De-implementation of unnecessary antibiotic use for upper respiratory tract infections in ambulatory HIV care in Mozambique: a two-arm parallel cluster-randomized controlled hybrid type II trial

BACKGROUND: Antibiotics are commonly overused to treat upper respiratory tract infections (URTIs) in HIV-infected adults in primary healthcare settings, even though viruses cause most URTIs. Therefore, a de-implementation of unnecessary antibiotic prescribing for URTIs was implemented in these settings. Thus, this study aimed to evaluate a strategy to de-implement unnecessary antibiotic prescriptions among ambulatory HIV-infected adults with acute URTI symptoms using the reach-effectiveness-adoption-implementation-maintenance (RE-AIM) framework. METHODS: de Maio, Bagamoyo, and Matola-2, whilst Alto Maé, Hulene, and Ndlavela as control) in Mozambique. Quantitative data were collected from June to September 2024, while qualitative data were collected from October to December 2024. The intervention included a clinical decision support algorithm (CDSA), training and supervision of clinicians, and prescription audits. The intervention was evaluated using four dimensions of the RE-AIM framework: reach, effectiveness, adoption, and implementation. We used Pearson's chi-square test and relative risk to assess the effect of the intervention. RESULTS: Among 387 HIV-infected adults approached, 379 (97.9%) were successfully recruited, with 182 (48%) in the intervention and 197 (52%) in the control group. Among the recruited patients, the mean age was 44 ± 12.3 years, and 286 (75.5%) were female. The intervention resulted in 33.2% fewer antibiotics prescribed compared to controls (RR = 0.41; 95% CI: 0.31-0.55). The antibiotic prescribing rate was 23.1% in the intervention and 56.3% in the control group. All three intervention sites (100%) and all clinicians (100%) demonstrated a commitment to de-implementing antibiotics. The implementation protocol was delivered as planned. Almost all participants (n = 21) in focus group discussions (FGD) were either satisfied or very satisfied with the intervention. They reported the effectiveness of the CDSA and the change in attitudes and antibiotic prescribing practices. CONCLUSIONS: Based on the RE-AIM evaluation, the implementation of the planned intervention was successful as it effectively promoted de-implementation and reduced unnecessary antibiotics for URTIs. The strategy employed in this study should be evaluated in other areas to determine if the same findings are observed elsewhere. TRIAL REGISTRATION: ISRCTN, ISRCTN88272350. Registered 16 May 2024, https://www.isrctn.com/ISRCTN88272350.