Electronic clinical decision algorithms for the integrated primary care management of febrile children in low-resource settings: review of existing tools

Keitel, Kristina; D’Acremont, Valérie

doi:10.1016/j.cmi.2018.04.014

Cited by 55 publications

(70 citation statements)

References 30 publications

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“…Thus, even though our study did not show a risk of missing a serious infection, diagnostic sensitivity of parasite detection must still be adapted to clinical relevance (i.e., there is a need to define parasitemic thresholds to guide clinicians on whether the detected parasites are likely to be symptomatic and/or a risk for community transmission). More importantly, training and guidance to clinicians should be provided to help manage febrile patients in an integrated way, through the provision of (electronic) evidence-based algorithms and guidelines [ 32 ]. Indeed, in this study, clinicians strictly followed electronic algorithms, which are not yet widely available elsewhere and may have helped avoid missing serious infections.…”

Section: Discussionmentioning

confidence: 99%

Clinical relevance of low-density Plasmodium falciparum parasitemia in untreated febrile children: A cohort study

et al. 2020

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Background Low-density (LD) Plasmodium infections are missed by standard malaria rapid diagnostic tests (standard mRDT) when the blood antigen concentration is below the detection threshold. The clinical impact of these LD infections is unknown. This study investigates the clinical presentation and outcome of untreated febrile children with LD infections attending primary care facilities in a moderately endemic area of Tanzania. Methods/findings This cohort study includes 2,801 febrile pediatric outpatients (median age 13.5 months [range 2-59], female:male ratio 0.8:1.0) recruited in Dar es Salaam, Tanzania between 01 December 2014 and 28 February 2016. Treatment decisions were guided by a clinical decision support algorithm run on a mobile app, which also collected clinical data. Only standard mRDT+ cases received antimalarials. Outcomes (clinical failure, secondary hospitalization, and death) were collected in follow-up visits or interviews on days 3, 7, and 28. After patient recruitment had ended, frozen blood from all 2,801 patients was tested for Plasmodium falciparum (Pf) by ultrasensitive-quantitative polymerase chain reaction (qPCR), standard mRDT, and "ultrasensitive" mRDT. As the latter did not improve sensitivity beyond standard mRDT, it is hereafter excluded. Clinical features and outcomes in LD patients (standard mRDT-/ultrasensitive-qPCR+, not given antimalarials) were compared with those with no detectable (ND) parasitemia (standard mRDT-/ultrasensitive-qPCR-) or high-density (HD) infections (standard mRDT+/ultrasensitive-qPCR+, antimalarial-treated). Pf positivity rate was 7.1% (n = 199/2,801) and 9.8% (n = 274/2,801) by standard mRDT and ultrasensitive qPCR, respectively. Thus, 28.0% (n = 76/274) of ultrasensitive qPCR+ cases were not detected by standard mRDT and labeled "LD". LD patients were, on

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Section: Discussionmentioning

confidence: 99%

Clinical relevance of low-density Plasmodium falciparum parasitemia in untreated febrile children: A cohort study

et al. 2020

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“…Few studies have focused on CDSS for the management of infectious diseases in LMICs and in particular in West Africa. A recent review identified 6 CDSS for the management of febrile children in primary care in LMICs [ 35 ]. In a pilot cluster-randomized controlled study, the clinical algorithm for management of childhood illness available on smartphones (e-ALMANACH) increased the number of children screened for red flags and decreased antibiotic prescription in Tanzania [ 36 ].…”

Section: Discussionmentioning

confidence: 99%

Paving the Way for the Implementation of a Decision Support System for Antibiotic Prescribing in Primary Care in West Africa: Preimplementation and Co-Design Workshop With Physicians

Peiffer-Smadja¹,

Poda²,

Ouédraogo³

et al. 2020

J Med Internet Res

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Background Suboptimal use of antibiotics is a driver of antimicrobial resistance (AMR). Clinical decision support systems (CDSS) can assist prescribers with rapid access to up-to-date information. In low- and middle-income countries (LMIC), the introduction of CDSS for antibiotic prescribing could have a measurable impact. However, interventions to implement them are challenging because of cultural and structural constraints, and their adoption and sustainability in routine clinical care are often limited. Preimplementation research is needed to ensure relevant adaptation and fit within the context of primary care in West Africa. Objective This study examined the requirements for a CDSS adapted to the context of primary care in West Africa, to analyze the barriers and facilitators of its implementation and adaptation, and to ensure co-designed solutions for its adaptation and sustainable use. Methods We organized a workshop in Burkina Faso in June 2019 with 47 health care professionals representing 9 West African countries and 6 medical specialties. The workshop began with a presentation of Antibioclic, a publicly funded CDSS for antibiotic prescribing in primary care that provides personalized antibiotic recommendations for 37 infectious diseases. Antibioclic is freely available on the web and as a smartphone app (iOS, Android). The presentation was followed by a roundtable discussion and completion of a questionnaire with open-ended questions by participants. Qualitative data were analyzed using thematic analysis. Results Most of the participants had access to a smartphone during their clinical consultations (35/47, 74%), but only 49% (23/47) had access to a computer and none used CDSS for antibiotic prescribing. The participants considered that CDSS could have a number of benefits including updating the knowledge of practitioners on antibiotic prescribing, improving clinical care and reducing AMR, encouraging the establishment of national guidelines, and developing surveillance capabilities in primary care. The most frequently mentioned contextual barrier to implementing a CDSS was the potential risk of increasing self-medication in West Africa, where antibiotics can be bought without a prescription. The need for the CDSS to be tailored to the local epidemiology of infectious diseases and AMR was highlighted along with the availability of diagnostic tests and antibiotics using national guidelines where available. Participants endorsed co-design involving all stakeholders, including nurses, midwives, and pharmacists, as central to any introduction of CDSS. A phased approach was suggested by initiating and evaluating CDSS at a pilot site, followed by dissemination using professional networks and social media. The lack of widespread internet access and computers could be circumvented by a mobile app with an offline mode. Conclusions Our study provides valuable information for the development and implementation of a CDSS for antibiotic prescribing among primary care prescribers in LMICs and may, in turn, contribute to improving antibiotic use, clinical outcomes and decreasing AMR.

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“…Under the assumption that only a minority of patients at the primary health care level require antibiotics, CRP/PCT testing was restricted to children with severity indicators and was used to rule in the need for antibiotics. An impressive reduction of antibiotic use was demonstrated in the interventional arm (11.5% compared with 94.9% in routine care) in this study setting, with a trend to lower mortality [ 6 , 23 ].…”

Section: Evidence Base In Sub-saharan Africamentioning

confidence: 99%

Point of care biomarkers to guide antibiotic prescription for acute febrile illness in sub-Saharan Africa: promises and caveats

Griensven

Cnops

Weggheleire

et al. 2020

Open Forum Infectious Diseases

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Electronic clinical decision algorithms for the integrated primary care management of febrile children in low-resource settings: review of existing tools

Cited by 55 publications

References 30 publications

Clinical relevance of low-density Plasmodium falciparum parasitemia in untreated febrile children: A cohort study

Clinical relevance of low-density Plasmodium falciparum parasitemia in untreated febrile children: A cohort study

Paving the Way for the Implementation of a Decision Support System for Antibiotic Prescribing in Primary Care in West Africa: Preimplementation and Co-Design Workshop With Physicians

Point of care biomarkers to guide antibiotic prescription for acute febrile illness in sub-Saharan Africa: promises and caveats

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