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Shaikh OA, Asghar Z, Aftab RM, Amin S, Shaikh G, Nashwan AJ. Antimicrobial resistant strains of Salmonella typhi: The role of illicit antibiotics sales, misuse, and self-medication practices in Pakistan. J Infect Public Health 2023; 16:1591-1597. [PMID: 37572573 DOI: 10.1016/j.jiph.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 07/11/2023] [Accepted: 08/01/2023] [Indexed: 08/14/2023] Open
Abstract
Typhoid fever, caused by the bacterium Salmonella typhi, is an often-fatal illness prevalent in Africa and South Asia. The illness has seen an alarming rise in multi-drug-resistant (MDR) and extensive drug-resistant (XDR) strains, particularly in Pakistan. The MDR strain links to the H58 haplotype, and its XDR variant exhibits fluoroquinolone resistance due to an IncY plasmid. The increasing prevalence of these resistant strains is concerning, given the global antimicrobial resistance (AMR) issue. Causes include misuse of antibiotics in self-limiting infections and an unregulated drug market. Pakistan's Sindh province first reported the XDR typhoid strain, highlighting the urgent need to investigate the relationship between AMR development and external factors. This narrative review intends to scrutinize the state of AMR in Pakistan, considering illicit drug sales, healthcare worker education gaps, and self-medication behaviors.
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Affiliation(s)
- Omer A Shaikh
- Department of Medicine, Ziauddin University, Karachi, Pakistan
| | - Zoha Asghar
- Department of Medicine, Ziauddin University, Karachi, Pakistan
| | - Rameel M Aftab
- Department of Medicine, Ziauddin University, Karachi, Pakistan
| | - Shifa Amin
- Department of Medicine, Ziauddin University, Karachi, Pakistan
| | - Gulrukh Shaikh
- Department of Medicine, Liaquat National Hospital and Medical College, Karachi, Pakistan
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2
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Nkeramahame J, Olliaro P, Horgan P, Dittrich S. Perspective on the Integration of Diagnostic Algorithms for Fever Management. Clin Infect Dis 2023; 77:S211-S213. [PMID: 37490737 PMCID: PMC10368406 DOI: 10.1093/cid/ciad325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2023] Open
Abstract
The AMR Diagnostics Use Accelerator Program was established to address antimicrobial resistance. Here, we bring into broad perspective the findings and missed opportunities of the first phase of the program and look toward the second phase.
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Affiliation(s)
| | - Piero Olliaro
- Medical Affairs, FIND, Geneva, Switzerland
- International Severe Acute Respiratory and Emerging Infection Consortium, Pandemic Sciences Institute, University of Oxford, Oxford, United Kingdom
| | - Philip Horgan
- Medical Affairs, FIND, Geneva, Switzerland
- Nuffield Department of Medicine, Big Data Institute, University of Oxford, Oxford, United Kingdom
- Department of Medicine, Evidence & Impact - Oxford, Oxford, United Kingdom
| | - Sabine Dittrich
- Medical Affairs, FIND, Geneva, Switzerland
- Center for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Deggendorf Institute of Technology, European Campus Rottal Inn, Pfarrkirchen, Germany
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3
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Kapisi J, Sserwanga A, Kitutu FE, Rutebemberwa E, Awor P, Weber S, Keller T, Kaawa-Mafigiri D, Ekusai-Sebatta D, Horgan P, Dittrich S, Moore CE, Salami O, Olliaro P, Nkeramahame J, Hopkins H. Impact of the Introduction of a Package of Diagnostic Tools, Diagnostic Algorithm, and Training and Communication on Outpatient Acute Fever Case Management at 3 Diverse Sites in Uganda: Results of a Randomized Controlled Trial. Clin Infect Dis 2023; 77:S156-S170. [PMID: 37490746 PMCID: PMC10368415 DOI: 10.1093/cid/ciad341] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Indexed: 07/27/2023] Open
Abstract
BACKGROUND Increasing trends of antimicrobial resistance are observed around the world, driven in part by excessive use of antimicrobials. Limited access to diagnostics, particularly in low- and middle-income countries, contributes to diagnostic uncertainty, which may promote unnecessary antibiotic use. We investigated whether introducing a package of diagnostic tools, clinical algorithm, and training-and-communication messages could safely reduce antibiotic prescribing compared with current standard-of-care for febrile patients presenting to outpatient clinics in Uganda. METHODS This was an open-label, multicenter, 2-arm randomized controlled trial conducted at 3 public health facilities (Aduku, Nagongera, and Kihihi health center IVs) comparing the proportions of antibiotic prescriptions and clinical outcomes for febrile outpatients aged ≥1 year. The intervention arm included a package of point-of-care tests, a diagnostic and treatment algorithm, and training-and-communication messages. Standard-of-care was provided to patients in the control arm. RESULTS A total of 2400 patients were enrolled, with 49.5% in the intervention arm. Overall, there was no significant difference in antibiotic prescriptions between the study arms (relative risk [RR]: 1.03; 95% CI: .96-1.11). In the intervention arm, patients with positive malaria test results (313/500 [62.6%] vs 170/473 [35.9%]) had a higher RR of being prescribed antibiotics (1.74; 1.52-2.00), while those with negative malaria results (348/688 [50.6%] vs 376/508 [74.0%]) had a lower RR (.68; .63-.75). There was no significant difference in clinical outcomes. CONCLUSIONS This study found that a diagnostic intervention for management of febrile outpatients did not achieve the desired impact on antibiotic prescribing at 3 diverse and representative health facility sites in Uganda.
