{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,24]],"date-time":"2026-07-24T14:04:51Z","timestamp":1784901891798,"version":"3.55.0"},"reference-count":19,"publisher":"BMJ","issue":"7","license":[{"start":{"date-parts":[[2026,7,24]],"date-time":"2026-07-24T00:00:00Z","timestamp":1784851200000},"content-version":"unspecified","delay-in-days":23,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"funder":[{"name":"FPS Health, Food Chain Safety and Environment and RIZIV-INAMI","award":["ZL3D1914"],"award-info":[{"award-number":["ZL3D1914"]}]}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Open"],"accepted":{"date-parts":[[2026,7,10]]},"published-print":{"date-parts":[[2026,7]]},"abstract":"<jats:sec>\n                    <jats:title>Introduction<\/jats:title>\n                    <jats:p>Inappropriate antibiotic prescribing in primary care remains a major driver of antimicrobial resistance, despite national guidelines and audit-and-feedback systems. Digital antimicrobial stewardship tools may support clinicians in making evidence-based prescribing decisions. The Prescription Search Support (PSS) tool translates guideline recommendations into an interactive decision tree integrated into electronic health records (EHR). This project aims to evaluate the impact of implementing the tool on antibiotic prescribing behaviour in Belgian general practice and to understand the contextual factors influencing its adoption.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods and analysis<\/jats:title>\n                    <jats:p>This stepped-wedge cluster randomised trial includes four steps over 12 months. Belgian general practices were randomised in a 1:3:3:3 ratio using stratified block randomisation. All practices start in the control condition, where physicians are expected to provide usual care. At each step, one cluster transitions to the intervention, where PSS becomes accessible through the EHR. The primary objective is to assess whether the implementation of the tool reduces practice-level antibiotic prescribing rates. The primary analysis will use generalised linear mixed models with a logit link, accounting for clustering, time effects and relevant covariates. Secondary analyses include subgroup analyses by region, EHR vendor and intensity of tool use. A nested process evaluation, combining user log file analysis and semistructured interviews, will assess usability, acceptability, fidelity and mechanisms of impact. Sample size calculations indicate that at least 36\u201348 practices are required to detect a 5% absolute reduction in prescribing with 80% power. All quantitative analyses will be performed in R, and qualitative data will be analysed using reflexive thematic analysis.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Ethics and dissemination<\/jats:title>\n                    <jats:p>The study will be conducted in compliance with the principles of the Declaration of Helsinki (current version) and the principles of Good Clinical Practice and in accordance with all applicable regulatory requirements. Ethics approval for this study was obtained on 10 October 2025 from the Ethical Committee Research UZ\/KU Leuven under reference MP037810. We will ensure that the findings of the study will be disseminated to relevant stakeholders beyond the scientific world including the public, healthcare providers and policy makers. The process evaluation that is part of this trial will inform the further implementation strategy. It will be essential to educate physicians on using this new PSS tool in daily practice.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Trial registration number<\/jats:title>\n                    <jats:p>\n                      <jats:ext-link xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" ext-link-type=\"clintrialgov\" xlink:href=\"NCT07347015\">NCT07347015<\/jats:ext-link>\n                      .\n                    <\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmjopen-2026-120670","type":"journal-article","created":{"date-parts":[[2026,7,24]],"date-time":"2026-07-24T13:20:18Z","timestamp":1784899218000},"page":"e120670","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":0,"title":["Impact evaluation of a Prescription Search Support (PSS) for antimicrobials: protocol for a stepped-wedge cluster randomised trial in Belgian primary care"],"prefix":"10.1136","volume":"16","clinical-trial-number":[{"clinical-trial-number":"nct07347015","registry":"10.18810\/clinical-trials-gov"}],"author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-7166-7211","authenticated-orcid":false,"given":"Jan Yvan","family":"Verbakel","sequence":"first","affiliation":[{"name":"Leuven Unit for Health Technology Assessment Research (LUHTAR), Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium"},{"name":"Academic Centre for General Practice, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3242-2318","authenticated-orcid":false,"given":"Hannelore","family":"Dillen","sequence":"additional","affiliation":[{"name":"Leuven Unit for Health Technology Assessment Research (LUHTAR), Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium"},{"name":"Academic Centre for General Practice, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Annelien","family":"Dankaerts","sequence":"additional","affiliation":[{"name":"Leuven Unit for Health Technology Assessment Research (LUHTAR), Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium"},{"name":"Academic Centre for General Practice, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nele","family":"Michiels","sequence":"additional","affiliation":[{"name":"Faculty