Implementation and effectiveness of a smartphone app targeted at improving physicians adherence to antimicrobial treatment guidelines

The effectiveness of mHealth interventions for improving antimicrobial guideline adherence remains insufficiently understood in resource-limited settings. This study evaluated a context-adapted smartphone Standard Treatment Guideline (STG) app designed to improve physicians’ adherence to antimicrobial treatment guidelines in Ethiopia. A type 1 hybrid effectiveness–implementation cluster-randomized trial was conducted in 20 hospitals randomized to a smartphone app plus training or paper-based guidelines and retrospectively registered (PACTR202504495116733). The primary outcome was guideline-adherent prescribing, defined as correct antibiotic selection, dose, frequency, and duration when treatment was indicated, or appropriately documented non-prescribing when antibiotics were not indicated across 1433 patient charts. Secondary outcomes included overall antibiotic use and broad-spectrum antibiotic use. Guideline adherence improved by 26.7 percentage points in crude difference-in-differences analysis, and the adjusted intervention-by-endline effect showed higher odds of guideline-adherent prescribing (aOR 3.89; 95% CI: 1.96–7.73). Overall, antibiotic use declined from 96.9% to 82.2% in the intervention arm. In a post-hoc sensitivity analysis using all eligible charts, broad-spectrum antibiotic use declined from 83.9 to 57.5%. These findings support the potential value of a multicomponent intervention combining an offline STG app with training and implementation support for improving guideline-concordant antimicrobial prescribing; however, the independent contribution of the mobile application cannot be determined.