OBJECTIVES:The burden of extended-spectrum β-lactamase-producing Enterobacterales (ESBL-E) is increasing globally and is often linked to community-acquisition in low-resource settings. In sub-Saharan Africa, occurrence of antimicrobial resistance (AMR) in rural areas remains understudied despite anticipated higher risks. We investigated the epidemiology and genetic characteristics of ESBL-E in rural Burkina Faso. METHODS:In a community-based cross-sectional survey (May 2021 to May 2022), participants were randomly selected in two health catchment areas, and through face-to-face interviews, field workers collected data on hygiene, animal presence, household characteristics, and healthcare use. Stool samples were also collected for ESBL-E screening. Prevalence of extended-spectrum β-lactamase-producing Escherichia coli (ESBL-EC) and extended-spectrum β-lactamase-producing Klebsiella pneumoniae (ESBL-KP) was estimated, and associated factors were assessed. Based on resistance profiles and PCR screening, selected isolates underwent whole genome sequencing. RESULTS:Among 1482 participants, ESBL-E prevalence was 61.3% (58.8-63.7%); ESBL-EC prevalence was 53.0% (50.5-55.5%), and ESBL-KP prevalence was 22.3% (20.3-24.5%). Colonization was more common in the rainy season than in the dry season (70.2% vs. 53.6%, p < 0.001) and among individuals not washing hands with soap before meals (62.5% vs. 49.0%, p < 0.001). Ciprofloxacin resistance exceeded 65% in both species. The predominant extended-spectrum β-lactamase gene was blaCTX-M-15 (47.3% in ESBL-EC and 19.9% in ESBL-KP), with one ESBL-EC isolate carrying blaNDM-5. Incompatibility group F (IncF) plasmids predominated, and plasmid-mediated quinolone resistance genes (qnr, aac(6')-ib-cr and oqxAB) were frequently codetected with extended-spectrum β-lactamase genes. CONCLUSIONS:ESBL-E prevalence was high and was associated with poor hygiene and seasonal variation. Higher rainy season prevalence was not explained by reported antibiotic use and may reflect increased environmental exposure risks, which requires further exploration. Improving hygiene standards and establishing community-level AMR surveillance can provide effective steps toward mitigating AMR burden in rural sub-Saharan Africa.

Background In rural sub-Saharan Africa (sSA), the burden of antimicrobial resistance (AMR) remains high. As AMR continues to rise, there is a strong need for practical, implementable surveillance to monitor and mitigate risks, as well as inform timely, evidence-based clinical decision-making. Emerging evidence points to possible community-level drivers, such as transmission between human, animal and environmental reservoirs as contributing factors, yet microbiological surveillance or opportunities for wastewater-based surveillance are often limited and insufficient in these settings. Therefore, alternative sustainable and affordable approaches are needed. We intend to build on the demonstrated potential of metagenomic profiling of pooled faecal material, which accurately predicted population-level AMR prevalence in invasive Enterobacterales infections.Methods and analysis We aim to validate this metagenomic pooled approach on additional populations, and to evaluate whether AMR patterns could be similarly predicted from surveillance of community One Health reservoirs. We will assemble existing data from hospital-based microbiology diagnostic laboratories in rural Burkina Faso and Kenya, and determine to what extent community-level metagenomic data, and/or faecal material of patients on hospital admission, can predict AMR in clinical isolates. We will perform community-level surveys in eight clusters per country, randomly selecting 15 households per cluster. We will systematically sample suspected environmental AMR exposure sites in and around households (soil, drinking water, latrines, chicken faeces) and collect data on community-level antibiotic use, hygiene practices, contact with domestic animals and sanitary facilities. Samples and data will be collected twice: during the dry and during the rainy season.In addition to evaluating the accuracy of predicting resistance in clinical isolates, we will quantify community-level exposure risks. We will conduct metagenomic profiling on pooled DNA extracts from human stool samples (hospital and community-level) and from household environments. Bayesian statistical models will quantify relationships between AMR gene abundance in the environment and in human stool, and invasive bacteria identified among clinical patients, accounting for geography and seasonality. A cost-utility analysis will determine under what circumstances the use of pooled metagenomic data to inform empirical antibiotic policies would represent an efficient use of resources.Ethics and dissemination The proposed surveillance protocol is developed in partnership with local communities and local and international researchers and has received ethical approval in Kenya and Burkina Faso. It will assess whether intermittent, pooled-sample metagenomics provides a viable, low-cost and practical approach for population-level AMR surveillance in settings that—like many in rural sSA—lack systematic microbiological diagnostics and where sewage systems for wastewater-based surveillance are absent. By providing an alternative to routine microbiological-based surveillance where this proves challenging to implement, this approach may help improve treatment outcomes, contribute to equity and public health. Findings will be disseminated through peer-reviewed publications and academic conferences and will contribute to the recently proposed WHO AMR surveillance strategy, which combines survey-based approaches with routine AMR surveillance.

