The impact of interventions to modify antibiotic use in children with suspected infections in ambulatory healthcare settings in LMICs: a systematic review.

Background and objectives: Antimicrobial resistance (AMR) is a growing threat to child health in low- and middle-income countries (LMICs), where inadequate antibiotic access frequently causes morbidity and mortality. We sought to identify effective interventions to optimize antibiotic use in children with suspected infections in LMIC ambulatory healthcare settings. Methods: MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Infectious Disease Group Specialized Register, Web of Science, PsycInfo, WHO library database (WHOLIS) and regional databases (inception until 16 December 2024) were searched to identify studies of interventions to optimize antibiotic use in children in LMIC peripheral healthcare settings. Results: Our search identified 7154 articles post de-duplication; 23 studies met the inclusion and Integrated quality Criteria for the Review of Multiple Study designs (ICROMS) assessment criteria. Seventeen were randomized trials, conducted in five LMICs, four upper-middle income countries (UMICs) and two low-income countries (LICs). Single-intervention studies investigated electronic algorithms ( Conclusions: Initial evidence suggests that algorithmic decision-support tools combined with point-of-care diagnostics and provider education can reduce antibiotic prescribing in children attending ambulatory healthcare settings in LMICs, with most studies demonstrating no compromise of clinical outcomes. However, few studies assessed prescription appropriateness or microbiological outcomes, limiting conclusions about long-term impact. Future interventions should prioritize context-adaptable strategies that incorporate rapid diagnostics, evaluate clinical and appropriateness outcomes, and consider implementation feasibility across diverse LMIC settings.