Determinants of Antibiotic Prescribing for Acute Respiratory Infections in Primary Care: A Retrospective Cross-Sectional Study at the Eduardo Mondlane University Health Center, Maputo, Mozambique
primary care research
Quick verdict
Preprint claims ARI antibiotic prescribing in Maputo (69.4%) tracks presentation, not diagnosis; plausible, but collinearity and small n weaken the key claim.
Summary
This retrospective cross-sectional study analyzed 196 clinical records of patients with acute respiratory infections (ARIs) seen at the Eduardo Mondlane University Health Center in Maputo, Mozambique, between April and August 2024, to identify factors associated with antibiotic prescribing. Antibiotics were prescribed in 69.4% of encounters (136/196), roughly two to three times the WHO-recommended 20-26.8% range. Amoxicillin dominated (45.4% of patients), followed by azithromycin (26.0%); 43.4% of the 189 recorded antibiotic instances fell in the WHO AWaRe 'Watch' category, with amoxicillin-plus-azithromycin accounting for 96.2% of the 53 combination prescriptions. Using chi-square tests, Cramer's V, and multivariable logistic regression with likelihood-ratio testing, AIC/BIC selection, and explicit handling of a quasi-separation in a small prescriber category, the final model retained clinical category and presenting signs/symptoms (chi2(8)=36.58, McFadden R2=0.151, AUC=0.760): fever, nasal congestion, rhinorrhea, and cold-type symptoms predicted lower prescribing odds than cough, and nurse-reviewed patients were prescribed less than physician-reviewed patients. Diagnosis, age, sex, and prescriber nationality were not independently associated. Key limitations: convenience sampling with no described record-selection flow, moderate collinearity (V of 0.26-0.44) that may have absorbed the diagnosis effect, an in-sample AUC without validation, a clinically under-defined 'clinical category' variable the authors themselves flag, and no symptom-duration or severity data. Data and code are available only on request.
Review complete
Assessment at a glance
6
risk flags identified
● high 0
● medium 3
● low 3
5 strengths · 5 weaknesses · 5 author questions
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Key claims under review
- Antibiotic prescribing prevalence for ARIs at CS-UEM was 69.4% (136/196), two to three times the WHO-recommended 20-26.8% outpatient range.
- After multivariable adjustment, prescribing was independently associated with clinical category and presenting signs/symptoms, but not with diagnosis, age, sex, or prescriber nationality.
- Fever, nasal congestion, rhinorrhea, and cold-type symptoms carried significantly lower prescribing odds than cough (ORs 0.11-0.21), and general nurses prescribed less than physicians (OR 0.29).
- 43.4% of the 189 recorded antibiotic instances were WHO AWaRe Watch class, with the amoxicillin+azithromycin combination in 96.2% of the 53 combination prescriptions, identifying concrete stewardship targets.
Strengths
Genuine local evidence gap
First quantified analysis of ARI antibiotic-prescribing determinants at CS-UEM, a general-population primary care facility; the Introduction credibly situates the 69.4% figure against the LMIC meta-analytic range of 44-60% [30] and Harare's 70.5% [31].
Transparent data-quality handling
Merging the two outcome indicator columns, correcting one sex-coding error, and pre-model collinearity screening (Cramer's V matrix) are all documented in Methods/Results — unusual candor for chart-review studies.
Statistically careful categorical modeling
Actionable stewardship framing
Honest limitations section
Weaknesses
Sampling process unreported
Null diagnosis finding is confounded by design
Key predictor operationally undefined
Uncvalidated discrimination and crude symptom coding
AWaRe metric conflation
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Scope & Claims
This retrospective, single-center cross-sectional study reviews 196 clinical records of patients with acute respiratory infections (ARIs) seen at the Eduardo Mondlane University Health Center (CS-UEM), Maputo, Mozambique, between April and August 2024, aiming to identify clinical factors associated with antibiotic prescribing. Its four central claims: (1) prescribing prevalence was 69.4% (136/196), two to three times the WHO-recommended 20-26.8% outpatient range [9]; (2) after multivariable adjustment, prescribing was associated with clinical category and presenting signs/symptoms but not with diagnosis, age, sex, or prescriber nationality; (3) fever, nasal congestion, rhinorrhea, and cold-type symptoms carried lower prescribing odds than cough (ORs 0.15, 0.21, 0.11, 0.18), and general nurses prescribed less than physicians (OR 0.29); (4) 43.4% of the 189 recorded antibiotic instances were AWaRe Watch class, and amoxicillin+azithromycin accounted for 96.2% of the 53 combination prescriptions, framed as priority stewardship targets. The Results are framed descriptively, but the Discussion advances the stronger thesis that presentation, not diagnosis, drives prescribing — a claim this review finds only partially supported.
The remaining sections cover Methodology Assessment, Statistical Evidence, Results & Reproducibility, Limitations & Risks, and Verdict & Recommendations.
- All 5 strengths & 5 weaknesses, analyzed in detail
- 6 risk flags with severity, section & reviewer questions
- Methods & statistical evidence assessment
- 5 questions a peer reviewer would ask
- Full six-dimension evaluation report & recommendations
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Frequently asked questions
How often were antibiotics prescribed for acute respiratory infections in this Mozambican study?
In 69.4% of the 196 patient records reviewed (136/196) at the Eduardo Mondlane University Health Center in Maputo between April and August 2024 — roughly two to three times the WHO-recommended 20-26.8% range for outpatient antibiotic prescribing.
What predicted whether an ARI patient received an antibiotic?
The internal clinical category (which type of professional saw the patient) and the presenting signs and symptoms. Fever, nasal congestion, runny nose, and cold-like symptoms were linked to lower prescribing odds than cough, and general nurses prescribed less than physicians; diagnosis, age, sex, and prescriber nationality showed no independent association.
Which antibiotics were used, and how do they compare with WHO guidance?
Amoxicillin (45.4% of patients) and azithromycin (26.0%) dominated. Of the 189 recorded antibiotic instances, 43.4% belonged to the WHO AWaRe 'Watch' category, which is above WHO's target of at least 60-70% 'Access' consumption; the amoxicillin+azithromycin combination alone accounted for 96.2% of combination prescriptions.
Is the study data or analysis code publicly available?
No. The paper states that anonymized data, the structured collection form, and the Python analysis code can be made available only upon reasonable request, subject to approval by the institution that holds the data.
About this review
This is an AI-generated preliminary review by Evolve.Pub, produced from the openly available text of the paper. It is not peer review and does not represent the authors' views. The canonical record of the paper is at the publisher link above.
- Figures 1 (Pareto) and 2 (ROC) appear only as captions in the extracted text; their visual content could not be independently verified.
- Review is based on the embedded preprint text alone; the structured data-collection form and analysis code were not available.
- medRxiv preprint, not yet journal peer reviewed; the extracted text appears complete through the reference list.
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