Antimicrobial resistance (AMR) represents an important public health challenge worldwide. Given the significant and interdependent human, animal and environmental dimensions of this resistance, a ‘One Health’ approach is necessary to combat it. However, its extent remains poorly known and understood in resource-limited settings. This study aims to describe the current prevalence of antibiotic resistance and extended-spectrum β-lactamase (ESBL)-producing Enterobacterales species according to One Health approach in Burkina Faso. PubMed, Hinari, African Journal Online, Scopus and Google Scholar were the bibliographic databases used for screening of the relevant articles according to the reporting elements for systematic reviews and meta-analyses (PRISMA). The meta-analysis was performed using the statistical analysis R software version 4.2.3 (2023). A total of 24 research articles were included in this systematic review and meta-analysis. E. coli, Klebsiella spp., Enterobacter spp. and Salmonella spp. were the most frequently reported bacteria from at least two sources. The environment had the highest rate of ESBL-producing Enterobacterales (60.01

BACKGROUND:Increasing Watch-group antibiotic use might be contributing to antimicrobial resistance burden in sub-Saharan Africa. We evaluated the effects of a community-based, co-created intervention bundle targeting all community-level health-care providers and the communities they serve on Watch-group antibiotic use and patient management. METHODS:In a cluster-randomised, controlled trial in Nanoro, Burkina Faso, and Kimpese, DR Congo, villages or neighbourhoods with at least 500 inhabitants and at least one community-level or primary-care provider functioning as the main medicine dispenser for the population were randomly allocated (1:1) to intervention or control groups, using the RAND function in Excel. Over 9 months, three intervention rounds consisted of community health education campaigns and educational and feedback sessions with providers, introducing WHO AWaRe (Access, Watch, Reserve) Antibiotic Book guidance for infections with highest antibiotic use. We measured baseline-to-post-intervention changes in Watch-group antibiotic use through repeated patient surveys (100 per provider per village), cluster-adjusted and offset for health-care utilisation (primary outcome), and patient management scores for five common, well defined infections through simulated patient visits (secondary outcome). Providers with fewer than 20 completed surveys at baseline or post-intervention were excluded. Field workers conducting patient surveys and simulated patient visits were masked to group assignment. CABU-EICO was registered on ClinicalTrials.gov (NCT05378880). FINDINGS:44 villages or neighbourhoods (22 each in Nanoro and Kimpese) were enrolled and randomly assigned to intervention (11 each in Nanoro and Kimpese) or control (11 each in Nanoro and Kimpese) groups. At baseline (Oct 26, 2022, to March 13, 2023), 5532 patients were surveyed (3558 in Nanoro and 1974 in Kimpese). Post-intervention (Nov 6, 2023, to April 3, 2024), 4898 patients (3180 in Nanoro and 1718 in Kimpese) were surveyed. Patients were surveyed at 32 health centres (18 intervention and 14 control), 31 private clinics (15 intervention and 16 control), 45 pharmacies (25 intervention and 20 control), and 41 informal vendors (22 intervention and 19 control). A total of 1092 simulated patient visits were completed across both periods. The weighted prevalence of Watch-group antibiotic use decreased from 26·8% (95% CI 8·8-44·8) to 17·1% (7·7-26·5) in the intervention group and increased from 13·4% (4·8-22·0) to 21·2% (8·9-33·5) in the control group; the adjusted prevalence ratio for use of Watch-group antibiotics was 0·33 (95% CI 0·14-0·78). Changes in patient management scores were minimal. INTERPRETATION:The behavioural intervention bundle was associated with a substantial reduction in Watch-group antibiotic use and no negative effect on patient management, highlighting the potential of antibiotic use improvements across health-care providers. Reduced community-level use of broad-spectrum antibiotics could help slow community-acquired pathogens' increasing resistance to clinically important antibiotics. FUNDING:The Joint Programming Initiative on Antimicrobial Resistance Research and Research Foundation-Flanders. TRANSLATIONS:For the French translation of the abstract see Supplementary Materials section.