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Affiliation(s)
- James Kapisi
- Department of Disease Surveillance, Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Asadu Sserwanga
- Department of Disease Surveillance, Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Freddy Eric Kitutu
- Department of Pharmacy, Makerere University School of Health Sciences, Kampala, Uganda
| | - Elizeus Rutebemberwa
- Department of Health Policy, Planning, and Management, Makerere University School of Public Health, Kampala, Uganda
| | - Phyllis Awor
- Department of Health Policy, Planning, and Management, Makerere University School of Public Health, Kampala, Uganda
| | - Stephan Weber
- Department of Statistics, ACOMED Statistics, Leipzig, Germany
| | - Thomas Keller
- Department of Statistics, ACOMED Statistics, Leipzig, Germany
| | | | - Deborah Ekusai-Sebatta
- Department of Disease Surveillance, Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Philip Horgan
- FIND, Geneva, Switzerland
- Nuffield Department of Medicine, Big Data Institute, University of Oxford, Oxford, United Kingdom
- Evidence & Impact Oxford, Oxford, United Kingdom
| | - Sabine Dittrich
- FIND, Geneva, Switzerland
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
- Deggendorf Institute of Technology, European-Campus-Rottal-Inn, Pfarrkirchen, Germany
| | - Catrin E Moore
- Nuffield Department of Medicine, Big Data Institute, University of Oxford, Oxford, United Kingdom
- Centre for Neonatal and Paediatric Infection, Institute for Infection and Immunity, St George's University of London, London, United Kingdom
| | | | - Piero Olliaro
- FIND, Geneva, Switzerland
- Nuffield Department of Medicine, Pandemic Sciences Institute, University of Oxford, Oxford, United Kingdom
| | | | - Heidi Hopkins
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
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4
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Neupane R, Bhathena M, Das G, Long E, Beard J, Solomon H, Simon JL, Nisar YB, MacLeod WB, Hamer DH. Antibiotic resistance trends for common bacterial aetiologies of childhood diarrhoea in low- and middle-income countries: A systematic review. J Glob Health 2023; 13:04060. [PMID: 37475599 PMCID: PMC10359834 DOI: 10.7189/jogh.13.04060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/22/2023] Open
Abstract
Background Diarrhoea is the second most common cause of death among children under the age of five worldwide. The World Health Organization (WHO) recommends treating diarrhoea with oral rehydration therapy, intravenous fluids for severe dehydration, and zinc supplements. Antibiotics are only recommended to treat acute, invasive diarrhoea. Rising antibiotic resistance has led to a decrease in the effectiveness of treatments for diarrhoea. Methods A systematic literature review in PubMed, Web of Science, and EMBASE was conducted to identify articles relevant to antibiotic-resistant childhood diarrhoea. Articles in English published between 1990 to 2020 that described antibiotic resistance patterns of common pathogens causing childhood diarrhoea in low- and middle-income countries were included. The studies were limited to papers that categorized children as 0-5 years or 0-10 years old. The proportion of isolates with resistance to major classes of antibiotics stratified by major WHO global regions and time was determined. Results Quantitative data were extracted from 44 articles that met screening criteria; most focused on children under five years. Escherichia coli isolates had relatively high resistance rates to ampicillin and tetracycline in the African (AFR), American (AMR), and Eastern Mediterranean Regions (EMR). There was moderate to high resistance to ampicillin and third generation cephalosporins among Salmonella spp in the AFR, EMR, and the Western Pacific Region (WPR). Resistance rates for ampicillin, co-trimoxazole, and chloramphenicol for Shigella in the AFR started at an alarmingly high rate ( ~ 90%) in 2006 and fluctuated over time. There were limited antibiotic resistance data for Aeromonas, Yersinia, and V. cholerae. The 161 isolates of Campylobacter analysed showed initially low rates of fluoroquinolone resistance with high rates of resistance in recent years, especially in the Southeast Asian Region. Conclusions Resistance to inexpensive antibiotics for treatment of invasive diarrhoea in children under ten years is widespread (although data on 6- to 10-year-old children are limited), and resistance rates to fluoroquinolones and later-generation cephalosporins are increasing. A strong regional surveillance system is needed to carefully monitor trends in antibiotic resistance, future studies should include school-aged children, and interventions are needed to reduce inappropriate use of antibiotics for the treatment of community-acquired, non-invasive diarrhoea. Registration This systematic review was registered in Prospero (registration number CRD42020204004) in August 2020.
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Affiliation(s)
- Raghavee Neupane
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Myra Bhathena
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Gopika Das
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Elizabeth Long
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Jennifer Beard
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Hiwote Solomon
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Jon L Simon
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Yasir B Nisar
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - William B MacLeod
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Davidson H Hamer
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
- Section of Infectious Diseases, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
- Center for Emerging Infectious Diseases Policy and Research, Boston University, Boston, Massachusetts, USA
- National Emerging Infectious Disease Laboratory, Boston University, Boston, Massachusetts, USA
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, Massachusetts, USA
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5
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Satria YAA, Utami MS, Prasudi A. Prevalence of antibiotics prescription amongst patients with and without COVID-19 in low- and middle-income countries: a systematic review and meta-analysis. Pathog Glob Health 2023; 117:437-449. [PMID: 36562085 PMCID: PMC10262768 DOI: 10.1080/20477724.2022.2160892] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Antimicrobial resistance (AMR) poses a substantial risk to public health. In low-income and middle-income (LMICs) nations, the impact of AMR is significantly more severe. The absence of data from low-income countries (LMICs) causes this topic to be frequently overlooked. Additionally, the COVID-19 pandemic could make the AMR issue even worse. Earlier guidelines recommended antibiotic use in patients with COVID-19, even in those without bacterial coinfection. This study aims to investigate the proportion of antibiotic prescriptions in LMICs among patients with and without coronavirus disease-2019 (COVID-19), the proportion of inappropriate antibiotics, and multi-antibiotic prescribing. We followed the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA). We retrieved data through online databases, including PubMed, Scopus, and ScienceDirect. Amongst COVID-19 patients, the meta-analytic estimate of antibiotic prescription was 0.80 (95% CI: 0.72-0.88), whereas antibiotic use among patients with non-COVID-19 infections was 0.54 (95% CI: 0.49-0.58). Half of those prescribed antibiotics (0.52, 95% CI: 0.32-0.72) are inappropriate prescriptions. In addition, we found that one-third of antibiotics prescriptions consisted of more than one antibiotic (0.32, 95% CI: 0.21-0.43). In conclusion, antibiotics are highly prescribed across LMICs, and their use is increased in patients with COVID-19. Amongst those prescriptions, inappropriate and multiple use was not uncommon. This study has several limitations, as it included two studies in an ambulatory setting, and some of the studies included in the analysis were conducted on a small scale. Nevertheless, our findings suggest that urgent action to improve prescribing practices is essential.
