Guideline adherence, AWaRe antibiotics, and outcomes in severe childhood pneumonia in Tanzania

Background: Lower respiratory tract infections are the leading infectious cause of death in children under five, particularly in sub-Saharan Africa. Adherence to World Health Organization (WHO) antibiotic guidelines for severe pneumonia is suboptimal in high-burden settings. Methods: We conducted a retrospective observational study at St. Gaspar Hospital, Itigi, Tanzania, including children aged 2–59 months admitted with severe pneumonia between May 2021 and April 2024. Adherence was defined as the prescription of ampicillin or benzylpenicillin plus gentamicin within 48 h of admission, irrespective of dosage. Clinical features, laboratory results, and outcomes were compared between adherent and non-adherent groups. Results: We included 81 children (42.0% female; mean age 13.1 ± 11.7 months). Adherence to WHO guidelines occurred in 64 patients (79.0%); 11 (13.6%) received at least one antibiotic from the WHO Watch group. Comorbidities were more frequent among patients receiving non-adherent prescriptions. No significant differences in mortality, length of stay, or oxygen requirement were observed between groups. Gentamicin was underdosed in all cases, with most prescriptions at 5 mg/kg/day. Eleven patients (13.7%) died, and 23 (28.4%) were clinically diagnosed with measles. Conclusions: Adherence to WHO guidelines in this Tanzanian referral hospital was higher than reported in several previous studies from African settings. Adherence was not associated with differences in clinical outcomes. All patients receiving gentamicin were prescribed doses lower than the recommended 7.5 mg/kg/day. The high proportion of measles cases highlights the ongoing impact of reduced vaccination coverage following the COVID-19 pandemic. Local and national health authorities should prioritise optimising gentamicin dosing and strengthening measles immunisation efforts.