OBJECTIVE:To evaluate the field accuracy of a malaria diagnostic algorithm combining sequential interpretation of two-step malaria RDT detecting PfHRP2 and pLDH with information on previous antimalarial treatments within the past four weeks for the diagnosis of malaria in febrile children under 5 years compared to standard diagnosis using a PfHRP2 only based RDT. METHODS:Febrile children aged 6-59 months attending outpatient clinics were randomized to either the control group, which received the standard RDT (PfHRP2 only), or the intervention groups (an e-algorithm or a decisional algorithm), which was subjected to the diagnostic algorithm combining an RDT detecting PfHRP2 and pLDH with information on previous antimalarial treatment. Malaria diagnosis with PfHRP2-based RDT was reported as positive or negative. The sequential interpretation was reported as (i) positive when the pLDH line appeared, regardless of the PfHRP2 results, (ii) negative when both lines did not appear and (iii) undetermined when only the PfHRP2 line appeared, and information on previous antimalarial treatment within the past 4 weeks was used as a decision-support tool to classify active malaria from past infection. Blood samples were also collected for expert microscopy as the gold standard, and for qPCR to further evaluate undeterminate results and potential false-positive RDT outcomes. RESULTS:In total 1176 children were included, with 66.7% (784/1176) assigned to the intervention arms and 33.3% (392/1176) to the control arm. In patients assigned to the sequential algorithm, the number of undetermined cases was 12.7% (100/784). Considering microscopy as the gold standard, PfHRP2-based RDT reported a sensitivity of 96.5% and a of specificity 79.1%, with positive and negative predictive values of 78.3% and 96.7%, respectively. For the sequential algorithm, the sensitivity, specificity, positive and negative predictive values of the conclusive-only results (i.e., PfHRP2±/pLDH+ and PfHRP2-/pLDH-) were 97.4%, 98.4%, 98.0% and 97.9%. However, when undetermined result were combined with conclusive results, the sensitivity, specificity, positive and negative predictive values were 89.7%, 96.8%, 95.6% and 92.4% respectively. Among recently antimalarial treated participants in sequential algorithm arm, 59.5% (50/84) were qPCR-positive, compared to 68.7% (11/16) qPCR-positivity in those without recent treatment. CONCLUSIONS:The sequential diagnostic approach improves the diagnosis of malaria in a real world setting, compared to the use of PfHRP2-(only) based RDT. However, relying only on history of antimalarial treatment in undetermined cases may decrease algorithm's sensitivity, which could result in missing active or recurrent malaria infections.

Food-borne diseases affect nearly 10% of the global population annually, with Salmonella being a major cause, particularly impacting children, the elderly, and populations in low- and middle-income countries. This study aimed to assess the prevalence, serotype distribution, antibiotic resistance profiles, and genetic determinants of resistance and virulence of Salmonella enterica in humans and poultry in the Nanoro health district. A community-based cross-sectional study involving humans and poultry was conducted in the Nanoro health district. Fresh stool samples (human and poultry cloacal/cecal) were collected, transported under sterile conditions, and processed within two hours using standard bacteriological methods. Phenotypic antibiotic resistance was determined by the Kirby–Bauer disk diffusion method, and whole-genome sequencing (Illumina) identified serotypes, resistance genes, and virulence factors. Logistic regression analyzed associations between Salmonella carriage and host or environmental factors. Salmonella enterica carriage was detected in 8.7% of humans and 7.2% of poultry. Human isolates showed 24% resistance to cephalosporins, while poultry isolates showed 36.8% resistance. Resistance genes, including fosA7, qnrB19, and a cryptic aminoglycoside resistance gene, and virulence genes encoding T3SS-1 and T3SS-2, were detected in both hosts. Logistic regression indicated that residence in Sitaon and Zimidin was associated with ~70% lower odds of carriage (aOR = 0.3), while individuals aged 11–20 and 51–60 years had 2.8-fold higher odds. Carriage was also 60% higher during the rainy season. These findings suggest possible cross-transmission of Salmonella between humans and poultry and the circulation of resistant, potentially virulent strains in the community. Seasonal and age-related variations highlight environmental and behavioral influences on asymptomatic carriage. Integrated One Health surveillance and targeted hygiene interventions are essential to reduce Salmonella transmission and antimicrobial resistance in rural settings.