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Affiliation(s)
| | - Monica Suci Utami
- Undergraduate Program, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Sleman, Indonesia
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Siribhadra A, Ngamprasertchai T, Rattanaumpawan P, Lawpoolsri S, Luvira V, Pitisuttithum P. Antimicrobial Stewardship in Tropical Infectious Diseases: Focusing on Dengue and Malaria. Trop Med Infect Dis 2022; 7:tropicalmed7080159. [PMID: 36006251 PMCID: PMC9412681 DOI: 10.3390/tropicalmed7080159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 07/23/2022] [Accepted: 07/28/2022] [Indexed: 11/17/2022] Open
Abstract
Acute undifferentiated febrile illness (AUFI) is the presenting symptom of various tropical and infectious diseases. Viral infection is generally the most common cause of AUFI, accounting for 8–11.8% of cases; thus, antibiotics might be unnecessary. Dengue and malaria are common tropical infectious diseases requiring effective supportive treatment and antimalarial agents, respectively. The uncertainty of early diagnosis results in widespread empirical antimicrobial treatment in high -income as well as in low-and middle-income countries. Although rapid diagnostic tests (RDTs) have been shown to limit antibiotic prescriptions in dengue and malaria, we observed a wide range of antibiotic prescriptions for 13–92.7% of cases in previous literature, particularly in RDT-negative malaria cases. Given several RDT limitations, antimicrobial stewardship (AMS) appears to be an effective strategy for controlling unnecessary antibiotic use and antimicrobial resistance (AMR) prevention. This program should be endorsed by a multidisciplinary team in tropical diseases to control collateral damage of inappropriate antimicrobial use. Empirical antibiotic treatment should be administered based on clinical judgement, microbiological evidence, and local epidemiological data. Rapid termination of antibiotic therapy, including disease control or elimination, is the mainstay of AMS in tropical diseases. Local and international sectors should implement an AMS programme to reduce AMR in the Tropics.
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Affiliation(s)
- Ashley Siribhadra
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok 10400, Thailand; (A.S.); (V.L.); (P.P.)
| | - Thundon Ngamprasertchai
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok 10400, Thailand; (A.S.); (V.L.); (P.P.)
- Correspondence:
| | - Pinyo Rattanaumpawan
- Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand;
| | - Saranath Lawpoolsri
- Department of Tropical Hygiene, Faculty of Tropical Medicine, Mahidol University, Bangkok 10400, Thailand;
| | - Viravarn Luvira
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok 10400, Thailand; (A.S.); (V.L.); (P.P.)
| | - Punnee Pitisuttithum
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok 10400, Thailand; (A.S.); (V.L.); (P.P.)
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Madut DB, Rubach MP, Bonnewell JP, Cutting ER, Carugati M, Kalengo N, Maze MJ, Morrissey AB, Mmbaga BT, Lwezaula BF, Kinabo G, Mbwasi R, Kilonzo KG, Maro VP, Crump JA. Trends in fever case management for febrile inpatients in a low malaria incidence setting of Tanzania. Trop Med Int Health 2021; 26:1668-1676. [PMID: 34598312 PMCID: PMC8639662 DOI: 10.1111/tmi.13683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES In 2010, WHO published guidelines emphasising parasitological confirmation of malaria before treatment. We present data on changes in fever case management in a low malaria transmission setting of northern Tanzania after 2010. METHODS We compared diagnoses, treatments and outcomes from two hospital-based prospective cohort studies, Cohort 1 (2011-2014) and Cohort 2 (2016-2019), that enrolled febrile children and adults. All participants underwent quality-assured malaria blood smear-microscopy. Participants who were malaria smear-microscopy negative but received a diagnosis of malaria or received an antimalarial were categorised as malaria over-diagnosis and over-treatment, respectively. RESULTS We analysed data from 2098 participants. The median (IQR) age was 27 (3-43) years and 1047 (50.0%) were female. Malaria was detected in 23 (2.3%) participants in Cohort 1 and 42 (3.8%) in Cohort 2 (p = 0.059). Malaria over-diagnosis occurred in 334 (35.0%) participants in Cohort 1 and 190 (17.7%) in Cohort 2 (p < 0.001). Malaria over-treatment occurred in 528 (55.1%) participants in Cohort 1 and 196 (18.3%) in Cohort 2 (p < 0.001). There were 30 (3.1%) deaths in Cohort 1 and 60 (5.4%) in Cohort 2 (p = 0.007). All deaths occurred among smear-negative participants. CONCLUSION We observed a substantial decline in malaria over-diagnosis and over-treatment among febrile inpatients in northern Tanzania between two time periods after 2010. Despite changes, some smear-negative participants were still diagnosed and treated for malaria. Our results highlight the need for continued monitoring of fever case management across different malaria epidemiological settings in sub-Saharan Africa.
