title: Impact of introduction of rapid diagnostic tests for malaria on antibiotic prescribing: analysis of observational and randomised studies in public and private healthcare settings.
abstract: ObjectivesTo 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.DesignAnalysisof nine preselected linked and codesigned observational and randomised studies (eight cluster or individually randomised trials and one observational study).SettingPublic and private healthcare settings, 2007-13, in Afghanistan, Cameroon, Ghana, Nigeria, Tanzania, and Uganda.Participants522 480 children and adults with acute febrile illness.InterventionsRapid diagnostic tests for malaria.Main outcome measuresProportions 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.ResultsAntibiotics 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.ConclusionsIntroduction 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.
authors.affiliation: London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK.
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authors.initials: H
authors.lastname: Hopkins
authors.affiliation: London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK.
authors.forename: Katia J
authors.initials: KJ
authors.lastname: Bruxvoort
authors.affiliation: London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK.
authors.forename: Matthew E
authors.initials: ME
authors.lastname: Cairns
authors.affiliation: London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK.
authors.forename: Clare I R
authors.initials: CI
authors.lastname: Chandler
authors.affiliation: London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK.
authors.forename: Baptiste
authors.initials: B
authors.lastname: Leurent
authors.affiliation: Ghana Health Service, Accra, Ghana.
authors.forename: Evelyn K
authors.initials: EK
authors.lastname: Ansah
authors.affiliation: Ensign College of Public Health, Kpong, Ghana.
authors.forename: Frank
authors.initials: F
authors.lastname: Baiden
authors.affiliation: University of California, San Francisco, CA, USA.
authors.forename: Kimberly A
authors.initials: KA
authors.lastname: Baltzell
authors.affiliation: Karolinska Institutet, Stockholm, 17176, Sweden.
authors.forename: Anders
authors.initials: A
authors.lastname: Björkman
authors.affiliation: London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK.
authors.forename: Helen E D
authors.initials: HE
authors.lastname: Burchett
authors.affiliation: London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK.
authors.forename: Siân E
authors.initials: SE
authors.lastname: Clarke
authors.affiliation: London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK.
authors.forename: Deborah D
authors.initials: DD
authors.lastname: DiLiberto
authors.affiliation: University of Gothenburg, Gothenburg, Sweden.
authors.forename: Kristina
authors.initials: K
authors.lastname: Elfving
authors.affiliation: London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK.
authors.forename: Catherine
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authors.lastname: Goodman
authors.affiliation: London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK.|University of Copenhagen, Copenhagen, DK1014, Denmark.
authors.forename: Kristian S
authors.initials: KS
authors.lastname: Hansen
authors.affiliation: US Centers for Disease Control and Prevention, Atlanta, GA, USA.
authors.forename: S Patrick
authors.initials: SP
authors.lastname: Kachur
authors.affiliation: London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK.
authors.forename: Sham
authors.initials: S
authors.lastname: Lal
authors.affiliation: Liverpool School of Tropical Medicine, Liverpool, UK.
authors.forename: David G
authors.initials: DG
authors.lastname: Lalloo
authors.affiliation: London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK.|Health Protection Research Organisation, Kabul, Afghanistan.
authors.forename: Toby
authors.initials: T
authors.lastname: Leslie
authors.affiliation: Centre for Medical Parasitology, University of Copenhagen and Copenhagen University Hospital, and Department for Veterinary Disease Biology, University of Copenhagen, Copenhagen, Denmark.
authors.forename: Pascal
authors.initials: P
authors.lastname: Magnussen
authors.affiliation: London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK.
authors.forename: Lindsay Mangham
authors.initials: LM
authors.lastname: Jefferies
authors.affiliation: Uppsala University, Uppsala, Sweden.
authors.forename: Andreas
authors.initials: A
authors.lastname: Mårtensson
authors.affiliation: Health Protection Research Organisation, Kabul, Afghanistan.
authors.forename: Ismail
authors.initials: I
authors.lastname: Mayan
authors.affiliation: Ministry of Health, Kampala, Uganda.|Makerere University School of Public Health, Kampala, Uganda.
authors.forename: Anthony K
authors.initials: AK
authors.lastname: Mbonye
authors.affiliation: Zanzibar Malaria Elimination Programme, Tanzania.
authors.forename: Mwinyi I
authors.initials: MI
authors.lastname: Msellem
authors.affiliation: Department of Pharmacology and Therapeutics, University of Nigeria, Enugu, Nigeria.
authors.forename: Obinna E
authors.initials: OE
authors.lastname: Onwujekwe
authors.affiliation: London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK.|Kintampo Health Research Centre, Kintampo, Ghana.
authors.forename: Seth
authors.initials: S
authors.lastname: Owusu-Agyei
authors.affiliation: London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK.
authors.forename: Hugh
authors.initials: H
authors.lastname: Reyburn
authors.affiliation: London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK.
authors.forename: Mark W
authors.initials: MW
authors.lastname: Rowland
authors.affiliation: Centre for Malaria Research, Karolinska Institutet, Stockholm, Sweden, and Health Metrics at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
authors.forename: Delér
authors.initials: D
authors.lastname: Shakely
authors.affiliation: Department of Infectious Disease Epidemiology, Statens Serum Institut, Copenhagen, Denmark.
authors.forename: Lasse S
authors.initials: LS
authors.lastname: Vestergaard
authors.affiliation: London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK.
authors.forename: Jayne
authors.initials: J
authors.lastname: Webster
authors.affiliation: London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK.|School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia.
authors.forename: Virginia L
authors.initials: VL
authors.lastname: Wiseman
authors.affiliation: London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK.
authors.forename: Shunmay
authors.initials: S
authors.lastname: Yeung
authors.affiliation: London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK.
authors.forename: David
authors.initials: D
authors.lastname: Schellenberg
authors.affiliation: London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK.
authors.forename: Sarah G
authors.initials: SG
authors.lastname: Staedke
authors.affiliation: London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK.
authors.forename: Christopher J M
authors.initials: CJ
authors.lastname: Whitty
mesh_terms: D000349:Africa / Q000453:epidemiology; D000553:Ambulatory Care; D000900:Anti-Bacterial Agents / Q000008:administration & dosage*; D000962:Antimalarials / Q000008:administration & dosage / Q000627:therapeutic use; D001208:Asia / Q000453:epidemiology; D003955:Diagnostic Tests, Routine; D005334:Fever / Q000097:blood / Q000175:diagnosis / Q000188:drug therapy; D006801:Humans; D008288:Malaria / Q000097:blood / Q000175:diagnosis* / Q000188:drug therapy*; D064887:Observational Studies as Topic; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D015397:Program Evaluation; D016032:Randomized Controlled Trials as Topic; D011933:Reagent Kits, Diagnostic
chemical_list: D000900:Anti-Bacterial Agents; D000962:Antimalarials; D011933:Reagent Kits, Diagnostic