---
title: "Smartphone vs Paper Antimicrobial Prescribing Guidelines in Laos: Stepped-Wedge Cluster RCT"
id: "plos-medicine-1-adherence-to-smartphone-delivered-antimicrobial-prescribing-guidelines-in"
canonical_url: "https://medichelpline.com/clinical-feed/plos-medicine-1-adherence-to-smartphone-delivered-antimicrobial-prescribing-guidelines-in"
content_type: "clinical_feed_article"
specialty: "Infectious Disease"
source_name: "PLOS Medicine"
source_url: "https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1005205"
published_at: "2026-08-27T14:00:00.000Z"
evidence_level: "Journal Feed"
license: "CC-BY-NC-4.0 / Informational Use"
---
# Smartphone vs Paper Antimicrobial Prescribing Guidelines in Laos: Stepped-Wedge Cluster RCT
## Provenance & Clinical Metadata
- **Canonical URL:** https://medichelpline.com/clinical-feed/plos-medicine-1-adherence-to-smartphone-delivered-antimicrobial-prescribing-guidelines-in
- **Specialty:** [Infectious Disease](https://medichelpline.com/clinical-feed/infectious-disease.md)
- **Primary Source:** PLOS Medicine
- **Source URL:** [Original Journal Publication](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1005205)
- **Published At:** 2026-08-27T14:00:00.000Z
- **Evidence Rating:** Journal Feed
## Executive GIST (TL;DR)
- This stepped-wedge cluster randomized controlled trial in six hospitals in Lao PDR evaluated whether a **smartphone application** delivering the national antimicrobial prescribing guidelines plus antimicrobial stewardship (AMS) training improved guideline adherence versus a paper-based guideline with training. - The trial ran from 2021–2022 using an open cohort design with three steps. Repeated point prevalence surveys (PPS) at ~4-month intervals assessed prescribing. Adherence required the correct antimicrobial(s) and correct dose per the guidelines. - A total of 3,561 inpatient and 3,905 outpatient antimicrobial prescriptions were assessed. In hospitalized patients, observed adherence was 17.0% (95% CI 15.0–19) with paper guidance and 25.6% (95% CI 23.1–28.3) with the smartphone intervention. - After adjustment for time, clustering, and confounders, the difference in inpatient adherence by delivery mode was not statistically significant (adjusted odds ratio aOR 1.26, 95% CI 0.8–1.9; p = 0.276). Outpatient analyses likewise showed no overall improvement (aOR 0.91, 95% CI 0.7–1.1; p = 0.406). - Temporal effects were seen in outpatient settings: hospitals exposed to the intervention earlier had higher adherence (32.1% in first group vs 19.1% in last group) with aOR 1.95 (95% CI 1.4–2.7; p < 0.001). - The study demonstrates feasibility of delivering national prescribing guidelines via a **smartphone application** in a low- and middle-income country, but did not show the pre-specified improvement in guideline adherence compared with paper-based guidelines. - The authors highlight that guideline availability alone is insufficient to ensure adherence; multiple contextual and behavioural factors influence prescribing. A key limitation: prescriptions could not be reliably linked to individual prescribers, so individual-level behaviour change could not be assessed. - The trial is registered (NCT04914793). De-identified data and analysis code are publicly available as reported in the article.
## Clinical Analysis & Structured Key Points
[ Skip to main content ](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1005205#main-content) Advertisement * [plos.org](https://plos.org/) * [Create account](https://community.plos.org/registration/new) * [Sign in](https://journals.plos.org/user/secure/login?page=%2Fplosmedicine%2Farticle%3Fid%3D10.1371%2Fjournal.pmed.1005205) * * About * Browse * Publish * [](https://journals.plos.org/plosmedicine/ "PLOS Medicine") * Search [advanced search](https://journals.plos.org/plosmedicine/search) * 0 [Save](https://journals.plos.org/plosmedicine/article/metrics?id=10.1371/journal.pmed.1005205#savedHeader) [Total Mendeley and Citeulike bookmarks.](https://journals.plos.org/plosmedicine/article/metrics?id=10.1371/journal.pmed.1005205#savedHeader) * 0 [Citation](https://journals.plos.org/plosmedicine/article/metrics?id=10.1371/journal.pmed.1005205#citedHeader) [Paper's citation count computed by Dimensions.](https://journals.plos.org/plosmedicine/article/metrics?id=10.1371/journal.pmed.1005205#citedHeader) * 13 [View](https://journals.plos.org/plosmedicine/article/metrics?id=10.1371/journal.pmed.1005205#viewedHeader) [PLOS views and downloads.](https://journals.plos.org/plosmedicine/article/metrics?id=10.1371/journal.pmed.1005205#viewedHeader) * 0 [Share](https://journals.plos.org/plosmedicine/article/metrics?id=10.1371/journal.pmed.1005205#discussedHeader) [Sum of Facebook, Twitter, Reddit and Wikipedia activity.](https://journals.plos.org/plosmedicine/article/metrics?id=10.1371/journal.pmed.1005205#discussedHeader) Open Access Peer-reviewed Research Article # Adherence to smartphone-delivered antimicrobial prescribing guidelines in hospitals in Lao PDR: A stepped-wedge cluster randomized controlled trial * Vilada Chansamouth , Roles Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing * E-mail: vilada@tropmedres.ac Affiliations Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), Mahosot Hospital, Vientiane, Lao