Electronic Clinical Decision Support Tools: Strategies to Improve the Management of Lower Respiratory Tract Infections in Low-Resource Settings

L. Gayani Tillekeratne Duke University School of Medicine, Department of Medicine, Durham, North Carolina;
Duke Global Health Institute, Durham, North Carolina;
Faculty of Medicine, Department of Medicine, University of Ruhuna, Galle, Sri Lanka;
Ruhuna-Duke Centre for Infectious Diseases, Faculty of Medicine, University of Ruhuna, Galle, Sri Lanka;

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Warsha De Soyza Faculty of Medicine, Department of Medicine, University of Ruhuna, Galle, Sri Lanka;
Ruhuna-Duke Centre for Infectious Diseases, Faculty of Medicine, University of Ruhuna, Galle, Sri Lanka;

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Maria D. Iglesias-Ussel Duke University School of Medicine, Department of Medicine, Durham, North Carolina;

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Stefany Olague Duke Clinical Research Institute, Durham, North Carolina;

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Dhammika Palangasinghe Faculty of Medicine, Department of Medicine, University of Ruhuna, Galle, Sri Lanka;
Ruhuna-Duke Centre for Infectious Diseases, Faculty of Medicine, University of Ruhuna, Galle, Sri Lanka;

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Ajith Nagahawatte Duke Global Health Institute, Durham, North Carolina;
Ruhuna-Duke Centre for Infectious Diseases, Faculty of Medicine, University of Ruhuna, Galle, Sri Lanka;
Faculty of Medicine, Department of Microbiology, University of Ruhuna, Galle, Sri Lanka;

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Thilini Wickramatunga Ruhuna-Duke Centre for Infectious Diseases, Faculty of Medicine, University of Ruhuna, Galle, Sri Lanka;

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Jayani Gamage Ruhuna-Duke Centre for Infectious Diseases, Faculty of Medicine, University of Ruhuna, Galle, Sri Lanka;

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Ruvini Kurukulasooriya Ruhuna-Duke Centre for Infectious Diseases, Faculty of Medicine, University of Ruhuna, Galle, Sri Lanka;

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Madureka Premamali Ruhuna-Duke Centre for Infectious Diseases, Faculty of Medicine, University of Ruhuna, Galle, Sri Lanka;

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James Ngocho Kilimanjaro Christian Medical Centre, Moshi, Tanzania;

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Armstrong Obale Duke Global Health Institute, Durham, North Carolina;
Ruhuna-Duke Centre for Infectious Diseases, Faculty of Medicine, University of Ruhuna, Galle, Sri Lanka;

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Kate Sanborn Duke Global Health Institute, Durham, North Carolina;

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John Gallis Duke Global Health Institute, Durham, North Carolina;

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Christopher W. Woods Duke University School of Medicine, Department of Medicine, Durham, North Carolina;
Duke Global Health Institute, Durham, North Carolina;
Ruhuna-Duke Centre for Infectious Diseases, Faculty of Medicine, University of Ruhuna, Galle, Sri Lanka;

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Susanna Naggie Duke University School of Medicine, Department of Medicine, Durham, North Carolina;
Duke Clinical Research Institute, Durham, North Carolina;

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Truls Ostbye Duke Global Health Institute, Durham, North Carolina;
Ruhuna-Duke Centre for Infectious Diseases, Faculty of Medicine, University of Ruhuna, Galle, Sri Lanka;
Duke University School of Medicine, Department of Family Medicine and Community Health, Durham, North Carolina;

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Hrishikesh Chakraborty Duke Clinical Research Institute, Durham, North Carolina;
Duke University School of Medicine, Department of Biostatistics and Bioinformatics, Durham, North Carolina;

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Eric Laber Duke Global Health Institute, Durham, North Carolina;
Duke University School of Medicine, Department of Biostatistics and Bioinformatics, Durham, North Carolina;

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Evan Myers Duke Clinical Research Institute, Durham, North Carolina;
Duke University School of Medicine, Department of Obstetrics & Gynecology, Durham, North Carolina;

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Melissa Watt University of Utah, Salt Lake City, Utah

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Champica K. Bodinayake Duke Global Health Institute, Durham, North Carolina;
Faculty of Medicine, Department of Medicine, University of Ruhuna, Galle, Sri Lanka;
Ruhuna-Duke Centre for Infectious Diseases, Faculty of Medicine, University of Ruhuna, Galle, Sri Lanka;