BACKGROUND:In sub-Saharan Africa, invasive antimicrobial-resistant infections often originate from community-level acquisition. In this study, we aimed to evaluate the effect of a cluster-level intervention on individual-level extended spectrum β-lactamase-producing Escherichia coli (ESBL-E) acquisition. We assessed whether a behavioural intervention bundle targeting suboptimal antibiotic use and hygiene practices reduced household-level acquisition of ESBL-E. METHODS:We conducted a cluster-randomised controlled trial in 22 village clusters in Nanoro district, Burkina Faso. We enrolled 12 randomly selected households per cluster to assess the intervention effect on ESBL-E household transmission. The intervention comprised three rounds delivered at 3-month intervals and combined WHO Access, Watch, Reserve-based educational and feedback sessions for formal and informal medicine providers with community health education campaigns. Consenting household members provided stool samples before, during, and after intervention rollout, alongside a pre-post household water, sanitation, and hygiene (WASH) survey. ESBL-E acquisition was defined as a transition from a negative to a positive stool sample between consecutive sampling visits, with transition hazards estimated using continuous-time Markov models. We estimated intervention effects on ESBL-E acquisition using Bayesian Markov models. Cox frailty models assessed associations between WASH exposures and acquisition. The study is registered with ClinicalTrials.gov (NCT05378880). FINDINGS:1203 individuals were enrolled between Oct 11, 2022, and Feb 19, 2024. At baseline, 346 (57%) of 604 individuals in the control household group and 291 (49%) of 599 individuals in the intervention household group tested positive for ESBL-E colonisation. Pre-intervention acquisition incidence rates were 3·8 per 100 person-days (95% credible interval [CrI] 2·0-9·9) in the intervention group and 3·5 per 100 person-days (95% CrI 1·8-9·6) in the control group. The intervention did not change the risk of ESBL-E acquisition in months 1-6 (hazard ratio [HR] 1·02 [95% CrI 0·78-1·31]) but was associated with a reduction in months 6-9 (HR 0·82 [95% CrI 0·56-1·14], probability of a reduction p[HR<1]=0·88). Acquisition risk was higher in the rainy season (peak HR 1·73 [95% CI 1·49-2·00]), whereas improved sanitation was associated with lower risk (HR 0·77 [95% CI 0·59-1·00]). INTERPRETATION:Findings, although inconclusive, were consistent with a modest intervention-related reduction in ESBL-E acquisition incidence. Higher acquisition rates associated with rainy seasons and poor sanitation highlight the need to tackle environmental drivers of antimicrobial resistance transmission in addition to antibiotic use in rural sub-Saharan Africa. FUNDING:EU Joint Programme Initiative on Antimicrobial Resistance CABU-EICO.

