AMR Dx Use Accelerator

What is this project?

The AMR Diagnostic (Dx) Use Accelerator is a platform to evaluate a package of social (training and communications) and clinical (diagnostic tools and clinical algorithms) interventions to improve the management of acute febrile illnesses (AFIs) and reduce unnecessary antibiotic use.

Why are we working on it?

Many AFIs present with highly non-specific, overlapping signs and symptoms that are difficult to distinguish clinically. This ambiguity is especially problematic in children. Furthermore, the already challenging work of frontline healthcare workers in this area has been exacerbated by COVID-19.

As a result, fevers are often underdiagnosed and either over-treated or mistreated; many healthcare workers fall into the habit of prescribing antibiotics “just in case” – even though the cause of the infection may be viral, and the antibiotics would therefore be ineffective. This practice contributes to the insufficient management of AFIs, generating avoidable morbidity and mortality. It also fuels the growth of antimicrobial resistance (AMR), a global health security challenge that threatens individuals’ health and the stability of healthcare systems – both now and in the future – by compromising our ability to reliably treat infectious diseases with antibiotics.

What does it involve?

To generate evidence, we have enrolled almost 22,000 patients in what may be the largest study ever conducted on improving point-of-care diagnostic use to positively impact AMR and improve fever patients’ health outcomes. In a unique design combining a qualitative exploration of behaviours with a quantitative two-arm, clinic-based randomized controlled trial, we are conducting studies with harmonized protocols across eight sites in five countries (Burkina Faso; Ghana; India; Nepal; Uganda). This approach will enable us to draw both locally relevant and generally applicable conclusions on how to improve AFI patient management.

Although the study primarily targets children and adolescents as a recognized vulnerable group, some sites have also included adults for broader population representation. Patients in these groups presenting with acute undifferentiated febrile illnesses (AUFIs) at outpatient clinics or peripheral health centres in low- and middle-income countries (LMICs) are eligible to participate.

The AMR Dx Use Accelerator will assess changes in antibiotic prescription rates and differences in patient outcomes across two workstreams:

(1) Clinical intervention study: The project will address critical steps in the decision-making process by studying the effects of a package of interventions – designed to help healthcare workers reach a case-management decision – on clinical outcomes and antibiotic prescriptions compared with standard care practices as the control. In general, these existing practices involve few or even no diagnostic procedures. The package of interventions includes:

Diagnostics available at the point of care that may not be used locally at present
Decision trees and diagnostic algorithms to support clinical decision-making
Improved, standardized clinic patient flows
A training and communications package based on intelligence gathered during the social science pre-intervention

AMR Diagnostic (Dx) Use Accelerator - Diagnostic algorithm — Diagnostic algorithm

Clinical and diagnostic algorithm factsheet
Electronic clinical and diagnostic algorithm – testimonial video

(2) Behaviour change activities: Through a better understanding of the factors that promote or hinder adherence to prescriptions, the project aims to ensure that informed case-management decisions result in improved health outcomes. It will also focus on gaining a better understanding of the factors that promote or hinder the uptake of diagnostics and associated prescribing by healthcare workers.

What do we expect to achieve?

The AMR Dx Use Accelerator will generate evidence on the impact of diagnostic tools and of the behaviours affecting adherence to prescription, which will assist international organizations and policymakers to make informed changes to policies and practices. The project will lay the groundwork for a robust route to diagnostic uptake that improves patient care globally, reduces the unnecessary antibiotic use that drives AMR and brings us closer to achieving universal health coverage.

What is the timescale?

AMR Dx Use Accelerator activities are expected to run until 2022. The first phase, initiated in 2018, focused on common AFIs reflecting prevailing causes of infections within the study countries. In response to the COVID-19 pandemic, and to account for the subsequent changes in local needs at primary care facilities, a second phase will be launched in 2021 that adds COVID-19 diagnostic tests to the package of fever diagnostics in several countries. Patient enrolment in African sites will be completed by end of 2021 and data collection by end of 2022.

Partners and funding

The studies in India are being conducted through a partnership with the Indian Council of Medical Research (ICMR).

The University of Oxford is supporting FIND and the clinical sites with due diligence, protocol development, diagnostics training and quality assurance, social science and behaviour change components, statistical analysis, grant management, site monitoring, and process evaluation.

The WHO Special Programme for Research and Training in Tropical Diseases (TDR) is providing technical support, and collaborating with us on study design and implementation.

Activities are supported by UK aid from the British people, and the Swiss Agency for Development and Cooperation (SDC), and the Ministry for Economic Cooperation and Development (BMZ).