Determinants of antibiotic over-prescription in children aged 2–59 months attending primary care in Burkina Faso, Guinea, and Mali: the AIRE multi-country cross-sectional study

Background West Africa bears a high burden of infectious diseases and the highest antimicrobial resistance–related mortality worldwide, partly due to inappropriate antibiotic use. However, evidence on the extent and determinants of antibiotic over-use remains limited. The AIRE project integrated pulse oximetry into the Integrated Management of Childhood Illness (IMCI) guidelines for children under five in primary health centres (PHCs). Within this project, we quantified antibiotic over-prescription and its correlates among children attending PHCs in Burkina Faso, Guinea, and Mali. Methods Children aged 2–59 months, eligible for SpO 2 measurement, excluding uncomplicated non-respiratory cases, were recruited with parental consent in a facility-based cross-sectional study (12 PHCs, 4/country). IMCI symptoms, diagnoses, and clinicians' antibiotic prescriptions were recorded. Antibiotic overprescription, defined as the proportion of children receiving antibiotics among those not eligible for antibiotic treatment based on national IMCI guidelines, was estimated using a standardised algorithm, and modified Poisson regression models were used to identify its determinants. Findings Between June 2021 and June 2022, 9791 children were recruited. Antibiotic over-prescription proportions among children not eligible for antibiotic treatment were 53.2% in Burkina Faso (1423/2675), 75.9% in Guinea (331/436), and 45.1% in Mali (775/1719). Over-prescription was common for coughs, colds, and fevers. Respiratory symptoms, younger age, consultations during the dry season, and negative malaria tests were independent correlates of over-prescription. Interpretation Findings highlight widespread antibiotic overprescription, reflecting poor adherence to guidelines. Antimicrobial stewardship programmes—combining prescriber training, awareness-raising, and access to simple diagnostic tools—are now essential in West African primary care settings.