A simulated patient study of antibiotic utilization within the informal healthcare sector for pediatric viral infections in Adamawa State, Nigeria
Abstract
Antimicrobial resistance (AMR) is a leading cause of mortality in Sub-Saharan Africa, with Nigeria bearing a significant burden. The informal medicine retail sector operates largely outside national antimicrobial stewardship frameworks, yet the extent of inappropriate antibiotic dispensing for pediatric illnesses remains poorly quantified. We conducted a cross-sectional study using simulated patient methodology in 315 Patent and Proprietary Medicine Vendor shops across 10 Local Government Areas in Adamawa State, Nigeria (June–December 2025). Trained actors presented a standardized scenario of a 3-year-old child with viral infection symptoms (dry cough, low-grade fever) using a three-level escalation protocol. Dispensed antibiotics were classified using WHO AWaRe criteria and analyzed using multivariate logistic regression. Of the 315 outlets visited, 78.4% were Patent and Proprietary Medicine Vendor (PPMV) operated, 53.7% were male-operated, and 45.4% of vendors had more than 10 years of practice experience. Antibiotics were dispensed without prescription in 85.1% of visits. Among these, 54.9% were WHO "Watch" antibiotics (azithromycin, ciprofloxacin, cefixime, ceftriaxone) and 8.2% were "Reserve" antibiotics (oral colistin, levofloxacin) a fundamental inversion of appropriate AWaRe distribution. Only 3.8% of vendors provided AMR counseling. Outlets in high socio-economic neighborhoods had 2.45-fold higher odds of dispensing Watch/Reserve antibiotics (aOR: 2.45, 95%CI:…
How strong is the evidence?
Evidence Hub reads this as a cross-sectional, done in people. Its evidence level is 4 of 5 (Low · observational). Observational designs can show an association but not prove cause.
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