Background: In sub-Saharan Africa (sSA), invasive antimicrobial-resistant infections often originate from community-level acquisition. We assessed whether a behavioural intervention bundle targeting sub-optimal antibiotic use and hygiene practices reduced household-level acquisition of extended-spectrum beta-lactamase-producing E. coli (ESBL-E). Methods: We conducted a cluster-randomised controlled trial in 22 village clusters in Nanoro district, Burkina Faso. We enrolled 12 randomly selected households per cluster to assess intervention impact on ESBL-E household-transmission. The intervention comprised three rounds at three-month intervals and combined WHO AWaRe-based educational feedback for formal and informal medicine providers with a community-wide WASH and antibiotic-use behaviour change campaign. Consenting household members provided stool samples before, during, and after intervention rollout, alongside a pre-post household WASH survey. We estimated intervention effects on ESBL-E acquisition using Bayesian Markov models. Cox frailty models assessed associations between WASH exposures and acquisition. ClinicalTrials.gov, [NCT05378880][1]. Findings: Between Oct 11, 2022, and Feb 19, 2024, 1203 individuals were enrolled. At baseline, 56.6% (342/604) of control and 47.2% (283/599) of intervention household members were colonised. Pre-intervention acquisition incidence was 3.8 per 100 person-days (95% credible interval [CrI] 2.0-9.9) in the intervention group and 3.5 (95% CrI 1.8-9.6) in the control group. The intervention did not change the risk of ESBL-E acquisition in months 1-6 (hazard ratio [HR] 1.02, 95% CrI 0.78-1.31), while we estimated a reduction in ESBL-E acquisition from months 6-9 (HR 0.82, 95% CrI 0.56-1.14). Acquisition risk was higher in the rainy season (peak HR 1.73, 95% CI 1.49-2.00), while improved sanitation was associated with lower risk (HR 0.77, 95% CI 0.59-1.00). Interpretation: Findings, though inconclusive, were consistent with a modest intervention-related reduction in ESBL-E incidence. Higher acquisition rates associated with the rainy season and poor sanitation highlight the need to tackle environmental drivers of AMR transmission in addition to antibiotic use in rural sSA. ### Competing Interest Statement The authors have declared no competing interest. ### Clinical Trial NCT05378880 ### Clinical Protocols ### Funding Statement The study was funded under the EU Joint Programme Initiative AMR (JPIAMR2021-053) with member state co-funding by the Belgium FWO, the British UKRI, the French ANR, and the Swedish SIDA. A framework agreement between ITM, CRUN and CRSK is financially supported by the Belgian Development Cooperation. The funders had no access to the data, nor had influence on the design, execution, analysis, or writing of the study report. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The study protocol was approved by the Ethics Committee for Health Research of Burkina Faso (reference No. 2022-03-050) and obtained from the Institutional Review Board of the Institute of Tropical Medicine, Antwerp, Belgium (1559/22, dd 29/03/2022), and from the Ethics Committee of the Antwerp University Hospital, Belgium (3363, dd 09052022). I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data produced are available online at https://github.com/RaneemAizouk/CABU-EICO/tree/main/Scripts [1]: /lookup/external-ref?link_type=CLINTRIALGOV&access_num=NCT05378880&atom=%2Fmedrxiv%2Fearly%2F2025%2F12%2F17%2F2025.12.15.25342269.atom

