UTILISATION AND DETERMINANTS OF BLOOD CULTURE IN MANAGING SEPSIS AMONG HOSPITALISED CHILDREN <5 YEARS: A MIXED-METHOD STUDY AT FOUR AMR SURVEILLANCE SITES IN UGANDA, 2024-2025

Abstract Sepsis caused by drug-resistant pathogens remains a major contributor to under-five mortality in low- and middle-income countries, threatening progress toward Sustainable Development Goal (SDG) 3.2. Blood culture, the gold standard for sepsis diagnosis and antimicrobial stewardship, remains underutilised in routine pediatric care. This study assessed the extent and determinants of blood culture utilisation among hospitalised children under five years with suspected sepsis at four antimicrobial resistance (AMR) surveillance sites in Uganda. We conducted a cross-sectional mixed-methods study involving retrospective review of 384 pediatric patient records and in-depth interviews with 20 clinicians. Modified Poisson regression was used to identify factors associated with blood culture requests, while thematic analysis explored behavioral and contextual influences on diagnostic practices. Blood cultures were requested in 28.1% of suspected sepsis cases. Higher utilisation was independently associated with markers of clinical severity, including severe acute malnutrition (adjusted prevalence ratio [aPR] 1.3, 95% CI: 1.14–1.34), sickle cell disease (aPR 1.3, 95% CI: 1.19–1.40), and presence of WHO danger signs (aPR 1.1, 95% CI: 1.00–1.14). Senior clinician involvement (aPR 1.2, 95% CI: 1.08–1.32) and consultant review (aPR 1.4, 95% CI: 1.21–1.48) were also associated with higher use, while prior antibiotic exposure reduced the likelihood of blood culture request (aPR 0.9, 95% CI: 0.84–0.96). Qualitative findings identified four overarching themes influencing diagnostic behavior: motivation amid systemic constraints, institutional and environmental barriers, mentorship and teamwork, and emotional fatigue in the context of adaptive practices. Despite high clinician awareness, blood culture utilisation remains low, driven primarily by health system fragility, inefficient workflows, and emotional exhaustion rather than knowledge gaps. Improving utilisation will require integrated behavioral, workflow, and structural interventions, including clinical decision support and strengthened microbiology laboratory capacity, to enhance pediatric sepsis care, antimicrobial stewardship, and progress toward SDG 3.2.