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Effect of Antibiotic Prescription Audits on Appropriate Antibiotic Prescribing in Nigerian Hospitals

Abstract

Inappropriate antibiotic prescribing is an important public health concern in Nigeria and contributes to antimicrobial resistance, avoidable adverse drug reactions, increased healthcare costs, prolonged hospitalization, and poor treatment outcomes. In hospital settings, inappropriate antibiotic use may involve unnecessary prescribing, incorrect antibiotic selection, inappropriate dosage or duration, unnecessary combination therapy, and failure to follow established antimicrobial treatment guidelines. Antibiotic prescription audits provide a structured approach for reviewing prescribing practices against established clinical guidelines and identifying areas requiring improvement. Regular audit and feedback may promote adherence to evidence-based prescribing standards, strengthen antimicrobial stewardship, and improve the quality of antibiotic use in hospitals. Against this background, this study investigates the effect of antibiotic prescription audits on appropriate antibiotic prescribing in Nigerian hospitals. The study will be anchored on the Donabedian Model of Healthcare Quality, the Theory of Planned Behavior, and Social Cognitive Theory. The Donabedian Model explains healthcare quality through structure, process, and outcome, with prescription auditing representing an important quality-improvement process and appropriate antibiotic prescribing serving as a measurable indicator of prescribing quality. The Theory of Planned Behavior explains how healthcare professionals' attitudes, subjective norms, perceived behavioural control, and behavioural intentions may influence antibiotic prescribing decisions. Social Cognitive Theory emphasizes knowledge, self-efficacy, observational learning, feedback, and organizational influences in shaping prescribing behaviour. Collectively, these theoretical perspectives provide a suitable framework for explaining how antibiotic prescription audits may influence appropriate antibiotic prescribing in Nigerian hospitals. The study will adopt a quantitative quasi-experimental research design. The study population will comprise medical doctors and other authorized prescribers involved in antibiotic prescribing in selected public and private hospitals across Nigeria, while antibiotic prescriptions and patient records will also be reviewed. A multistage sampling technique will be used to select states, local government areas, hospitals, clinical departments, prescribers, and eligible antibiotic prescriptions. Antibiotic prescription audits will be measured using indicators such as frequency of prescription review, use of standardized audit criteria, adherence to antimicrobial prescribing guidelines, audit coverage, documentation of audit findings, provision of prescriber feedback, identification of inappropriate prescribing, corrective recommendations, and follow-up audits. Appropriate antibiotic prescribing will be assessed using indicators such as correct indication, appropriate antibiotic selection, correct dose, appropriate route of administration, appropriate treatment duration, appropriate dosing frequency, documentation of allergy status, consideration of microbiological results where available, de-escalation when indicated, avoidance of unnecessary combination therapy, and compliance with hospital or national antimicrobial treatment guidelines. Data will be collected using structured questionnaires, antibiotic prescription records, patient medical records, pharmacy records, laboratory reports, antimicrobial stewardship documentation, and prescription-audit forms. Prescribing practices will be assessed before and after implementation of the audit intervention. Descriptive statistics will be used to summarize prescribers' characteristics, antibiotic prescribing patterns, audit activities, and levels of prescribing appropriateness. Inferential statistical techniques, including chi-square tests, paired sample tests, correlation analysis, and logistic or multiple regression analysis where appropriate, will be used to determine the effect of antibiotic prescription audits on appropriate antibiotic prescribing. Diagnostic tests will also be conducted to assess the reliability, validity, and robustness of the findings. The study is expected to find that antibiotic prescription audits have a significant positive effect on appropriate antibiotic prescribing in Nigerian hospitals. Hospitals implementing regular prescription audits are expected to demonstrate improved compliance with antimicrobial prescribing guidelines, more appropriate antibiotic selection, improved dosing and treatment duration, and reduced unnecessary antibiotic use compared with prescribing practices before the audit intervention. Audit feedback may increase prescribers' awareness of inappropriate prescribing patterns, strengthen adherence to evidence-based treatment recommendations, and promote accountability for antibiotic use. Repeated monitoring may also support the development of an institutional culture of antimicrobial stewardship. However, heavy clinical workloads, inadequate microbiology services, limited access to updated prescribing guidelines, prescriber resistance to feedback, insufficient antimicrobial stewardship personnel, and weak hospital management support may reduce the effectiveness of prescription audits. The study therefore expects regular, structured, evidence-based, and feedback-oriented antibiotic prescription audits to contribute significantly to improved antibiotic prescribing practices in Nigerian hospitals. The study is expected to contribute to the literature on antibiotic prescription audits, appropriate antibiotic prescribing, antimicrobial stewardship, antimicrobial resistance, hospital pharmacy practice, clinical governance, prescription quality, and public health in Nigeria. The findings will provide useful information to the Federal Ministry of Health and Social Welfare, Nigeria Centre for Disease Control and Prevention, Pharmacy Council of Nigeria, medical and pharmacy professional bodies, hospital management, antimicrobial stewardship committees, physicians, pharmacists, microbiologists, infection prevention teams, development partners, and policymakers regarding strategies for improving antibiotic use. The study will also provide evidence-based recommendations for institutionalizing routine antibiotic prescription audits, strengthening audit-and-feedback systems, improving access to antimicrobial prescribing guidelines and microbiological testing, establishing or strengthening antimicrobial stewardship programmes, training prescribers, and developing sustainable monitoring systems to promote appropriate antibiotic prescribing across Nigerian hospitals.

Keywords: Antibiotic prescription audits, appropriate antibiotic prescribing, antimicrobial stewardship, antimicrobial resistance, antibiotic use, prescription quality, hospital prescribing, clinical governance, infection prevention, Nigeria, public health.