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Affiliation(s)
- Deng B Madut
- Division of Infectious Diseases and International Health, Duke University Medical Center, Durham, North Carolina, USA
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
| | - Matthew P Rubach
- Division of Infectious Diseases and International Health, Duke University Medical Center, Durham, North Carolina, USA
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
| | - John P Bonnewell
- Division of Infectious Diseases and International Health, Duke University Medical Center, Durham, North Carolina, USA
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
- Department of Pathology, Duke University, Durham, North Carolina, USA
| | - Elena R Cutting
- Duke University School of Medicine, Durham, North Carolina, USA
| | - Manuela Carugati
- Division of Infectious Diseases and International Health, Duke University Medical Center, Durham, North Carolina, USA
| | | | - Michael J Maze
- Department of Medicine, University of Otago, Christchurch, New Zealand
- Centre for International Health, University of Otago, Dunedin, New Zealand
| | - Anne B Morrissey
- Division of Infectious Diseases and International Health, Duke University Medical Center, Durham, North Carolina, USA
| | - Blandina T Mmbaga
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Kilimanjaro Christian Medical University College, Tumaini University, Moshi, Tanzania
| | | | - Grace Kinabo
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Ronald Mbwasi
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Kajiru G Kilonzo
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Kilimanjaro Christian Medical University College, Tumaini University, Moshi, Tanzania
| | - Venance P Maro
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Kilimanjaro Christian Medical University College, Tumaini University, Moshi, Tanzania
| | - John A Crump
- Division of Infectious Diseases and International Health, Duke University Medical Center, Durham, North Carolina, USA
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
- Centre for International Health, University of Otago, Dunedin, New Zealand
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D’Arcy N, Ashiru-Oredope D, Olaoye O, Afriyie D, Akello Z, Ankrah D, Asima DM, Banda DC, Barrett S, Brandish C, Brayson J, Benedict P, Dodoo CC, Garraghan F, Hoyelah J, Jani Y, Kitutu FE, Kizito IM, Labi AK, Mirfenderesky M, Murdan S, Murray C, Obeng-Nkrumah N, Olum WJ, Opintan JA, Panford-Quainoo E, Pauwels I, Sefah I, Sneddon J, St. Clair Jones A, Versporten A. Antibiotic Prescribing Patterns in Ghana, Uganda, Zambia and Tanzania Hospitals: Results from the Global Point Prevalence Survey (G-PPS) on Antimicrobial Use and Stewardship Interventions Implemented. Antibiotics (Basel) 2021; 10:antibiotics10091122. [PMID: 34572704 PMCID: PMC8469030 DOI: 10.3390/antibiotics10091122] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Revised: 09/03/2021] [Accepted: 09/13/2021] [Indexed: 11/19/2022] Open
Abstract
Antimicrobial resistance (AMR) remains an important global public health issue with antimicrobial misuse and overuse being one of the main drivers. The Global Point Prevalence Survey (G-PPS) of Antimicrobial Consumption and Resistance assesses the prevalence and the quality of antimicrobial prescriptions across hospitals globally. G-PPS was carried out at 17 hospitals across Ghana, Uganda, Zambia and Tanzania. The overall prevalence of antimicrobial use was 50% (30–57%), with most antibiotics prescribed belonging to the WHO ‘Access’ and ‘Watch’ categories. No ‘Reserve’ category of antibiotics was prescribed across the study sites while antimicrobials belonging to the ‘Not Recommended’ group were prescribed infrequently. Antimicrobials were most often prescribed for prophylaxis for obstetric or gynaecological surgery, making up between 12 and 18% of total prescriptions across all countries. The most prescribed therapeutic subgroup of antimicrobials was ‘Antibacterials for systemic use’. As a result of the programme, PPS data are now readily available for the first time in the hospitals, strengthening the global commitment to improved antimicrobial surveillance. Antimicrobial stewardship interventions developed included the formation of AMS committees, the provision of training and the preparation of new AMS guidelines. Other common interventions included the presentation of findings to clinicians for increased awareness, and the promotion of a multi-disciplinary approach to successful AMS programmes. Repeat PPS would be necessary to continually monitor the impact of interventions implemented. Broader participation is also encouraged to strengthen the evidence base.
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Affiliation(s)
- Nikki D’Arcy
- Commonwealth Partnerships Programme on Antimicrobial Stewardship, Commonwealth Pharmacists Association, London E1W 1AW, UK; (N.D.); (O.O.)
| | - Diane Ashiru-Oredope
- Commonwealth Partnerships Programme on Antimicrobial Stewardship, Commonwealth Pharmacists Association, London E1W 1AW, UK; (N.D.); (O.O.)
- Correspondence: or
| | - Omotayo Olaoye
- Commonwealth Partnerships Programme on Antimicrobial Stewardship, Commonwealth Pharmacists Association, London E1W 1AW, UK; (N.D.); (O.O.)
| | - Daniel Afriyie
- Pharmacy Department, Ghana Police Hospital, Accra P.O. Box CT104, Ghana;
| | - Zainab Akello
- Laro Division, Gulu Regional Referral Hospital, Gulu P.O. Box 166, Uganda;
| | - Daniel Ankrah
- Korle-Bu Teaching Hospital, Accra P.O. Box 77, Ghana;
| | | | - David C. Banda
- Department of Pharmacy, University Teaching Hospital, Lusaka P.O. Box 50001, Zambia;
| | - Scott Barrett
- Pharmacy Department, North Tyneside Hospital, Northumbria Healthcare NHS Foundation Trust, Rake Lane, North Shields NE29 8NH, UK; (S.B.); (J.B.)
| | | | - Joseph Brayson
- Pharmacy Department, North Tyneside Hospital, Northumbria Healthcare NHS Foundation Trust, Rake Lane, North Shields NE29 8NH, UK; (S.B.); (J.B.)
| | - Peter Benedict
- Kilimanjaro Christian Medical Centre, Moshi P.O. Box 3010, Tanzania;
| | - Cornelius C. Dodoo
- School of Pharmacy, University of Health and Allied Sciences, PMB 31, Ho, Ghana;
| | - Frances Garraghan
- Manchester University NHS Foundation Trust, Oxford Road, Manchester M13 9WL, UK;
| | | | - Yogini Jani
- Centre for Medicines Optimisation Research and Education, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK;
| | - Freddy Eric Kitutu
- Sustainable Pharmaceutical Systems (SPS) Unit, Pharmacy Department, School of Health Sciences, Makerere University, Kampala P.O. Box 7062, Uganda;
| | | | - Appiah-Korang Labi
- Medical Microbiology Department, University of Ghana Medical School, Accra P.O. Box GP 4236, Ghana; (A.-K.L.); (J.A.O.)
| | | | - Sudaxshina Murdan
- UCL School of Pharmacy, University College London, 29-39 Brunswick Square, London WC1N 1AX, UK;
| | | | - Noah Obeng-Nkrumah
- Department of Medical Laboratory Sciences, University of Ghana School of Biomedical and Allied Health Sciences, Accra P.O. Box LG 25, Ghana;
| | | | - Japheth Awuletey Opintan
- Medical Microbiology Department, University of Ghana Medical School, Accra P.O. Box GP 4236, Ghana; (A.-K.L.); (J.A.O.)