PDR, Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao PDR, Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom [ ![ORCID logo](https://journals.plos.org/resource/img/orcid_16x16.png) https://orcid.org/0000-0003-3049-784X ](https://orcid.org/0000-0003-3049-784X "ORCID Registry") ⨯ * Danoy Chommanam, Roles Data curation, Investigation, Writing – review & editing Affiliation Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), Mahosot Hospital, Vientiane, Lao PDR ⨯ * Sue J. Lee, Roles Data curation, Formal analysis, Writing – review & editing Affiliations Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom, Mahidol Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand, Department of Infectious Diseases, Alfred Health and School of Translational Medicine, Monash University, Melbourne, Australia [ ![ORCID logo](https://journals.plos.org/resource/img/orcid_16x16.png) https://orcid.org/0000-0002-8409-4248 ](https://orcid.org/0000-0002-8409-4248 "ORCID Registry") ⨯ * Susath Vongphachanh, Roles Investigation, Resources, Writing – review & editing Affiliation Mahosot Hospital, Vientiane, Lao PDR ⨯ * Manivanh Vongsouvath, Roles Investigation, Resources, Writing – review & editing Affiliations Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), Mahosot Hospital, Vientiane, Lao PDR, Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao PDR, Mahosot Hospital, Vientiane, Lao PDR ⨯ * Sommay Keomany, Roles Investigation, Resources, Writing – review & editing Affiliation Salavan Provincial Hospital, Salavan, Salavan Province, Lao PDR ⨯ * Viladeth Paphasiri, Roles Investigation, Resources, Writing – review & editing Affiliation Xiengkhuang Provincial Hospital, Phonsavan, Xiengkhuang Province, Lao PDR ⨯ * Chanthala Phamisith, Roles Investigation, Resources, Writing – review & editing Affiliation Savannakhet Provincial Hospital, Kayson Phomvihane, Savannakhet Province, Lao PDR ⨯ * Siho Sengsavang, Roles Investigation, Resources, Writing – review & editing Affiliation Vientiane Provincial Hospital, Viengkham, Vientiane Province, Lao PDR ⨯ * Phouvieng Douangdala, Roles Investigation, Resources, Writing – review & editing Affiliation Luang Namtha Provincial Hospital, Luang Namtha, Luang Namtha Province, Lao PDR ⨯ * Khamsay Detleuxay, Roles Investigation, Resources, Writing – review & editing Affiliation Department of Healthcare and Rehabilitation, Ministry of Health, Vientiane, Lao PDR ⨯ * Sommana Rattana, Roles Investigation, Resources, Writing – review & editing Affiliation Department of Healthcare and Rehabilitation, Ministry of Health, Vientiane, Lao PDR ⨯ * Bandith Soumphonphakdy, Roles Investigation, Resources, Writing – review & editing Affiliation Children’s Hospital, Vientiane, Lao PDR [ ![ORCID logo](https://journals.plos.org/resource/img/orcid_16x16.png) https://orcid.org/0009-0000-0776-081X ](https://orcid.org/0009-0000-0776-081X "ORCID Registry") ⨯ * Valy Keoluangkhot, Roles Investigation, Resources, Writing – review & editing Affiliation Mahosot Hospital, Vientiane, Lao PDR ⨯ * Mavuto Mukaka, Roles Formal analysis, Writing – review & editing Affiliations Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom, Mahidol Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand [ ![ORCID logo](https://journals.plos.org/resource/img/orcid_16x16.png) https://orcid.org/0000-0002-5036-6583 ](https://orcid.org/0000-0002-5036-6583 "ORCID Registry") ⨯ * Nicholas P. J. Day, Roles Conceptualization, Funding acquisition, Methodology, Supervision, Writing – review & editing Affiliations Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom, Mahidol Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand ⨯ * H. Rogier van Doorn, Roles Conceptualization, Methodology, Supervision, Writing – review & editing Affiliations Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom, Oxford University Clinical Research Unit, Hanoi, Viet Nam [ ![ORCID logo](https://journals.plos.org/resource/img/orcid_16x16.png) https://orcid.org/0000-0002-9807-1821 ](https://orcid.org/0000-0002-9807-1821 "ORCID Registry") ⨯ * Paul Turner, Roles Conceptualization, Methodology, Software, Supervision, Writing – review & editing Affiliations Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom, Cambodia Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia [ ![ORCID logo](https://journals.plos.org/resource/img/orcid_16x16.png) https://orcid.org/0000-0002-1013-7815 ](https://orcid.org/0000-0002-1013-7815 "ORCID Registry") ⨯ * Mayfong Mayxay, Roles Conceptualization, Methodology, Supervision, Writing – review & editing Affiliations Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), Mahosot Hospital, Vientiane, Lao PDR, Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom, Institute of Research and Education Development (IRED), University of Health Sciences, Ministry of Health, Vientiane, Lao PDR, Saw Swee Hock School of Public Health, National University of Singapore (NUS), Singapore, Singapore ⨯ * Paul N. Newton, Roles Conceptualization, Methodology, Supervision, Writing – review & editing Affiliations Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), Mahosot Hospital, Vientiane, Lao PDR, Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom, Mahidol Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom [ ![ORCID