Prescribing Antibiotics for Pediatric Outpatients? There's an App for That

A digital clinical decision support algorithm, ePOCT+, reduced the number of antibiotic prescriptions for pediatric outpatients without adverse health outcomes compared to usual care, in a cluster randomized controlled trial1 conducted in Tanzania.

When used in conjunction with pertinent clinical data such as C-reactive protein, hemoglobin, and pulse oximetry, the investigators suggest that the use of the digital tool to safely reduce antibiotic prescribing could help to mitigate development of bacterial antimicrobial resistance (AMR).¹

"The use of the ePOCT+ digital clinical decision support algorithm (CDSA) package resulted in a close to three-fold reduction in the likelihood of a sick child receiving an antibiotic prescription compared to children in usual care facilities.Despite substantially fewer antibiotic prescriptions, clinical failure did not increase in intervention facilities," lead author Rainer Tan, MD, Centre for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland, and colleagues reported.

Although AMR is a global health issue, attributable for 1.27 million deaths in 2019, Tan and colleagues point out that the highest burden has been in sub-Saharan Africa. They note that in Tanzania, as in many resource-constrained countries, more than 50% of sick children receive antibiotics at health facilities, with 80 to 90% prescribed in outpatient treatment, "and most deemed inappropriate."

Tan and colleagues developed the ePOCT+ to be used in conjunction with several point-of-care tests to help prescribers determine when antimicrobial treatment is likely to be appropriate.² The CDSA provides guidance on what symptoms and signs to assess, advises on what tests to perform, and proposes appropriate diagnoses, treatment and management. The current version is applicable for treating infants as young as 2 months through children under 15 years of age.

The trial compared outcomes with the CDSA in 20 primary care outpatient clinics to those in 20 clinics applying usual care. Over 11 months, 23,593 consultations were included from the 20 ePOCT+ health facilities, and 20,713 from 20 usual care facilities The cluster design of the trial refers to comparing outcomes in the populations, rather than by individual.The primary outcomes were number of antibiotic prescriptions; and of clinical failure, corresponding to determination of "not cured," "not improved," or unscheduled hospitalization. Secondary safety outcomes were death and non-referred secondary hospitalization.

The investigators reported that antibiotics were prescribed at the CDSA facilities for 23.2% of the population, compared to 70.1% receiving antibiotic prescriptions in facilities with treatment as usual (adjusted difference -46.4%, [95% CI, -57.6 to -35.2]). The intervention was determined noninferior for clinical failure (adjusted relative risk 0.97 [0.85 to 1.10). There was no difference between CDSA and treatment as usual facilities in the secondary safety outcomes of death, and non-referred secondary hospitalizations by day 7.

Effectiveness of the CDSA depends on whether it is utilized, the investigators point out.

"Although the present findings are encouraging, it is important to note that nearly 25% of patients were not managed using ePOCT+ in the intervention arm," they indicated.

"It is reasonable to assume that not all health providers use the digital tool to manage all patients, just as health providers do not consult the IMCI paper chartbook every time they see a patient," Tan and colleagues acknowledge.

The investigators are now seeking to determine factors that could have reduced use of the CDSA, such as the impact of benchmarking and mentoring dashboards, and how health providers can be better supported in using the tool.

References

1.Tan R, Kavishe G, Luwanda LB, et al. Adigital health algorithm to guide antibiotic prescription in pediatric outpatient care: A cluster randomized controlled trial. Nat Med 2024; 30:76-84.

2.Tan R, Cobuccio L, Beynon, et al. ePOCT+ and the medAL-suite: Development of an electronic clinical decision support algorithm and digital platform for pediatric outpatients in low- and middle-income countries. PLoS Digit Health 2023; 19:2(1):e0000170. doi:10.1371/journal.pdig.0000170. Accessed January 31, 2024.