| | | | - Ines Pauwels
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), Faculty of Medicine and Health Sciences, University of Antwerp, Universiteitsplein 1, 2610 Antwerp, Belgium; (I.P.); (A.V.)
| | - Israel Sefah
- Department of Pharmacy, Keta Municipal Hospital, Keta-Dzelukope P.O. Box WT82, Ghana;
| | - Jacqueline Sneddon
- Scottish Antimicrobial Prescribing Group, Healthcare Improvement Scotland, Delta House, 50 West Nile Street, Glasgow G1 2NP, UK;
| | | | - Ann Versporten
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), Faculty of Medicine and Health Sciences, University of Antwerp, Universiteitsplein 1, 2610 Antwerp, Belgium; (I.P.); (A.V.)
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Velu RM, Kwenda G, Libonda L, Chisenga CC, Flavien BN, Chilyabanyama ON, Simunyandi M, Bosomprah S, Sande NC, Changula K, Muleya W, Mburu MM, Mubemba B, Chitanga S, Tembo J, Bates M, Kapata N, Orba Y, Kajihara M, Takada A, Sawa H, Chilengi R, Simulundu E. Mosquito-Borne Viral Pathogens Detected in Zambia: A Systematic Review. Pathogens 2021; 10:pathogens10081007. [PMID: 34451471 PMCID: PMC8401848 DOI: 10.3390/pathogens10081007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 07/27/2021] [Accepted: 08/05/2021] [Indexed: 11/16/2022] Open
Abstract
Emerging and re-emerging mosquito-borne viral diseases are a threat to global health. This systematic review aimed to investigate the available evidence of mosquito-borne viral pathogens reported in Zambia. A search of literature was conducted in PubMed and Google Scholar for articles published from 1 January 1930 to 30 June 2020 using a combination of keywords. Eight mosquito-borne viruses belonging to three families, Togaviridae, Flaviviridae and Phenuiviridae were reported. Three viruses (Chikungunya virus, Mayaro virus, Mwinilunga virus) were reported among the togaviruses whilst four (dengue virus, West Nile virus, yellow fever virus, Zika virus) were among the flavivirus and only one virus, Rift Valley fever virus, was reported in the Phenuiviridae family. The majority of these mosquito-borne viruses were reported in Western and North-Western provinces. Aedes and Culex species were the main mosquito-borne viral vectors reported. Farming, fishing, movement of people and rain patterns were among factors associated with mosquito-borne viral infection in Zambia. Better diagnostic methods, such as the use of molecular tools, to detect the viruses in potential vectors, humans, and animals, including the recognition of arboviral risk zones and how the viruses circulate, are important for improved surveillance and design of effective prevention and control measures.
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Affiliation(s)
- Rachel Milomba Velu
- Centre for Infectious Disease Research in Zambia, Lusaka P.O. Box 34681, Zambia; (C.C.C.); (O.N.C.); (M.S.); (S.B.); (R.C.)
- Department of Disease Control, School of Veterinary Medicine, University of Zambia, Lusaka P.O. Box 32379, Zambia; (N.C.S.); (A.T.); (E.S.)
- Correspondence: (R.M.V.); (H.S.)
| | - Geoffrey Kwenda
- Department of Biomedical Sciences, School of Health Sciences, University of Zambia, Lusaka P.O. Box 50110, Zambia; (G.K.); (S.C.)
- Africa Center of Excellence for Infectious Diseases of Humans and Animals, University of Zambia, Lusaka P.O. Box 32379, Zambia
| | - Liyali Libonda
- Department of Disease Control and Prevention, School of Medicine and Health Sciences, Eden University, Lusaka P.O. Box 37727, Zambia; (L.L.); (B.N.F.)
| | - Caroline Cleopatra Chisenga
- Centre for Infectious Disease Research in Zambia, Lusaka P.O. Box 34681, Zambia; (C.C.C.); (O.N.C.); (M.S.); (S.B.); (R.C.)
| | - Bumbangi Nsoni Flavien
- Department of Disease Control and Prevention, School of Medicine and Health Sciences, Eden University, Lusaka P.O. Box 37727, Zambia; (L.L.); (B.N.F.)
| | | | - Michelo Simunyandi
- Centre for Infectious Disease Research in Zambia, Lusaka P.O. Box 34681, Zambia; (C.C.C.); (O.N.C.); (M.S.); (S.B.); (R.C.)
| | - Samuel Bosomprah
- Centre for Infectious Disease Research in Zambia, Lusaka P.O. Box 34681, Zambia; (C.C.C.); (O.N.C.); (M.S.); (S.B.); (R.C.)
- Department of Biostatistics, School of Public Health, University of Ghana, Accra P.O. Box LG13, Ghana
| | - Nicholus Chintu Sande
- Department of Disease Control, School of Veterinary Medicine, University of Zambia, Lusaka P.O. Box 32379, Zambia; (N.C.S.); (A.T.); (E.S.)
| | - Katendi Changula
- Department of Paraclinical Studies, School of Veterinary Medicine, University of Zambia, Lusaka P.O. Box 32379, Zambia;
| | - Walter Muleya
- Department of Biomedical Sciences, School of Veterinary Medicine, University of Zambia, Lusaka P.O. Box 32379, Zambia;
| | | | - Benjamin Mubemba
- Department of Zoology and Aquatic Sciences, School of Natural Resources, Copperbelt University, Kitwe P.O. Box 21692, Zambia;
| | - Simbarashe Chitanga
- Department of Biomedical Sciences, School of Health Sciences, University of Zambia, Lusaka P.O. Box 50110, Zambia; (G.K.); (S.C.)
