Impact of introduction of rapid diagnostic tests for malaria on antibiotic prescribing: analysis of observational and randomised studies in public and private healthcare settings.

Hopkins, Heidi, Bruxvoort, Katia J, Cairns, Matthew E, Chandler, Clare I R, Leurent, Baptiste, Ansah, Evelyn K, Baiden, Frank, Baltzell, Kimberly A, Björkman, Anders, Burchett, Helen E D, Clarke, Siân E, DiLiberto, Deborah D, Elfving, Kristina, Goodman, Catherine, Hansen, Kristian S, Kachur, S Patrick, Lal, Sham, Lalloo, David ORCID: https://orcid.org/0000-0001-7680-2200, Leslie, Toby, Magnussen, Pascal, Jefferies, Lindsay Mangham, Mårtensson, Andreas, Mayan, Ismail, Mbonye, Anthony K, Msellem, Mwinyi I, Onwujekwe, Obinna E, Owusu-Agyei, Seth, Reyburn, Hugh, Rowland, Mark W, Shakely, Delér, Vestergaard, Lasse S, Webster, Jayne, Wiseman, Virginia L, Yeung, Shunmay, Schellenberg, David, Staedke, Sarah G and Whitty, Christopher J M (2017) 'Impact of introduction of rapid diagnostic tests for malaria on antibiotic prescribing: analysis of observational and randomised studies in public and private healthcare settings.'. British Medical Journal (BMJ), Vol 356, Issue j1054.

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Abstract

Objectives
 To examine the impact of use of rapid diagnostic tests for malaria on prescribing of antimicrobials, specifically antibiotics, for acute febrile illness in Africa and Asia.
Design
Analysisof nine preselected linked and codesigned observational and randomised studies (eight cluster or individually randomised trials and one observational study).
Setting
Public and private healthcare settings, 2007-13, in Afghanistan, Cameroon, Ghana, Nigeria, Tanzania, and Uganda.
Participants
 522 480 children and adults with acute febrile illness.
Interventions
Rapid diagnostic tests for malaria.
Main outcome measures
Proportions of patients for whom an antibiotic was prescribed in trial groups who had undergone rapid diagnostic testing compared with controls and in patients with negative test results compared with patients with positive results. A secondary aim compared classes of antibiotics prescribed in different settings.
Results
Antibiotics were prescribed to 127 052/238 797 (53%) patients in control groups and 167 714/283 683 (59%) patients in intervention groups. Antibiotics were prescribed to 40% (35 505/89 719) of patients with a positive test result for malaria and to 69% (39 400/57 080) of those with a negative result. All but one study showed a trend toward more antibiotic prescribing in groups who underwent rapid diagnostic tests. Random effects meta-analysis of the trials showed that the overall risk of antibiotic prescription was 21% higher (95% confidence interval 7% to 36%) in intervention settings. In most intervention settings, patients with negative test results received more antibiotic prescriptions than patients with positive results for all the most commonly used classes: penicillins, trimethoprim-sulfamethoxazole (one exception), tetracyclines, and metronidazole.Conclusions Introduction of rapid diagnostic tests for malaria to reduce unnecessary use of antimalarials-a beneficial public health outcome-could drive up untargeted use of antibiotics. That 69% of patients were prescribed antibiotics when test results were negative probably represents overprescription.This included antibiotics from several classes, including those like metronidazole that are seldom appropriate for febrile illness, across varied clinical, health system, and epidemiological settings. It is often assumed that better disease specific diagnostics will reduce antimicrobial overuse, but they might simply shift it from one antimicrobial class to another. Current global implementation of malaria testing might increase untargeted antibiotic use and must be examined. [Abstract copyright: Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.]

Item Type:	Article
Subjects:	QV Pharmacology > Anti-Bacterial Agents. Tissue Extracts > QV 350.5 Specific drugs, A-Z QV Pharmacology > Anti-Bacterial Agents. Tissue Extracts > QV 354 Penicillins WA Public Health > Health Problems of Special Population Groups > WA 395 Health in developing countries WC Communicable Diseases > Tropical and Parasitic Diseases > WC 680 Tropical diseases (General) WC Communicable Diseases > Tropical and Parasitic Diseases > WC 750 Malaria WC Communicable Diseases > Tropical and Parasitic Diseases > WC 770 Therapy
Faculty: Department:	Clinical Sciences & International Health > Clinical Sciences Department Clinical Sciences & International Health > International Public Health Department
Digital Object Identifer (DOI):	https://doi.org/10.1136/bmj.j1054
SWORD Depositor:	JISC Pubrouter
Depositing User:	Stacy Murtagh
Date Deposited:	24 Apr 2017 15:09
Last Modified:	14 Feb 2019 16:44
URI:	https://archive.lstmed.ac.uk/id/eprint/6998

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