The overuse of antibiotics has contributed to antimicrobial resistance, which stands at 30 percent, according to Rwanda Biomedical Centre (RBC).

Antimicrobial resistance (AMR) occurs when germs such as bacteria, viruses, and fungi develop the ability to withstand drugs designed to kill them, including antibiotics.

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To address this growing global threat, a digital clinical decision support tool being tested in Rwanda’s primary healthcare system is showing promising results. The tool has reduced the overuse of antibiotics among children by 46 percent.

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Dr. Jean-Claude Semuto who leads scientific innovation at RBC said the tool, known as ePOCT+, was developed to help healthcare providers make more accurate treatment decisions for children presenting with infectious diseases at health centres.

He explained that primary healthcare facilities in Rwanda, like many across sub-Saharan Africa, often operate with limited diagnostic capacity. This makes it difficult to distinguish between viral and bacterial infections, especially in young patients, leading to frequent precautionary antibiotic prescriptions.

He said: "Children under the age of 15 are especially affected, as infectious diseases are common during childhood. Without adequate diagnostic tools, clinicians may rely on limited information when making treatment decisions. The digital tool was designed to address that gap.

"The system comes in to see how we can reduce antibiotic use among children under 15 by helping clinicians follow treatment guidelines.”

Semuto said that although treatment guidelines are in place, it can be difficult for healthcare providers to keep up with updates and apply them consistently, especially at primary healthcare level. He explained that ePOCT+ functions as a step-by-step digital guide during patient consultations. When a child arrives at a health facility, the healthcare provider enters information into a tablet-based application, which prompts the appropriate questions and examinations based on the symptoms presented.

As the consultation progresses, the application guides the provider through a structured assessment, ensuring key signs and symptoms are evaluated. It can also recommend laboratory tests or additional assessments when necessary.

Once tests are conducted, the results are entered into the system. During follow-up, the application analyses all collected information, including clinical signs, symptoms, and laboratory results, and suggests treatment options based on established medical guidelines and expert input.

"The decision on which treatment to use is suggested by the application, but the clinician still has the ability to consider or ignore it depending on the specific case,” Semuto said.

The recommendations are based on national treatment guidelines and input from paediatric specialists familiar with Rwanda’s healthcare system.

A nurse at Cyangugu Health Center, Jeanne Mukamana, said the tool has transformed how she treats children after using it for about three years.

"Before we started using the app, children with flu, cough, or tonsillitis were often given antibiotics unnecessarily. This contributed to antimicrobial resistance,” she said.

The application guides healthcare workers through each consultation, helping them make more accurate decisions.

"It asks questions which guide us in prescription. It helps in finding symptoms and suggests medication. In a month, we used to prescribe 2,000 courses of antibiotics, and 1,200 of those were given to children with anemia. Since we started using the app, that number has dropped by three-quarters,” the nurse said.

Mukamana added that record-keeping has improved, as patient details are now entered directly into the system instead of being written on paper. She also noted that the process is efficient, with consultations taking less than 30 minutes from start to finish.

Training was an important part of adopting the tool. Staff received guidance on how to use the application, which is available in both French and English.

According to Semuto, the tool was developed through a research project that lasted about five years, undergoing several iterations before reaching a final version suitable for field testing.

The study led by Semuto, Dr. Alexandra Kulinkina, an epidemiologist, and other researchers, was conducted in 32 health centres across Nyamasheke and Rusizi districts. Sixteen facilities continued providing routine care, while the other 16 used the digital tool.

"After a period of evaluation, the remaining facilities also adopted the application, allowing all participating centres to test the system. In total, nearly 60,000 consultations involving sick children aged 14 years and younger were included in the study,” he said.

Results showed that antibiotic prescription rates dropped from 71 percent in facilities providing standard care to 25 percent in those using ePOCT+. Despite the reduction, children recovered at similar rates in both groups, suggesting that fewer prescriptions did not compromise treatment outcomes.

The application also integrates simple diagnostic tests, such as measuring oxygen levels, haemoglobin, and markers of inflammation, to help clinicians determine whether antibiotics are necessary.

Semuto said that while the results are encouraging, the trial revealed challenges, including limited digital literacy among some healthcare providers, who initially struggled to use the tablet-based system. However, this improved after short training sessions.

"Another challenge was consultation time, because the tool requires thorough assessments aligned with treatment guidelines, consultations at first took longer. Over time, as clinicians became more familiar with the system, the process became faster.”

He noted that internet connectivity posed occasional difficulties. Although the system requires internet access to transmit data to a central server, it can function offline within health facilities, with data synchronised later when a connection is available.

The researcher added that the system was designed specifically for primary healthcare facilities and may not be suitable for higher-level hospitals handling more severe or complex cases.

"For now, the app is limited to the two districts where the study was conducted. However, efforts are underway to integrate its features into the country’s broader electronic medical records system so it can eventually be scaled nationally,” he said.

If expanded, researchers believe the approach could strengthen primary healthcare services, reduce referrals to hospitals, and help ease congestion and lower healthcare costs.

Richard Bishumba, the chairperson of AMR Initiative Rwanda, said the tool is a strong example of how digital health innovation can improve clinical decision-making and address antimicrobial resistance at the point of care.

Bishumba said reduction in unnecessary antibiotic prescriptions, without compromising patient outcomes, shows that tools like ePOCT+ can support more precise, evidence-based decisions, especially in resource-limited environments.

"I see this as a strong signal that combining technology, local clinical guidelines, and frontline training can help preserve the effectiveness of antibiotics,” Bishumba said.