The study, led by Faiza Mohamed Juma of the Catholic University of Health and Allied Sciences in Mwanza and Mnazi Mmoja Hospital, was nested within the ZanTOTO project, an initiative supported by the International Centre for Antimicrobial Resistance Solutions in Copenhagen. Researchers deployed two WHO instruments in parallel: the Point Prevalence Survey tool, applied at two time points between February 2024 and May 2025 to capture which hospitalized children were on antibiotics and why, and the Health Care Facility Core Element Indicators Tool, administered once in April 2024 to score how well each hospital’s antimicrobial stewardship program was actually functioning. The survey covered the full spectrum of Zanzibar’s hospital tiers: one tertiary referral center, one regional hospital, and three district hospitals spread across the islands of Unguja and Pemba.

Of the 943 eligible pediatric patients, all aged thirteen or younger, 826 were on antibiotics on the survey days. The gradient across hospital tiers was striking and ran in an unexpected direction. At the regional Abdulla Mzee Hospital, 99.4 percent of children received antibiotics; district hospitals ranged from 92.0 to 96.9 percent. Yet at Mnazi Mmoja, the tertiary facility best equipped with diagnostics and specialist expertise, the figure fell to 71.8 percent. Statistical modeling confirmed the pattern: after adjustment, antibiotic use was significantly more prevalent in regional hospitals (adjusted prevalence ratio 1.39) and district hospitals (1.35) than at the tertiary center. Severity mattered too, with children classified by the McCabe score as having an ultimately fatal underlying condition significantly more likely to be treated.

The reverse gradient, with the weakest-resourced facilities prescribing most intensively, is the study’s most technically telling signal. The authors interpret it as a reflection of limited diagnostic capacity and fewer clinical decision-support resources at lower-tier hospitals, where clinicians confronting febrile infants have little choice but to treat empirically. The demographic profile of the wards reinforces the point: nearly two-thirds of admissions were infants under twelve months, a population in which bacterial sepsis can kill within hours and in which clinical signs alone cannot reliably distinguish bacterial from viral illness. Without laboratory confirmation, broad-spectrum coverage becomes the defensive default.

That defensive default is visible in the drug list. Gentamicin accounted for 35.7 percent of the 1,385 recorded prescriptions, ampicillin for 31.8 percent, and ceftriaxone for 16.1 percent; together these three agents made up 83.6 percent of everything prescribed. Categorizing the prescriptions with the WHO’s AWaRe framework reveals the deeper concern. The framework divides antibiotics into Access drugs, first- and second-choice agents with lower resistance potential; Watch drugs, higher-resistance-potential antibiotics that demand prioritized stewardship; and Reserve drugs, last-resort options. WHO targets call for more than 60 percent of use to come from the Access category and no more than 28 percent from Watch. Zanzibar’s pediatric wards inverted those targets: Watch drugs made up 53.8 percent of prescriptions while Access drugs accounted for only 45.8 percent. Reserve use, at 0.4 percent, was appropriately minimal.

Why children were being treated is equally revealing. Community-acquired infections drove 60.4 percent of antibiotic indications, with pneumonia at 27.3 percent and clinical sepsis at 18.0 percent the leading diagnoses. Hospital-acquired infections accounted for another 20.6 percent, while prophylaxis was comparatively rare at about 12 percent combined. But the diagnostic pipeline feeding these clinical labels was nearly empty: only 10.9 percent of antibiotic courses were supported by bacteriological culture results, and among the cultures that were done, blood cultures overwhelmingly dominated. Antimicrobial susceptibility testing was performed for just 30.4 percent of patients at Vitongoji District Hospital, the best performer, and fell to between 0.6 and 4.6 percent elsewhere, with none at all at Kinyasini. Only two of the five hospitals had functional microbiology laboratory capacity during the study period.