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Lower respiratory tract infection (LRTI) is a common reason for hospitalization and antibacterial use globally. There is considerable overlap in the clinical presentation of bacterial and viral LRTIs. Low- or middle-income countries (LMICs) face the dual challenge of appropriately targeting antibacterials for bacterial LRTI while reducing inappropriate antibacterials for viral LRTI. We propose a framework by which an electronic clinical decision support tool (eCDST) for diagnosing LRTI and reducing unnecessary antibacterial use may be developed, validated, and prospectively evaluated in an LMIC. The developed tool would be data driven, low-cost, feasible in the local setting, adaptable based on resource availability, and updated in real time, with prospective assessment to identify its clinical impact. We draw upon our team’s recent experience developing an eCDST for LRTI management in Sri Lanka. Publicly sharing such processes and data is valuable, such that we can collectively improve clinical care in LMICs and other settings.

Author Notes

Financial support: This work was supported by a grant from the National Institute of Allergy and Infectious Diseases (R01AI168420).

Current contact information: L. Gayani Tillekeratne, Duke University School of Medicine, Durham, NC, Duke Global Health Institute, Durham, NC, Faculty of Medicine, University of Ruhuna, Galle, Sri Lanka, and Ruhuna-Duke Centre for Infectious Diseases, Faculty of Medicine, University of Ruhuna, Galle, Sri Lanka, E-mail: gayani.tillekeratne@duke.edu. Warsha De Soyza, Faculty of Medicine, University of Ruhuna, Galle, Sri Lanka, and Ruhuna-Duke Centre for Infectious Diseases, Faculty of Medicine, University of Ruhuna, Galle, Sri Lanka, E-mail: warshadez@gmail.com. Maria Iglesias de Ussel, Duke University School of Medicine, Durham, NC, E-mail: maria.iglesiasdeussel@duke.edu. Stefany Olague, Duke Clinical Research Institute, Durham, NC, E-mail: stefany.olague@duke.edu. Dhammika Palangasinghe, Thilini Wickramatunga, Jayani Gamage, Ruvini >Kurukulasooriya, and Madureka Premamali, Faculty of Medicine, University of Ruhuna, Galle, Sri Lanka, and Ruhuna-Duke Centre for Infectious Diseases, Faculty of Medicine, University of Ruhuna, Galle, Sri Lanka, E-mails: dhammikarandula@gmail.com, thilini.wickradukeruhuna@gmail.com, Ruhuna-Duke Centre for Infectious Diseases, Faculty of Medicine, University of Ruhuna, Galle, Sri Lanka, and Duke Global Health Institute, Durham, NC, E-mails: ajithnagahawatte@yahoo.co.uk and bodinayake@gmail.com. James Ngocho, Kilimanjaro Christian Medical Centre, Moshi, Tanzania, E-mail: james.ngocho@kcmuco.ac.tz. Armstrong Obale, Duke Global Health Institute, Durham, NC, and Ruhuna-Duke Centre for Infectious Diseases, Faculty of Medicine, University of Ruhuna, Galle, Sri Lanka, E-mail: mbi.obale@duke.edu. Kate Sanborn and John Gallis, Duke Global Health Institute, Durham, NC, E-mails: kate.sanborn@duke.edu and john.gallis@duke.edu. Christopher W. Woods and Truls Ostbye, Duke University School of Medicine, Durham, NC, Duke Global Health Institute, Durham, NC, and Ruhuna-Duke Centre for Infectious Diseases, Faculty of Medicine, University of Ruhuna, Galle, Sri Lanka, E-mails: chris.woods@duke.edu and truls.ostbye@duke.edu. Susanna Naggie, Hrishikesh Chakraborty, and Evan Myers, Duke University School of Medicine, Durham, NC, and Duke Clinical Research Institute, Durham, NC, E-mails: susanna.naggie@duke.edu, hrishikesh.chakraborty@duke.edu, and evan.myers@duke.edu. Eric Laber, Duke University School of Medicine, Durham, NC, and Duke Global Health Institute, Durham, NC, E-mail: eric.laber@duke.edu. Melissa Watt, University of Utah, Salt Lake City, UT, E-mail: melissa.watt@hsc.utah.edu.

Address correspondence to L. Gayani Tillekeratne, Duke University School of Medicine, Durham, NC 27710. E-mail: gayani.tillekeratne@duke.edu
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