of Medicine, KU Leuven, Leuven, Belgium"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5244-1930","authenticated-orcid":false,"given":"Bert","family":"Vaes","sequence":"additional","affiliation":[{"name":"Academic Centre for General Practice, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tine","family":"De Burghgraeve","sequence":"additional","affiliation":[{"name":"Leuven Unit for Health Technology Assessment Research (LUHTAR), Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium"},{"name":"Academic Centre for General Practice, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2026,7,24]]},"reference":[{"key":"2026072406201241000_16.7.e120670.1","unstructured":"BELMAP 2025: one health report of antimicrobial consumption and resistance in Belgium. Brussels, Belgium, 2025."},{"key":"2026072406201241000_16.7.e120670.2","unstructured":"RIZIV . PSS antimicrobieel: beslissingsondersteunend platform bij het voorschrijven van antibiotica. Available: https:\/\/www.riziv.fgov.be\/nl\/thema-s\/egezondheid\/beslissingsondersteunend-platform-voor-voorschrijvers-meer-gepaste-zorg-en-minder-veiligheidsrisico-s\/pss-antimicrobieel-beslissingsondersteunend-platform-bij-het-voorschrijven-van-antibiotica [Accessed 31 Mar 2026]."},{"key":"2026072406201241000_16.7.e120670.3","unstructured":"European Centre for Disease Prevention and Control . Antimicrobial consumption in the EU\/EEA (ESAC-Net) - annual epidemiological report 2024. Stockholm ECDC; 2025."},{"key":"2026072406201241000_16.7.e120670.4","unstructured":"FOD Volksgezondheid; Veiligheid van de Voedselketen en Leefmilieu . Belgische commissie voor de co\u00f6rdinatie van het antibioticabeleid (BAPCOC). 2024. Available: https:\/\/overlegorganen.gezondheid.belgie.be\/nl\/advies-en-overlegorgaan\/commissies\/BAPCOC [Accessed 18 Mar 2026]."},{"key":"2026072406201241000_16.7.e120670.5","unstructured":"BCFI . BAPCOC - Belgische Gids voor Anti-Infectieuze Behandeling in de Ambulante Praktijk. 2022. Available: https:\/\/www.bcfi.be\/nl\/chapters\/12?frag=8000010 [Accessed 18 Mar 2026]."},{"key":"2026072406201241000_16.7.e120670.6","unstructured":"Domus Medica . Antibioticabarometer. 2024. Available: https:\/\/www.domusmedica.be\/expertisedomein\/ict\/antibioticabarometer [Accessed 3 Apr 2026]."},{"key":"2026072406201241000_16.7.e120670.7","doi-asserted-by":"crossref","DOI":"10.1093\/intqhc\/mzag037","article-title":"Development and early implementation of automated audit and feedback monitoring instruments in Belgian primary care: lessons for scalable systems","volume":"38","author":"Raat","year":"2026","journal-title":"Int J Qual Health Care"},{"key":"2026072406201241000_16.7.e120670.8","doi-asserted-by":"crossref","DOI":"10.2196\/14984","article-title":"Health Professions Digital Education on Antibiotic Management: Systematic Review and Meta-Analysis by the Digital Health Education Collaboration","volume":"21","author":"Kyaw","year":"2019","journal-title":"J Med Internet Res"},{"key":"2026072406201241000_16.7.e120670.9","doi-asserted-by":"crossref","first-page":"416","DOI":"10.5116\/ijme.5a11.8422","article-title":"Can a smartphone app improve medical trainees\u2019 knowledge of antibiotics?","volume":"8","author":"Fralick","year":"2017","journal-title":"Int J Med Educ"},{"key":"2026072406201241000_16.7.e120670.10","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0239751","article-title":"Use of stewardship smartphone applications by physicians and prescribing of antimicrobials in hospitals: A systematic review","volume":"15","author":"Helou","year":"2020","journal-title":"PLoS One"},{"key":"2026072406201241000_16.7.e120670.11","doi-asserted-by":"crossref","DOI":"10.2196\/25741","article-title":"A Web Interface for Antibiotic Prescription Recommendations in Primary Care: User-Centered Design Approach","volume":"23","author":"Madar","year":"2021","journal-title":"J Med Internet Res"},{"key":"2026072406201241000_16.7.e120670.12","unstructured":"Dillen H , Vandoninck A , Vanduffel E , et al . Feasibility, usability, and uptake of a decision support tool for common infections: a mixed-methods pilot study for antimicrobial stewardship in ambulatory care."},{"key":"2026072406201241000_16.7.e120670.13","doi-asserted-by":"crossref","DOI":"10.1136\/bmj.h391","article-title":"The stepped wedge cluster randomised trial: rationale, design, analysis, and reporting","volume":"350","author":"Hemming","year":"2015","journal-title":"BMJ"},{"key":"2026072406201241000_16.7.e120670.14","unstructured":"UZ Leuven . Adverteren\/rekruteren voor klinische studies - richtlijnen Ethische Commissie Onderzoek. 2023. Available: https:\/\/www.uzleuven.be\/nl\/ethische-commissie-onderzoek\/templates-en-interne-richtlijnen-bij-starten-van-dossier-bij-ec-onderzoek\/adverterenrekruteren-voor-klinische-studies-richtlijnen-ec-onderzoek [Accessed 3 Feb 2026]."},{"key":"2026072406201241000_16.7.e120670.15","unstructured":"RIZIV . Het rationeel gebruik van de antibiotica bij het kind in de ambulante zorg. 2016."},{"key":"2026072406201241000_16.7.e120670.16","unstructured":"FOD Volksgezondheid; Veiligheid van de Voedselketen en Leefmilieu . Belgisch Nationaal Actieplan \u201cOne Health\u201d voor de bestrijding van antimicrobi\u00eble resistentie (AMR) 2020-2024. 2021."},{"key":"2026072406201241000_16.7.e120670.17","doi-asserted-by":"crossref","unstructured":"Leroy R , Christiaens W , Noordhout C , et al . Proposals for a more effective antibiotic policy in Belgium - report. 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