Non-prescription antibiotic use and its predictors among children in low- and middle-income countries: a systematic review and meta-analysis

Globally antibiotics are among the most commonly used drugs. Non-prescription use of antibiotics is a major factor for the emergence and spread of antimicrobial resistance one of the top global public health and development threats. This systematic review and meta-analysis aim to assess non-prescription antibiotic use and predictors among children in Low and middle-income countries.A comprehensive search of electronic databases was conducted from PubMed, Scopus and HINARI to identify primary studies published between 2000 and 2024. Observational studies conducted among children ≤ 18 years old and published in English language were included in the review. After screening, the studies were assessed using Joanna Briggs Institute (JBI) critical appraisal tool and data were extracted using a checklist. Heterogeneity was assessed using forest plot, Chocran's Q Test and I². The random effects meta-analysis model was employed to pool the prevalence of non-prescription antibiotic use among children in low-and middle-income countries. Sub-group analysis and meta-regression were performed to identify the sources of heterogeneity. Publication bias was assessed using funnel plots with Egger's test.The review was conducted among 32 cross-sectional studies with a sample size of 80,133 participants. The pooled prevalence of non-prescription antibiotic use among children in low-and middle-income countries was 38.86% (95% CI 34.32, 43.40; P < 0.0001) with high heterogeneity (I² = 99.38%, p < 0.001). The prevalence of non-prescribed antibiotic use among studies conducted in upper middle-income countries (30.85% (24.49%, 37.21%)) was low when compared to studies conducted in LMICs (44.00% (37.72%, 52.09%). Penicillin was the most often antibiotic class used without prescription, while upper respiratory infections were the most prevalent illness/symptoms that prompted non-prescription antibiotic use.The pooled prevalence of non-prescription antibiotic use among children in low-and middle-income countries is high indicating that two out of five children used non-prescribed antibiotics. This review is important for international organizations, ministry of health of the low-and middle- income countries, regulatory bodies and researchers.