LAUSR

In children with severe bacterial infection in low-resource settings, switch from intravenous to oral antibiotics is important to reduce nosocomial infections and costs. We report barriers to reliable oral antibiotic administration in children under five admitted to Kisantu hospital (DR Congo) with bloodstream infection. Qualitative observations were compiled during field studies (DeNTS/TreNTS study: NCT04473768/04850677). Antibiotics were procured by the hospital pharmacy and part of routine care.Oral switch mostly relied on Watch antibiotics (ciprofloxacin/azithromycin) due to predomination of multiresistant Salmonella bloodstream infections. Available oral formulations were conventional tablets and powders/granules for reconstitution. Water for reconstitution was rarely sterile and volumes were not exactly measured. Instructions on reconstitution and/or a volume mark on the bottle were missing for some in-country produced antibiotics. Accurate oral dosing was impeded by complex dose calculations and absence of dosing devices. Vomiting after administration suggested poor palatability. Bottle antisepsis was endangered by use of the cap for administration. Treatment compliance suffered from non-affordability.Insufficient availability of age-appropriate antibiotic formulations is a biohazard and driver of inappropriate antibiotic use, fuelling antimicrobial resistance. WHO should integrate antibiotics in pediatric drug optimization and medicine prequalification. National regulatory authorities should adopt stringent specifications for formulations and dosing devices when granting marketing authorizations. To enable safe and effective oral switch in low-resource settings, solid flexible dosing formulations based on age/weight bands of Watch antibiotics are needed