Effect of a community-based behavioural intervention bundle to improve antibiotic use and patient management in Burkina Faso and DR Congo: a cluster randomized controlled trial

Background
Sub-Saharan Africa has a high burden of disease due to antimicrobial resistance that is thought to be driven by a combination of sub-optimal antibiotic use and frequent exposures to AMR in different One Health compartments. We evaluated a community-based, co-created intervention bundle to improve antibiotic use and hygiene practices, targeting all community-level healthcare providers and communities.
Methods
In a cluster-randomised, controlled trial in 44 villages, we measured the intervention effect on antibiotic use through repeated patient surveys. Simulated patient visits, mimicking common infections, were used to monitor patient management. In 22 randomised intervention villages, three rounds of intervention activities (health education campaign, educational/feedback sessions) were implemented over nine months. Provider interventions focused on infections with highest antibiotic use, introducing WHO AWaRe Book guidance. Per provider type per village, 100 patient surveys and five simulated patient visits were conducted at baseline and post-intervention. Primary outcomes were the change in Watch antibiotic use and patient management scores. CABU-EICO was registered on clinicaltrials.gov/study/NCT05378880.
Findings
During the baseline period (Oct 26, 2022 to Mar 13, 2023), 5532 patients were surveyed at 63 health centres, 60 pharmacies, and 41 informal vendors. Post-intervention (Nov 6, 2023 to Apr 3, 2024), 4898 patients were surveyed. A total of 1092 simulated patient visits were completed across both periods. Weighted prevalence of Watch-antibiotic use decreased from 26·8% (95%CI 8·8-44·8) to 17·1% (95%CI 7·7-26·5) with a prevalence ratio (PR) of 0·29 (95%CI 0·10-0·82). Use of any systemic antibiotics decreased from 56·2 (95%CI 35·9-76·5) to 37·5% (95%CI 28·3-46·7), PR 0·48 (95%CI 0·26-0·88). At intervention health centres, patient management scores increased by 1·5 points (95%CI -0·77-3·68), at informal vendors by 0·29 points (95%CI -0·21-0·78).
Interpretation
The low-cost behavioural intervention bundle more than halved Watch and overall antibiotic use and did not negatively impact patient management, highlighting the potential of antibiotic use improvements across healthcare providers.