- School of Veterinary Medicine, University of Namibia, Windhoek Private Bag 13301, Namibia
- School of Life Sciences, University of KwaZulu-Natal, Private Bag X54001, Durban 4000, South Africa
| | - John Tembo
- HerpeZ Infection Research and Training, University Teaching Hospital, Lusaka Private Bag RW1X Ridgeway, Lusaka P.O. Box 10101, Zambia; (J.T.); (M.B.)
| | - Matthew Bates
- HerpeZ Infection Research and Training, University Teaching Hospital, Lusaka Private Bag RW1X Ridgeway, Lusaka P.O. Box 10101, Zambia; (J.T.); (M.B.)
- School of Life Sciences, University of Lincoln, Brayford Pool, Lincoln LN6 7TS, UK
| | - Nathan Kapata
- Zambia National Public Health Institute, Ministry of Health, Lusaka P.O. Box 30205, Zambia;
| | - Yasuko Orba
- Division of Molecular Pathobiology, International Institute for Zoonosis Control, Hokkaido University, N 20 W10, Kita-ku, Sapporo 001-0020, Japan;
| | - Masahiro Kajihara
- Division of Global Epidemiology, International Institute for Zoonosis Control, Hokkaido University, N 20 W10, Kita-ku, Sapporo 001-0020, Japan;
| | - Ayato Takada
- Department of Disease Control, School of Veterinary Medicine, University of Zambia, Lusaka P.O. Box 32379, Zambia; (N.C.S.); (A.T.); (E.S.)
- Africa Center of Excellence for Infectious Diseases of Humans and Animals, University of Zambia, Lusaka P.O. Box 32379, Zambia
- Division of Global Epidemiology, International Institute for Zoonosis Control, Hokkaido University, N 20 W10, Kita-ku, Sapporo 001-0020, Japan;
| | - Hirofumi Sawa
- Department of Disease Control, School of Veterinary Medicine, University of Zambia, Lusaka P.O. Box 32379, Zambia; (N.C.S.); (A.T.); (E.S.)
- Africa Center of Excellence for Infectious Diseases of Humans and Animals, University of Zambia, Lusaka P.O. Box 32379, Zambia
- Division of Molecular Pathobiology, International Institute for Zoonosis Control, Hokkaido University, N 20 W10, Kita-ku, Sapporo 001-0020, Japan;
- Global Virus Network, 725 W Lombard St., Baltimore, MD 21201, USA
- Correspondence: (R.M.V.); (H.S.)
| | - Roma Chilengi
- Centre for Infectious Disease Research in Zambia, Lusaka P.O. Box 34681, Zambia; (C.C.C.); (O.N.C.); (M.S.); (S.B.); (R.C.)
| | - Edgar Simulundu
- Department of Disease Control, School of Veterinary Medicine, University of Zambia, Lusaka P.O. Box 32379, Zambia; (N.C.S.); (A.T.); (E.S.)
- Macha Research Trust, Choma P.O. Box 630166, Zambia;
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10
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Otten T, de Mast Q, Koeneman B, Althaus T, Lubell Y, van der Ven A. Value of C-reactive protein in differentiating viral from bacterial aetiologies in patients with non-malaria acute undifferentiated fever in tropical areas: a meta-analysis and individual patient data study. Trans R Soc Trop Med Hyg 2021; 115:1130-1143. [PMID: 33644814 DOI: 10.1093/trstmh/traa186] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 11/23/2020] [Accepted: 12/22/2020] [Indexed: 12/21/2022] Open
Abstract
C-reactive protein (CRP) is used to discriminate common bacterial and viral infections, but its utility in tropical settings remains unknown. We performed a meta-analysis of studies performed in Asia and Africa. First, mean CRP levels for specific tropical infections were calculated. Thereafter, individual patient data (IPD) from patients with non-malarial undifferentiated fever (NMUF) who were tested for viral and bacterial pathogens were analysed, calculating separate cut-off values and their performance in classifying viral or bacterial disease. Mean CRP levels of 7307 patients from 13 countries were dengue 12.0 mg/l (standard error [SE] 2.7), chikungunya 41.0 mg/l (SE 19.5), influenza 15.9 mg/l (SE 6.3), Crimean-Congo haemorrhagic fever 9.7 mg/l (SE 4.7), Salmonella 61.9 mg/l (SE 5.4), Rickettsia 61.3 mg/l (SE 8.8), Coxiella burnetii 98.7 mg/l (SE 44.0) and Leptospira infections 113.8 mg/l (SE 23.1). IPD analysis of 1059 NMUF patients ≥5 y of age showed CRP <10 mg/l had 52% sensitivity (95% confidence interval [CI] 48 to 56) and 95% specificity (95% CI 93 to 97) to detect viral infections. CRP >40 mg/l had 74% sensitivity (95% CI 70 to 77) and 84% specificity (95% CI 81 to 87) to identify bacterial infections. Compared with routine care, the relative risk for incorrect classification was 0.64 (95% CI 0.55 to 0.75) and the number needed to test for one extra correctly classified case was 8 (95% CI 6 to 12). A two cut-off value CRP test may help clinicians to discriminate viral and bacterial aetiologies of NMUF in tropical areas.
