Implementing the WHO AWaRe Antibiotic Guidelines for Pediatric Pharyngitis/Tonsilitis in Ghana: An Implementation Research Approach

Abstract Background: Pharyngitis and tonsillitis are predominantly viral infections, yet antibiotics are frequently overprescribed, contributing to antimicrobial resistance. In low- and middle-income countries, limited access to diagnostic tools promotes empirical treatment, which fuels this overuse. The World Health Organization's AWaRe guidelines promote rational antibiotic use and incorporate the Centor clinical scoring tool, a method based on symptoms and signs for guiding evidence-based decisions in resource-limited settings. Objectives: This study aimed to adapt and implement the WHO AWaRe guidelines for managing acute pharyngitis and tonsillitis at a paediatric hospital in Ghana. It evaluated the impact on antibiotic prescribing, patient outcomes, and prescribers’ perceptions of the guideline’s acceptability, appropriateness, and feasibility. Methods: An implementation research design was employed using the Active Implementation Frameworks. A modified version of the guideline was co-developed with prescribers at the children’s hospital through an iterative process. One hundred and three (123) patients were conveniently sampled and followed up three days and one month after treatment to assess outcomes. Data were collected using focus group discussions, interviews, questionnaires, and medical record reviews. Antibiotic prescription prevalence over 4 months pre- and post-implementation was charted to observe trends and compared using interrupted time series analysis. Results: The modified guideline, which included local adaptations and visual decision aids, was rated moderately to highly acceptable, appropriate, and feasible. The antibiotic prescribing declined from pre- to post-implementation, but the reduction in trend was not statistically significant (Coef. = -5.7, p = 0.340). Fidelity to the guideline improved over time with ongoing support and targeted training. Most patients (87.80%) improved within three days, and none developed complications. Conclusion: Implementing the WHO AWaRe guideline with the Centor score was feasible and well-accepted, with favorable outcomes. While antibiotic prescribing declined, it was not statistically significant, possibly due to the short study period. Longer-term follow-up and broader implementation may further enhance the impact on antimicrobial stewardship. Keywords: Antibiotic stewardship, Centor score, pharyngitis, Active Implementation Frameworks, Ghana, pediatric care, AWaRe guidelines.