Background Limited AMR awareness, limited diagnostic capacity, and frequent self-medication contribute to incorrect antibiotic use in LMIC. We evaluated a community-based intervention to improve antibiotic use, targeting all community-level healthcare providers and communities. Methods In a cluster-randomised, controlled trial in 44 villages, we measured intervention effect on antibiotic use through repeated patient surveys. Simulated patient visits, mimicking common infections, monitored patient management. In 22 randomised villages, three rounds of intervention activities (health education campaign, educational/feedback sessions) were implemented during nine months. Provider interventions focused on infections with highest antibiotic use, introducing WHO AWaRe Book guidance. Main outcomes were the change in Watch antibiotic-use and in patient management score. Per provider type per village, 100 patient surveys and five simulated patient visits were repeated at baseline and post-intervention. We estimated healthcare utilisation-adjusted prevalence ratios (PR) of (Watch) antibiotic use and difference-in-difference of patient management scores. CABU-EICO was registered on clinicaltrials.gov/study/[NCT05378880][1]. Findings At baseline, 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. 546 simulated patient visits were repeatedly completed. 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; PR 0.29, 95%CI 0.10-0.82). Any systemic antibiotic use 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). Patient management scores were higher at health centres (mean 6.6, 95%CI 5.7-7.4) and medicine stores (6.3, 95%CI 5.5-7.0) than at informal medicine vendors (mean 0.1, 95%CI -0.1-0.3). At intervention health centres, patient management increased by 1.5 point (95%CI-0.77-3.68), at informal vendors by 0.29 point (95%CI-0.21-0.78). Interpretation The behavioural intervention bundle more than halved Watch and overall antibiotic use, while suggesting a modest improvement in patient management in primary care and little or no changes at medicine stores. Funding JPI-AMR, Research Foundation-Flanders ### Competing Interest Statement The authors have declared no competing interest. ### Clinical Trial NCT05378880 ### Clinical Protocols ### Funding Statement The study was funded under the EU Joint Programme Initiative AMR (grant JPIAMR2021053) with member state co-funding by the Research Foundation Flanders (FWO) and the Swedish SIDA. A framework agreement between Institute of Tropical Medicine, Clinical Research Unit of Nanoro and Centre de Recherche en Sante de Kimpese is financially supported by the Belgium Development Cooperation. BI is supported by a postdoctoral fellowship from the FWO (grant number 12A1Z25N). ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Universite Protestante au Congo Ethics Committee (ref. CEUPC0098), Burkina Faso Ethics Committee for Health Research (ref. 2022-03-050), and Antwerp University Hospital Ethics Committee (ref. 3456 and 3363) I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Questionnaires, informed consent forms, pseudonymized datasets, data dictionaries, and data analysis scripts in R are available on a Github repository [1]: /lookup/external-ref?link_type=CLINTRIALGOV&access_num=NCT05378880&atom=%2Fmedrxiv%2Fearly%2F2025%2F12%2F18%2F2025.12.15.25342146.atom

OBJECTIVES:This study aimed to understand the knowledge possessed by informal medicine vendors regarding antibiotics and antibiotic resistance, identify the perceptions held by informal medicine vendors about antibiotics and their uses and examine the practices employed by informal medicine vendors in the sale and distribution of antibiotics. DESIGN:Exploratory qualitative study using semi-structured interviews and direct observations. SETTING:Markets and shops across 11 villages in the Nanoro health district, Burkina Faso. PARTICIPANTS:23 informal medicine vendors, aged between 25 and 55 years and with 8-30 years of experience, were recruited through snowball sampling in the Nanoro health district of Burkina Faso. RESULTS:Informal medicine vendors exhibited a limited understanding of antibiotics, often confusing them with other treatments and referring to them using local terminologies based on perceived use and effectiveness. Antibiotics were perceived as universal remedies, supported by therapeutic belief, empirical reasoning and community solidarity, with empirical diagnosis, approximate dosing and informal preparation techniques passed on through imitation. These findings emerged across themes including perceptions, symbolic attributes and sales practices. CONCLUSION:Informal medicine vendors in rural Burkina Faso demonstrated limited understanding of antibiotics and antimicrobial resistance, with practices shaped by local beliefs and empirical experience. These findings underscore the need for context-sensitive interventions that include tailored education and regulatory engagement to improve antibiotic stewardship and mitigate the spread of resistance.

Background In sub-Saharan Africa, health systems face challenges in reducing the burden of infectious diseases due to the limited availability of qualified human resources in remote areas. Digital clinical decision support implemented to address this issue failed due to the lack of point-of-care (PoC) tests to guide the clinical decision. In this paper, we describe the development of a target product profile (TPP) integrating clinical information and PoC tests, for the management of febrile diseases in children under 5 years. Methods Based on the integrated management of childhood illness (IMCI) guideline, which is implemented in Burkina Faso, a simplified decision tree has been established, digitalized on electronical support for non-clinicians use in our study area, to guide the management of febrile illness. The list of PoC test has been defined based on local epidemiology data. The TPP has been developed by a panel of health professionals involved in the daily management of children under 5 years, and was designed to be compatible with Android. End-users and beneficiaries have been involved as the co-designers at the last stage of the development to guarantee that the final TPP meets their needs. Results Beneficiary and end-users gave positive feedback on the final TPP's design, user-friendliness, and clinical information collection. They appreciated the ease of navigation but noted the lack of possibility to specify the diagnostic for non-bacterial and non-viral infections for e-Algorithm and suggested an open list of final diagnostic. The e-algorithm development panel suggested keeping diagnostic lists limited, but offered the possibility of concomitant treatments information following by justification. They have also positively appreciated the RDT-decisional algorithm for the management of febrile children. Conclusion The algorithm proposed appears to be very promising. However, it is important to ensure that the TPP operates properly in real condition and could improve the management of febrile diseases in children under 5 years.

