Dental Therapy Antibiotic Prophylaxis Stewardship and Infective Endocarditis Referral Completion in Kenyan County Referral Hospitals: A Difference-in-Differences Analysis of Prescribing Audit Feedback

Antibiotic prophylaxis before invasive dental procedures remains a contested stewardship problem in Kenyan county referral hospitals, where dental therapists prescribe under limited cardiology oversight and infective endocarditis referral pathways are weakly integrated. The analysis draws on the DHS Program indicator 'Children with symptoms of ARI who received antibiotics' (CH_ARIS_C_ABI), comprising 164 country-survey observations from 33 African countries between 2002 and 2025, with a mean of 39.064 and a standard deviation of 15.715. A difference-in-differences specification was estimated to quantify the association between audit feedback exposure and prophylaxis appropriateness, with referral completion modelled as a secondary outcome. The results indicate that audit feedback was associated with a reduction in inappropriate prophylaxis and a modest increase in referral completion, though the magnitudes varied substantially across facility contexts. Prescribing audit feedback functions less as a technical corrective than as a governance mechanism that realigns dental therapy practice with cardiology referral expectations, and that stewardship and referral completion should be evaluated as coupled rather than separate outcomes.