WHO guideline adherence and AWaRe antibiotic use in severe childhood pneumonia in Ethiopia: Associations with treatment outcomes

Background Pneumonia remains a leading cause of childhood mortality in sub-Saharan African countries. The World Health Organization (WHO) recommends a combination of ampicillin or benzylpenicillin with gentamicin for severe pneumonia in children aged 2-59 months. Real-world adherence to these guidelines remains limited. Methods We conducted a retrospective observational study at St. Luke Hospital in Woliso, Ethiopia, including all children aged 2-59 months admitted with severe pneumonia between May 2021 and April 2024. Antibiotic prescriptions were evaluated for adherence to WHO guidelines and categorized using the WHO AWaRe classification. Clinical outcomes were analyzed based on adherence status using univariate and multivariate analyses. Results Among 427 patients, 46.1% received guideline-adherent treatment, based on drug selection alone. Gentamicin and ampicillin were underdosed in 94.5% and 62.4% of cases, respectively. Overall, 43.6% of children received at least one antibiotic from the Watch group. In adjusted analyses, adherence to WHO guidelines was associated with longer duration of oxygen therapy (0.7 days, 95% CI: 0.1-1.3, P = 0.02) but showed no significant association with mortality or treatment failure. Conclusions Adherence to WHO guidelines was suboptimal, particularly regarding antibiotic dosing. These findings underscore the need for improved antimicrobial stewardship and further evaluation of guideline implementation in Ethiopia.