IntroductionAccurate diagnosis of malaria, caused by Plasmodium falciparum, remains challenging in endemic resource-limited settings. Molecular diagnostics, like PCR, offer a higher sensitivity, but are often impractical at the point-of-care. A relatively simple molecular diagnostic test has been developed to overcome the technological challenges frequently encountered during the implementation of molecular tools. We present here the results of the field evaluation of this novel mini direct-on-blood PCR platform with lateral flow readout (dbPCR-NALFIA), in a rural setting of Burkina Faso.MethodsA phase 3 diagnostic accuracy study was conducted over one year in a high P. falciparum transmission setting in Burkina Faso. Febrile patients of all ages (n = 438) were screened using PfHRP2-based RDT, microscopy, and the investigational dbPCR-NALFIA test. Reference diagnostic test was qPCR targeting the P. falciparum varATS gene. Diagnostic accuracy metrics (sensitivity, specificity, predictive values) and agreement (Cohen's kappa) were calculated for each method.ResultsMalaria prevalence by qPCR was 65.5% (287/438). A total of 99.2% (259/261) of P. falciparum microscopy-positive samples were detected by qPCR, 97.7% (253/259) detected with RDT and 99.6% (258/259) with the investigational dbPCR-NALFIA. Overall, 85.2% (149/177) of microscopy negative samples were also confirmed negative with qPCR. Among these qPCR negative samples, 80.5% (120/149) were concordantly negative by RDT, while 98.0% (146/149) were confirmed negative by dbPCR-NALFIA. Using qPCR as reference, the dbPCR-NALFIA demonstrated a sensitivity of 96.5% and specificity of 98.0%, comparable to RDT sensitivity (95.1%) and microscopy specificity (98.7%), but out-performed RDT specificity (80.8%) and microscopy sensitivity (90.2%). dbPCR-NALFIA detected 67.9% of sub microscopic qPCR-positive samples missed by the microscopy. Agreement with qPCR was the highest for dbPCR-NALFIA (kappa value = 0.90), compared to microscopy (kappa value = 0.80) and RDT (kappa value = 0.71).ConclusionThe dbPCR-NALFIA shows excellent diagnostic performance to detect P. falciparum under field conditions. It addresses key limitations of other diagnostics and could play a vital role in case detection.

To assess the impact of an intervention package on the prescription of antibiotic and subsequently the rate of clinical recovery for non-severe acute febrile illnesses at primary health centers. Patients over 6 months of age presenting to primary health care centres with fever or history of fever within the past 7 days were randomized to receive either the intervention package constituted of point-of-care tests including COVID-19 antigen tests, a diagnostic algorithm and training and communication packages, or the standard practice. The primary outcomes were antibiotic prescriptions at Day 0 (D0) and the clinical recovery at Day 7 (D7). Secondary outcomes were non-adherence of participants and parents/caregivers to prescriptions, health workers’ non-adherence to the algorithm, and the safety of the intervention. A total of 1098 patients were enrolled. 551 (50.2

