at a large tertiary care level hospital in Uganda: a point prevalence survey.

Please find below, my comments and quality-improvement recommendations to the authors according to line numbers.

51 and 52: The inpatient indications for antibiotic therapy are listed as sepsis - 12.2%, respiratory infections - 18.3%, burn wounds - 14.1%, and gastrointestinal infections - 14.1%. These make up 74.7%. You need to account for the remaining 25.3% even if it is “others”.

53: Your study concludes that the prescription of “watch” antibiotics was high. Is this observation based on an objective of your study? Did you want to determine which type/group/class of antibiotics was mostly prescribed?

67: Please change from "misuse and -use" to "use and misuse" and note that self-medication and antibiotic over-prescription are examples of use and misuse of antibiotics, not separate issues.

69: Please state what the health agenda of the June 2021 G7 meeting was. It is an important detail to include especially if you want to use it to validate your work.

75 and 76: The high rates reported in the hospital "were" not "was".

79 and 80: Please state this clearly. Does it pose significant public health concerns of great socio-economic importance? Or what did you want us to know?

85: Your study aims to determine what exactly? Is it the prevalence of antimicrobial resistance or the rate of antibiotic prescription and/or misuse? What are the objectives of your study? These would have guided your write-up. Did you want to simply show high rates of antibiotic prescriptions? Or did you want to compare antibiotic resistance/prescription to the findings in other countries in East Africa, Africa as a whole, or outside Africa? Or did you want to assess the risk of developing AMRs in Uganda based on the records from Kiruddu Hospital?

90 to 95: Please rewrite this paragraph. There are too many redundant words here. Seeing that the study was not exactly about Kiruddu HRH, you did not need to describe it to the tiniest detail.

97: Please write SPIDAAR and ESKAPE in full at first mention with the acronyms in parentheses. You may then use the acronyms in subsequent mentions.

104: What makes up "all data"? All data regarding antibiotic prescription, adverse effects, patient compliance or reasons for non-compliance? Please clarify which data you collected and the exceptions you had.

160: Are the comorbidities significant? Did they in some way encourage or deter antibiotic use and/or misuse? Or did they contribute to antibiotic resistance? Please clarify this statement so that we can easily understand your point.

166: Why the in-depth financial analysis? Is it an objective of your work to show the financial implications of antibiotic use/misuse/resistance? This takes us back to the need for you to identify and clearly state your objectives. They are the road signs to guide your work.

173: It cannot be "most consumed" individual antibiotic and be so many. Please rewrite this.

222: “The total DDD per thousand inhabitants per day ‘was’ (not were) 6.05.”

273 to 275: Both sentences mean the same thing. You need only one

276: You should give a brief description of antibiograms so that we can understand why you think they can help to reduce indiscriminate antibiotic use and the development of AMRs.

303 to 304: It is said that common things occur commonly. Is it possible for the common reasons for poor compliance with national treatment guidelines to apply to your study?

333 - 334: “Establishment of robust antimicrobial stewardship measures could help improve and monitor the rational prescription of antibiotics.” Measures like what? You mentioned antibiotic stewardship programs several times but you neither explained these in practical terms nor did you give existing examples that can be copied by the Ugandan health administration.

Finally, what is the WHO’s AWaRE classification of antibiotics and how are the classes different from one another? If you found that most of the antibiotics in your study belonged to the "watch" class, what does this mean in terms of indications for use, tendency for self-medication, level of patient compliance, and likelihood of developing resistance?

Reviewer #3: I found the manuscript well written, good research question and the outcome was intelligently communicated. However, the authors were silent about the accessibility of POM antibiotics over the counter by the populace without any prescription as seen in most countries in the Sub-Saharan African region. These could also be a silent factor contributing to AMR because antibiotics are not easily accessible by people in western world.

Minor corrections observed are highlighted in the manuscript.

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Reviewer #1: Yes: Abdulhakeem Abayomi Olorukooba

Reviewer #2: Yes: Oluwafolayemi Doyeni

Reviewer #3: No

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Attachments

Attachment

Submitted filename: PONE-D-24-28507 Review doc.pdf

Antibiotic consumption and utilization at a large tertiary care level hospital in Uganda: a point prevalence survey.

PONE-D-24-28507R1

Dear Dr. Kizito,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Mabel Kamweli Aworh, DVM, MPH, PhD. FCVSN

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

Reviewer #3: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: (No Response)

Reviewer #3: Yes

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: (No Response)

Reviewer #3: Yes

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4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: (No Response)

Reviewer #3: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: (No Response)

Reviewer #3: Yes

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6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The Authors did a great job attending to the comments. All my comments have been satisfactorily addressed.

Reviewer #2: (No Response)

Reviewer #3: The authors have attended to all the concerns I raised earlier, and the manuscript is intelligently written

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Abdulhakeem Abayomi Olorukooba

Reviewer #2: Yes: Dr. Oluwafolayemi Doyeni

Reviewer #3: No

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