Implementing Point-of-Care Tests to Optimize Antibiotic Use for Vaginal Discharge: A Study Protocol for a Randomized Controlled Trial in Nepal

Background Vaginal discharge (VD) is a common health concern among women of reproductive age worldwide. In low- and lower-middle-income countries (LLMICs), one in four women experiences distressing VD which may indicate underlying infections. About one-third of these cases are caused by one of three curable sexually transmitted infections (STIs) – Chlamydia trachomatis [Ct] , Neisseria gonorrhea [Ng], Trichomonas vaginalis [Tv] – or by bacterial vaginosis (BV). Syndromic management, the standard approach to care in LLMICs, relies on empirical antibiotic treatment, often resulting in overtreatment and contributing to antimicrobial resistance. To reduce unnecessary use of antibiotics, affordable, accurate, and rapid diagnostic tests such as point-of-care tests (POCTs) are needed – particularly in settings where over-the-counter antibiotic use is common and psychosocial problems may be somatized. Additionally, education on VD and appropriate antibiotic use, along with recognition of mental health or domestic violence issues, may be important for facilitating acceptance of POCTs. Methods This study is a randomized controlled double-blind, superiority trial with follow-up assessments at 4 weeks and 4 months. Participants are randomly assigned to one of three study arms: Arm 1 receives treatment, based on syndromic management; Arm 2 receives POCT-guided treatment using the Cepheid GeneXpert® (for Ct and Ng ), pH and whiff tests (for BV and Tv ), and the OSOM® test (for Tv ); Arm 3 receives the same POCT-guided treatment as Arm 2, plus an educational intervention, and referral for psychosocial concerns. The primary outcome is the proportion of correct antibiotic prescriptions, comparing Arm 1 versus Arms 2 and 3. Secondary outcomes include over-the-counter antibiotic acquisition, subsequent health-seeking behavior, changes in VD symptom development over time, and STI prevalence. Discussion The trial assesses the effectiveness and impact of integrating POCTs into VD management in a resource-limited setting. Results of comparing syndromic-based management with POCT-guided diagnostic testing and treatment, both alone and combined with psychosocial and education-based intervention, inform strategies to reduce antibiotic overuse and improve broader reproductive health concerns. Trial registration Registered at ClinicalTrials.gov (Identifier NCT05977491) on 8 April 2023. https//clinicaltrials.gov/study/NCT05977491?cond=vaginal%20discharge&rank=6