The stewardship infrastructure meant to restrain and rationalize this prescribing was, by WHO standards, barely functioning. Hospitals scored from 7 to 41 percent on the Core Element assessment, and none approached the 50 percent threshold that marks even a partially operational program. Mnazi Mmoja, the tertiary hospital, scored highest at 41 percent; the regional and district hospitals scored below 25 percent, with Kivunge at just 7 percent. The component scores map the anatomy of the failure: leadership commitment was recorded at zero in two hospitals, accountability and responsibility at zero in two, drug and therapeutic committee function at zero in one, and monitoring, surveillance, reporting and feedback were weak nearly everywhere. The assessment also showed that most prescribing was done by general practitioners, 77.7 percent of prescriptions, with specialists contributing only 15 percent, a workforce structure very different from the multidisciplinary, specialist-led stewardship teams of high-income systems.

There were brighter spots. Adherence to the Zanzibar Standard Treatment Guidelines stood at 77.8 percent, suggesting that when clinicians prescribe, they are largely following the national rulebook; the problem is less disobedience than the structure around the rulebook. The near-total reliance on the parenteral route, 98.6 percent of doses, is consistent with the severity of the hospitalized population, though the authors note that missing data on intravenous-to-oral switching made it impossible to assess de-escalation practices, a core stewardship lever. The researchers also point to a promising local precedent: a feasibility study within the same ZanTOTO collaboration found that serial C-reactive protein point-of-care testing could help optimize antibiotic treatment in hospitalized Zanzibari children, offering a low-cost biomarker pathway where culture capacity is absent.

Set against international benchmarks, the numbers are sobering. Antibiotic use in the Zanzibar pediatric wards exceeds estimates from mainland Tanzania, where pediatric prevalence has been reported around 84 percent and all-ages prevalence near 62 percent, and from other sub-Saharan African settings including Kenya at 67.7 percent, Botswana at 70.6 percent, and Nigeria at 69.7 percent. It even edges past Bangladesh’s 91.2 percent at the district level and stands far above the sub-45 percent figures typical of European acute care hospitals, where robust stewardship systems and accessible diagnostics constrain empirical treatment. Comparable WHO point prevalence surveys in Uganda, Ghana, and across the Global-PPS network have consistently shown community-acquired infection as the leading indication, confirming that Zanzibar’s pattern is an intensified version of a regional norm rather than an anomaly.

The study’s authors are careful about its limits: incomplete medical documentation prevented assessment of dosing accuracy, comorbidities, and temporal trends, and the cross-sectional design captures snapshots rather than trajectories. But the direction of travel is clear. For Zanzibar, which adopted its own Action Plan on antimicrobial resistance in 2019 aligned with the WHO Global Action Plan, the survey provides the first comparable local evidence that stewardship governance, laboratory capacity, and prescribing culture all need reinforcement simultaneously. The authors call for facility-specific interventions tailored to each hospital tier, expanded diagnostic capacity, and future research into whether the prescriptions being written are actually appropriate, and into the barriers preventing stewardship programs from taking root. In a decade when antimicrobial resistance threatens to undo a century of pediatric medicine, the wards of Zanzibar offer a precise, data-rich map of where the system leaks, and a reminder that saving the antibiotics may depend less on new drugs than on the unglamorous machinery of committees, laboratories, and feedback loops that decide when to reach for them at all.

Subject of Research: Antibiotic use and antimicrobial stewardship performance in pediatric wards of Zanzibar public hospitals

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

Article References: Drivers influencing antibiotics use in pediatric wards across five public hospitals in Zanzibar: a WHO multiple point prevalence survey. (n.d.). https://doi.org/10.3389/frabi.2026.1874316

Image Credits: AI Generated

DOI: 10.3389/frabi.2026.1874316

Keywords: antibiotic use, antimicrobial stewardship, antimicrobial resistance, pediatrics, Zanzibar, WHO point prevalence survey, AWaRe classification, low- and middle-income countries, diagnostic capacity, hospital prescribing, Tanzania, public health