During a typical day at a clinic in rural Rwanda, nurses can see 60 patients a day. Adults and children line up with injuries, coughs and fevers, often after traveling many miles.
"Nurses are very busy, they're receiving all the things from the community, complicated or easy," says Dr. Victor Pacifique Rwandarwacu, a physician from Rwanda. That leaves little time for diagnosis.
When faced with a patient suffering from an illness, many nurses err on the side of prescribing something. Often, that's antibiotics. "You find them giving a high number of antibiotics, just in case," says Rwandarwacu. "They'd be like, 'OK, what if I don't give it, and then the patient comes back tonight?'"
That dynamic has led to extremely high prescription rates, according to new research by Rwandarwacu and his colleagues. Across 32 clinics in Rwanda, 71% of pediatric visits ended with an antibiotic prescription. That's likely much, much higher than necessary.
For a given patient, getting antibiotics for, say, a viral case of pneumonia may not be a big deal, even though antibiotics do nothing to stop the virus. But across a region or country, such high rates of unnecessary prescriptions can breed resistance.
"In sub-Saharan Africa, the rise in antimicrobial resistance is enormous," says Jean Claude Semuto Ngabonziza, a researcher at the Rwanda Biomedical Center who was also involved in the study. "We are at the edge of losing potential antibiotics."
But Ngabonziza, Rwandarwacu and their colleagues have developed a new tool that could help.
Their computer tablet-based tool, called ePOCT+, guides clinicians, step-by-step, through diagnosing a problem and suggesting a treatment. After those same 32 clinics implemented ePOCT+, antibiotic prescription rates plummeted from 71% to 25%, the researchers report in PLOS Medicine. That drop didn't lead to more kids getting sicker.
"The most important thing is they're not compromising health outcomes," says Dr. Sumanth Gandra, an infectious disease researcher at Washington University in St. Louis who wasn't involved in the study. "I think these tools will be really useful and can be scaled up."
A digital "second opinion"
In theory, nurses working in rural Rwanda and other parts of sub-Saharan Africa have access to clinical guidelines that offer best practices in diagnosing and treating patients. But in practice, this knowledge is often inaccessible or hard to apply to rural circumstances.
"Nurses would have a lot of books on the table, so they have to move from guideline to guideline to decide on each case of a patient," says Rwandarwacu.
The researchers wanted to distill all that information into an easy-to-use digital tool, something that could run on a tablet computer. They created ePOCT+, an algorithm that boiled down those guidelines into step-by-step instructions on assessing various symptoms. It also incorporated a few simple diagnostic tests, including oxygen levels and hemoglobin, which can give clues towards the underlying problem. Based on answers, the algorithm would guide clinicians toward a diagnosis and offer a treatment suggestion.
Say a patient comes in with suspected pneumonia. A nurse would examine the patient, tablet in hand, and enter information about symptoms. On average, the whole process takes about 10 minutes, says Alexandra Kulinkina, an epidemiologist at the Swiss Tropical and Public Health Institute and study co-author. "At the end, it's either simple pneumonia, bacterial pneumonia or viral pneumonia," she says. Only bacterial pneumonia would be treated with antibiotics.
Training the staff at the clinics on how to use ePOCT+ didn't take long, Kulinkina says. "One day of practicing was enough," she says. The researchers tracked the impact of the tool over nearly 60,000 visits. Antibiotic prescriptions dropped significantly, to just 25% of visits.
That's still likely higher than necessary, says Kulinkina. "Under ideal conditions, you'd expect maybe 10 to 15% of patients should walk away with a prescription," she says. In part, that's because nurses didn't always follow the guidelines. Still, it's a "dramatic reduction," she says.
The tool helped nurses catch other problems that often go missed, says Rwandarwacu, including malnutrition and anemia. "It was a surprising effect."
Overall, nurses and patients were generally positive about the experience, says Ngabonziza. "One mother told me 'This is exceptional, I felt more evaluated and examined than in previous consultations because the clinician was always checking,'" he says. Nurses appreciated the extra support too, he says, though they ended up spending more time with each patient, he says.
The Rwandan government took notice of the results too.
The Ministry of Health is currently developing an electronic medical record system for the entire country. The researchers have been talking with officials about the prospect of integrating some version of ePOCT+, says Kulinkina. "The Ministry of Health is, of course, interested in improving care quality for patients."
But she notes the most interest came from the Rwanda Social Security board, which funds the public health insurance system. Fewer antibiotic prescriptions could save them considerable money over time, she says.
Scaling up such a tool would have its challenges, including training thousands of health care workers. And it may not work as well as it did in this study. But trying is worth it, for both patients and stemming the rise of antibiotic resistance, says Jean Claude Semuto Ngabonziza, a researcher at the Rwanda Biomedical Center and study co-author.
"We are at the edge of losing potential antibiotics," he says. "Sometimes we do research and it's so-so, but this is really impactful."
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