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Affiliation(s)
- Twan Otten
- Department of International Health and Infectious Diseases, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Quirijn de Mast
- Department of International Health and Infectious Diseases, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Bouke Koeneman
- Department of International Health and Infectious Diseases, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Thomas Althaus
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, 10400, Thailand
| | - Yoel Lubell
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, 10400, Thailand
| | - André van der Ven
- Department of International Health and Infectious Diseases, Radboud University Medical Centre, Nijmegen, The Netherlands
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11
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Swe MMM, Ashley EA, Althaus T, Lubell Y, Smithuis F, Mclean ARD. Inter-prescriber variability in the decision to prescribe antibiotics to febrile patients attending primary care in Myanmar. JAC Antimicrob Resist 2021; 3:dlaa118. [PMID: 33506197 PMCID: PMC7814214 DOI: 10.1093/jacamr/dlaa118] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 12/08/2020] [Indexed: 11/13/2022] Open
Abstract
Background Most antibiotic prescribing occurs in primary care. Even within the same health facility, there may be differences between prescribers in their tendency to prescribe antibiotics, which may be masked by summary data. We aimed to quantify prescriber variability in antibiotic prescription to patients with acute fever in primary care clinics in Myanmar. Methods We conducted a secondary analysis of prescribing data from 1090 patient consultations with 40 prescribing doctors from a trial investigating the effect of point-of-care C-reactive protein (CRP) tests on antibiotic prescription for acute fever. We used multilevel logistic regression models to assess inter-prescriber variability in the decision to prescribe antibiotics. Results The median odds ratio (MOR) in the unadjusted model was 1.82 (95% CI: 1.47–2.56) indicating that when two prescribers from this population are randomly selected then in half of these pairs the odds of prescription will be greater than 1.82-fold higher in one prescriber than the other. The estimated variability from this sample of prescribers corresponds to a population of prescribers where the top 25% of prescribers will prescribe antibiotics to over 41% of patients while the bottom 25% will prescribe antibiotics to less than 23% of patients. Inter-prescriber variation in antibiotic prescribing remained after adjustment for patient characteristics and CRP information (P < 0.001). Conclusions Despite sharing the same management guidelines, there was substantial inter-prescriber variation in antibiotic prescription to patients with acute fever. This variation should be considered when designing trials and stewardship programmes aiming to reduce inappropriate antibiotic prescribing.
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Affiliation(s)
- Myo Maung Maung Swe
- Myanmar Oxford Clinical Research Unit, Yangon, Myanmar (MOCRU), Yangon, Myanmar.,The Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Elizabeth A Ashley
- Myanmar Oxford Clinical Research Unit, Yangon, Myanmar (MOCRU), Yangon, Myanmar.,Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), Vientiane, Laos
| | - Thomas Althaus
- The Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.,Mahidol Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Yoel Lubell
- The Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.,Mahidol Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Frank Smithuis
- Myanmar Oxford Clinical Research Unit, Yangon, Myanmar (MOCRU), Yangon, Myanmar.,The Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.,Medical Action Myanmar, Yangon, Myanmar
| | - Alistair R D Mclean
- Myanmar Oxford Clinical Research Unit, Yangon, Myanmar (MOCRU), Yangon, Myanmar.,The Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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12
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Opoku MM, Bonful HA, Koram KA. Antibiotic prescription for febrile outpatients: a health facility-based secondary data analysis for the Greater Accra region of Ghana. BMC Health Serv Res 2020; 20:978. [PMID: 33109158 PMCID: PMC7590657 DOI: 10.1186/s12913-020-05771-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 09/28/2020] [Indexed: 12/04/2022] Open
Abstract
Background Misguided prescription of antibiotics is an important contributor towards the emergence and spread of antibiotic resistance. The absence of effective interventions to control antibiotic use leads to increased consumption beyond the needed requirements. Antibiotic stewardship interventions must be appropriately targeted and assessed to enhance the controlled use of antibiotics. The objective of this study was to determine the factors associated with antibiotic prescription to febrile outpatients who seek care in health facilities within the Greater Accra region of Ghana. Methods Secondary data obtained from the medical records of 2519 febrile outpatients, consecutively sampled at the outpatient department of 6 health facilities in 3 municipalities during the baseline survey of a quasi-experiment in 2015 was used. The primary outcome was prescription of any antibiotic. Independent variables included patients’ demographics, symptoms, laboratory investigations (blood film microscopy, malaria rapid diagnostic test, full blood count, urine and stool routine examinations), diagnoses, and prescribers’ demographics. Crude and adjusted logistic regression analyses were used to determine the factors associated with antibiotic prescription. Results The prevalence of antibiotic prescription was 70.1% (95% CI: 67.7–72.4). Prescribers with more years of practice (> 5 years) were more likely to prescribe antibiotics compared to those with less than 3 years of practice (p < 0.001). Integrated Management of Neonatal and Childhood Illnesses (IMNCI) training was associated with a 2.3 (95% CI: 1.54, 3.53, p < 0.001) fold odds of antibiotic prescribing. Patients aged 5 years or more were 60% less likely to receive antibiotics compared with those under 5 years (AOR = 0.40, 95% CI: 0.32, 0.51; p < 0.001). Patients referred for laboratory investigations were 29% less likely to be prescribed antibiotics than those not referred. The presence of cough as a presenting symptom was associated with a 3.5 (95% CI: 2.54, 4.92) fold odds of antibiotic prescription. Conclusion Prescription of antibiotics to febrile outpatients was high. Promoting laboratory testing can potentially reduce irrational antibiotic prescription. Prescribing antibiotics for children under five and the prescribing practices of prescribers with longer years of practice should be targeted with interventions to reduce high use of antibiotics.
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Affiliation(s)
- Michael Mireku Opoku
- Department of Epidemiology and Disease Control, School of Public Health, University of Ghana, Legon, Ghana
| | - Harriet Affran Bonful
- Department of Epidemiology and Disease Control, School of Public Health, University of Ghana, Legon, Ghana.