logo](https://journals.plos.org/resource/img/orcid_16x16.png) https://orcid.org/0000-0002-4608-6431 ](https://orcid.org/0000-0002-4608-6431 "ORCID Registry") ⨯ * [ ... ], * Elizabeth A. Ashley Roles Conceptualization, Funding acquisition, Methodology, Supervision, Validation, Writing – review & editing Affiliations Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), Mahosot Hospital, Vientiane, Lao PDR, Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom [ ![ORCID logo](https://journals.plos.org/resource/img/orcid_16x16.png) https://orcid.org/0000-0002-7620-4822 ](https://orcid.org/0000-0002-7620-4822 "ORCID Registry") ⨯ * [ view all ] * [ view less ] # Adherence to smartphone-delivered antimicrobial prescribing guidelines in hospitals in Lao PDR: A stepped-wedge cluster randomized controlled trial * Vilada Chansamouth, * Danoy Chommanam, * Sue J. Lee, * Susath Vongphachanh, * Manivanh Vongsouvath, * Sommay Keomany, … * Viladeth Paphasiri, * Chanthala Phamisith, * Siho Sengsavang, * Phouvieng Douangdala ![PLOS](https://journals.plos.org/resource/img/logo-plos-full-color.svg) x * Published: August 27, 2026 * * [Article](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1005205) * [Authors](https://journals.plos.org/plosmedicine/article/authors?id=10.1371/journal.pmed.1005205) * [Metrics](https://journals.plos.org/plosmedicine/article/metrics?id=10.1371/journal.pmed.1005205) * [Comments](https://journals.plos.org/plosmedicine/article/comments?id=10.1371/journal.pmed.1005205) * [Media Coverage](http://plos.altmetric.com/details/doi/10.1371/journal.pmed.1005205) * [Peer Review](https://journals.plos.org/plosmedicine/article/peerReview?id=10.1371/journal.pmed.1005205) * [Abstract](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1005205#abstract0) * [Author summary](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1005205#abstract1) * [Introduction](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1005205#sec004) * [Methods](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1005205#sec005) * [Results](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1005205#sec015) * [Discussion](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1005205#sec025) * [Supporting information](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1005205#sec026) * [Acknowledgments](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1005205#ack) * [References](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1005205#references) * [Reader Comments](https://journals.plos.org/plosmedicine/article/comments?id=10.1371/journal.pmed.1005205) * [Figures](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1005205) ## Abstract ### Background Prescribing guidelines are a cornerstone of antimicrobial stewardship programs. Smartphone applications can increase access in low-and middle-income countries (LMICs). Following the release of the Lao national antimicrobial prescribing guidelines in 2021, this trial compared adherence to these guidelines delivered by a smartphone application versus the paper-based version among hospitalized patients and outpatients in six hospitals in Laos. ### Methods and findings An open cohort stepped-wedge cluster randomized controlled 3-step trial was conducted from 2021–2022. The intervention was a smartphone application-based prescribing guideline and antimicrobial stewardship (AMS) training. The reference was a paper-based version of the same guidelines. Adherence was defined as prescriptions using the correct antimicrobial(s) and correct dose based on the provided prescribing guidelines. The primary outcome was assessed via repeated point prevalence surveys (PPS) at ~4-month intervals. Data were analyzed using a mixed-effects regression model, accounting for time and clustering. Among 3,561 hospitalized patient prescriptions, overall guideline adherence was 17.0% (95% confidence interval or CI [15.0,19]) in the reference group, and 25.6% (95% CI [23.1,28.3]) in the intervention group. After accounting for time and cluster effects and adjusting for confounders (sequence of intervention, age, gender, prescribing indication, and hospital department), adherence did not differ by guideline delivery mode (adjusted odds ratio (aOR)=1.26 (95% CI [0.8,1.9]; _p_ = 0.276). Similar findings were observed in outpatient settings (aOR = 0.91 (95% CI [0.7,1.1]; _p_ = 0.406)). Outpatient adherence varied by time of intervention introduction, with the first group of hospitals exposed to the intervention showing higher odds of adherence (32.1% [302/940]; 95% CI [29.1,35.2]) compared with the last group (19.1% [241/1,261]; 95% CI [16.9,21.4]) with aOR = 1.95 (95% CI [1.4,2.7]; _p_ ). The full original study dataset is owned by a third party (the Ministry of Health). Access to the data may be requested through the Mahidol-Oxford Tropical Medicine Research Unit Data Access Committee. All data access requests and related enquiries should be submitted to datasharing@tropmedres.ac. The code used for sample size calculations and statistical analyses is available in the [S2 Text](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1005205#pmed.1005205.s023) and . For the purpose of open access, the author has applied a CC BY public copyright license to any Author Accepted manusc
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