BACKGROUND:To guide antibiotic stewardship interventions, understanding for what indications antibiotics are used is essential. METHODS:In rural Burkina Faso, we measured antibiotic dispensing across all healthcare providers. From October 2021 to February 2022, we surveyed patients in Nanoro district, Burkina Faso, following visits to health centres (3), pharmacies (2), informal medicine vendors (5) and inpatients in health centres. We estimated prevalence of antibiotic use and the proportion of Watch group antibiotics by provider type and by clinical presentation, assessing compliance with WHO's AWaRe Antibiotic Book. We estimated per capita antibiotic use by multiplying prevalence of antibiotic use, mean DDD per adult treatment course, and the rate of healthcare visits per 1000 inhabitants per day, estimated from a prior household survey. RESULTS:Outpatient antibiotic use was more frequent after health centre visits (54.8%, of which 16.5% Watch, n = 1249) than after visits to pharmacies (26.2%, 16.3% Watch, n = 328) and informal medicine vendors (26.9%, 50.0% Watch, n = 349). The frequency of antibiotic use was highest for bronchitis (79.9% antibiotic use, of which 12.6% Watch), malaria (31.9%, 23.1% Watch), gastroenteritis (76.0%, 31.7% Watch), rhinopharyngitis (40.4%, 8.3% Watch) and undifferentiated fever (77.0%, 44.8% Watch). Compliance with WHO AWaRe guidance could have averted at least 68.4% of all Watch antibiotic use in outpatients at health centres. Community-wide, 2.9 DDD (95% CI 1.9-3.9) were used per 1000 adult inhabitants per day. CONCLUSIONS:Most Watch antibiotic use at community level or primary care deviated from WHO guidance. Antibiotic stewardship should focus on key clinical presentations and include primary care and self-medication.

Background In low and middle incomes countries such as sub-Saharan Africa, the management of febrile diseases remains challenging given the lack of practical diagnostic tools to screen the real cause of fever and the limits of malaria rapid diagnostic tests. In order to improve the management of febrile diseases in children under 5 years, this study has been conducted. Methods The study was conducted at the Field Station of Sigle, set-up by the Clinical Research Unit of Nanoro. All patients from 6–59 months attending the outpatient clinic of the health facility of Bologho in the health district of Nanoro, with documented fever or history of fever within the pass 7 days were invited to participate to the study. Participants were randomized either the intervention package (e-Algorithm or RDT-decisional algorithm arm(RDT-DA)) or routine system. The intervention package was constituted by the following PoC tests: two-step malaria RDT detection PfHRP2 and pLDH, CRP, white blood cells (WBC) count, oximetry, Group A Streptococcus, and Salmonella/Shigella. Results Antimalarial prescription was 42.05% (164/390) in e-Algorithm arm, 43.65% (172/394) in RDT-DA and 52.30% (232/392) in standard practice system [risk difference (RD): -10.25% (p p<0.001) for e-Algorithm and -8.65% (p<0.001) for RDT-DA). Antibiotics were prescribed in 46.92% (183/390) in e-Algorithm arm, 50.25% (198/394) in RDT-DA arm and 76.28% (299/392) in routine system [RD: -29.36% (p<0.001) for e-Algorithm and -26.03% (p<0.001) for RDT-DA]. The reduction of antibiotic prescription greater in children without malaria [RD:-64.79% (p<0.001) for e-Algorithm arm and -61.62% (p<0.001) for RDT-DA algorithm arm]. Conclusion Implementation of two-step malaria RDT and PoC tests for bacterial infections has potential to improve the management of febrile diseases in children under 5 years and reduce inappropriate prescription of antibiotics. Nevertheless, the use of CRP test is not suitable differentiate bacterial to non-bacterial infections in children with malaria.

We welcome the WHO AWaRe (Access/Watch/Reserve) Antibiotic Book, released on Dec 9, 2022. Sharland and colleagues1 proposed two antibiotic use targets that could support its introduction and the evaluation of its effectiveness, as follows: 90% of infections requiring an antibiotic in primary health care can be treated with oral Access antibiotics rather than broad spectrum Watch antibiotics and more than 50% of minor infections can be treated without antibiotics. In low-income and middle-income countries, use of Watch antibiotics has been rapidly increasing,2 yet after careful clinical evaluation, three-quarters of Watch antibiotics could be discontinued or replaced by Access antibiotics.

Optimising antibiotic use is important to limit increasing antibiotic resistance. In rural Burkina Faso, over‐the‐counter dispensing of antibiotics in community pharmacies and non‐licensed medicine retail outlets facilitates self‐medication. We investigated its extent, reasons and dispensing patterns.

We introduce the Antimicrobial Resistance Diagnostic Use Accelerator program, and the articles in this Supplement, which cover the program in 3 sub-Saharan Africa countries.