Impact of the Introduction of a Package of Diagnostic Tools, Diagnostic Algorithm, and Training and Communication on Outpatient Acute Fever Case Management at 3 Diverse Sites in Uganda: Results of a Randomized Controlled Trial

Abstract

Background Increasing trends of antimicrobial resistance are observed around the world, driven in part by excessive use of antimicrobials. Limited access to diagnostics, particularly in low- and middle-income countries, contributes to diagnostic uncertainty, which may promote unnecessary antibiotic use. We investigated whether introducing a package of diagnostic tools, clinical algorithm, and training-and-communication messages could safely reduce antibiotic prescribing compared with current standard-of-care for febrile patients presenting to outpatient clinics in Uganda. Methods This was an open-label, multicenter, 2-arm randomized controlled trial conducted at 3 public health facilities (Aduku, Nagongera, and Kihihi health center IVs) comparing the proportions of antibiotic prescriptions and clinical outcomes for febrile outpatients aged ≥1 year. The intervention arm included a package of point-of-care tests, a diagnostic and treatment algorithm, and training-and-communication messages. Standard-of-care was provided to patients in the control arm. Results A total of 2400 patients were enrolled, with 49.5% in the intervention arm. Overall, there was no significant difference in antibiotic prescriptions between the study arms (relative risk [RR]: 1.03; 95% CI: .96–1.11). In the intervention arm, patients with positive malaria test results (313/500 [62.6%] vs 170/473 [35.9%]) had a higher RR of being prescribed antibiotics (1.74; 1.52–2.00), while those with negative malaria results (348/688 [50.6%] vs 376/508 [74.0%]) had a lower RR (.68; .63–.75). There was no significant difference in clinical outcomes. Conclusions This study found that a diagnostic intervention for management of febrile outpatients did not achieve the desired impact on antibiotic prescribing at 3 diverse and representative health facility sites in Uganda.

A digital health algorithm to guide antibiotic prescription in pediatric outpatient care: a cluster randomized controlled trial

“…The reduction of antibiotic prescription associated with the ePOCT+ intervention in our study is consistent with our previous research with CDSAs in Tanzania in more controlled research settings 20 , 21 , 33 . However, the results differ from other studies evaluating CDSAs implemented in routine health programs in Nigeria, Afghanistan, Burkina Faso and South-Africa, and in a controlled study setting in Uganda, which found smaller and even no reduction in antibiotic prescription 22 – 24 , 34 , 35 . There are a number of differences that may explain the divergent results.…”

A pilot study investigating severe community-acquired febrile illness through implementation of an innovative microbiological and nucleic acid amplification testing strategy in Timor-Leste (ISIN-MANAS-TL)

“…This is particularly true in low-middle–income countries. Studies of malaria RDTs and three recently published randomized controlled trials assessing the impact of implementing a package of diagnostic tools on antimicrobial prescribing are notable exceptions [15] , [16] , [17] , [18] , [19] .…”