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

Author:

Kapisi James1,Sserwanga Asadu1,Kitutu Freddy Eric2,Rutebemberwa Elizeus3,Awor Phyllis3,Weber Stephan4,Keller Thomas4,Kaawa-Mafigiri David5,Ekusai-Sebatta Deborah1,Horgan Philip678,Dittrich Sabine6910,Moore Catrin E711,Salami Olawale6,Olliaro Piero612,Nkeramahame Juvenal6,Hopkins Heidi13

Affiliation:

1. Department of Disease Surveillance, Infectious Diseases Research Collaboration , Kampala , Uganda

2. Department of Pharmacy, Makerere University School of Health Sciences , Kampala , Uganda

3. Department of Health Policy, Planning, and Management, Makerere University School of Public Health , Kampala , Uganda

4. Department of Statistics, ACOMED Statistics , Leipzig , Germany

5. Social Work and Social Administration, Makerere University , Kampala , Uganda

6. FIND , Geneva , Switzerland

7. Nuffield Department of Medicine, Big Data Institute, University of Oxford , Oxford , United Kingdom

8. Evidence & Impact Oxford , Oxford , United Kingdom

9. Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford , Oxford , United Kingdom

10. Deggendorf Institute of Technology, European-Campus-Rottal-Inn , Pfarrkirchen , Germany

11. Centre for Neonatal and Paediatric Infection, Institute for Infection and Immunity, St George's University of London , London , United Kingdom

12. Nuffield Department of Medicine, Pandemic Sciences Institute, University of Oxford , Oxford , United Kingdom

13. Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine , London , United Kingdom

Abstract

AbstractBackgroundIncreasing 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.MethodsThis 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.ResultsA 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.ConclusionsThis 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.

Funder

Swiss Agency for Development and Cooperation

Publisher

Oxford University Press (OUP)

Subject

Infectious Diseases,Microbiology (medical)

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