| | - Kwadwo Ansah Koram
- Department of Epidemiology, Noguchi Memorial Institute for Medical Research, University of Ghana, Legon, Ghana
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13
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Elven J, Dahal P, Ashley EA, Thomas NV, Shrestha P, Stepniewska K, Crump JA, Newton PN, Bell D, Reyburn H, Hopkins H, Guérin PJ. Non-malarial febrile illness: a systematic review of published aetiological studies and case reports from Africa, 1980-2015. BMC Med 2020; 18:279. [PMID: 32951596 PMCID: PMC7504660 DOI: 10.1186/s12916-020-01744-1] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Accepted: 08/13/2020] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND The availability of reliable point-of-care tests for malaria has heralded a paradigm shift in the management of febrile illnesses away from presumptive antimalarial therapy. In the absence of a definitive diagnosis, health care providers are more likely to prescribe empirical antimicrobials to those who test negative for malaria. To improve management and guide further test development, better understanding is needed of the true causative agents and their geographic variability. METHODS A systematic review of published literature was undertaken to characterise the spectrum of pathogens causing non-malaria febrile illness in Africa (1980-2015). Literature searches were conducted in English and French languages in six databases: MEDLINE, EMBASE, Global Health (CABI), WHO Global Health Library, PASCAL, and Bulletin de la Société Française de Parasitologie (BDSP). Selection criteria included reporting on an infection or infections with a confirmed diagnosis, defined as pathogens detected in or cultured from samples from normally sterile sites, or serological evidence of current or past infection. A number of published articles (rather than incidence or prevalence) reporting a given pathogen were presented. RESULTS A total of 16,523 records from 48 African countries were screened, of which 1065 (6.4%) met selection criteria. Bacterial infections were reported in 564 (53.0%) records, viral infections in 374 (35.1%), parasitic infections in 47 (4.4%), fungal infections in nine (0.8%), and 71 (6.7%) publications reported more than one pathogen group. Age range of the study population was not specified in 233 (21.9%) publications. Staphylococcus aureus (18.2%), non-typhoidal Salmonella (17.3%), and Escherichia coli (15.4%) were the commonly reported bacterial infections whereas Rift Valley fever virus (7.4%), yellow fever virus (7.0%), and Ebola virus (6.7%) were the most commonly reported viral infections. Dengue virus infection, previously not thought to be widespread in Africa, was reported in 54 (5.1%) of articles. CONCLUSIONS This review summarises the published reports of non-malaria pathogens that may cause febrile illness in Africa. As the threat of antimicrobial resistance looms, knowledge of the distribution of infectious agents causing fever should facilitate priority setting in the development of new diagnostic tools and improved antimicrobial stewardship. TRIAL REGISTRATION PROSPERO, CRD42016049281.
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Affiliation(s)
- Jeanne Elven
- Infectious Diseases Data Observatory, University of Oxford, New Richards Building,Old Road Campus,Headington, Oxford, OX3 7LG, UK
| | - Prabin Dahal
- Infectious Diseases Data Observatory, University of Oxford, New Richards Building,Old Road Campus,Headington, Oxford, OX3 7LG, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Elizabeth A Ashley
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
- Lao-Oxford-Mahosot Hospital-Wellcome Research Unit, Mahosot Hospital, Vientiane, Laos
| | - Nigel V Thomas
- Infectious Diseases Data Observatory, University of Oxford, New Richards Building,Old Road Campus,Headington, Oxford, OX3 7LG, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Poojan Shrestha
- Infectious Diseases Data Observatory, University of Oxford, New Richards Building,Old Road Campus,Headington, Oxford, OX3 7LG, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Kasia Stepniewska
- Infectious Diseases Data Observatory, University of Oxford, New Richards Building,Old Road Campus,Headington, Oxford, OX3 7LG, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - John A Crump
- Centre for International Health, University of Otago, Dunedin, New Zealand
| | - Paul N Newton
- Infectious Diseases Data Observatory, University of Oxford, New Richards Building,Old Road Campus,Headington, Oxford, OX3 7LG, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
- Lao-Oxford-Mahosot Hospital-Wellcome Research Unit, Mahosot Hospital, Vientiane, Laos
- London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - David Bell
- Independent consultant, Issaquah, Washington, USA
| | - Hugh Reyburn
- London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Heidi Hopkins
- London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK.
| | - Philippe J Guérin
- Infectious Diseases Data Observatory, University of Oxford, New Richards Building,Old Road Campus,Headington, Oxford, OX3 7LG, UK.
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK.
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14
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Kapito-Tembo A, Mathanga D, Bauleni A, Nyirenda O, Pensulo P, Ali D, Valim C, Taylor TE, Laufer MK. Prevalence and Clinical Management of Non-malarial Febrile Illnesses among Outpatients in the Era of Universal Malaria Testing in Malawi. Am J Trop Med Hyg 2020; 103:887-893. [PMID: 32588795 DOI: 10.4269/ajtmh.18-0800] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Increasing access to rapid diagnostic tests for malaria (mRDTs) has raised awareness of the challenges healthcare workers face in managing non-malarial febrile illnesses (NMFIs). We examined NMFI prevalence, clinical diagnoses, and prescribing practices in outpatient clinics across different malaria transmission settings in Malawi. Standardized facility-based malaria surveillance was conducted at three facilities one of every 4 weeks over 2 years. Information on demographics, presenting symptoms, temperature, clinical diagnosis, and treatment were collected from outpatients presenting with malaria-like symptoms. Of the 25,486 patients with fever, 69% had NMFI. Non-malarial febrile illness prevalence was lower in 5- to 15-year-old patients (55%) than in children < 5 years (72%) and adults > 15 years of age (77%). The most common clinical diagnoses among febrile patients with negative mRDTs in all age-groups and settings were respiratory infections (46%), sepsis (29%), gastroenteritis (13%), musculoskeletal pain (9%), and malaria (5%). Antibiotic prescribing was high in all age-groups and settings. Trimethoprim-sulfamethoxazole (40%) and amoxicillin (29%) were the most commonly prescribed antibiotics and were used for nearly all clinical diagnoses. In these settings with minimal access to diagnostic tools, patients with fever and a negative mRDT received a limited number of clinical diagnoses. Many were likely to be inaccurate and were associated with the inappropriate use of the limited range of available antibiotics. Prescription and diagnostic practices for NMFIs in the facilities require research and policy input. Resource-limited malaria-endemic countries urgently need more point-of-care diagnostic tools and evidence-based diagnosis and treatment algorithms to provide effective and cost-efficient care.
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Affiliation(s)
- Atupele Kapito-Tembo
- Malaria Alert Center, University of Malawi College of Medicine, Blantyre, Malawi
| | - Don Mathanga
- Malaria Alert Center, University of Malawi College of Medicine, Blantyre, Malawi
| | - Andrew Bauleni
- Malaria Alert Center, University of Malawi College of Medicine, Blantyre, Malawi
| | - Osward Nyirenda
- Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi
| | - Paul Pensulo
- Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi
| | - Doreen Ali
- Malawi National Malaria Control Program, Lilongwe, Malawi
| | - Clarissa Valim
- Department of Immunology and Infectious Diseases, Harvard School of Public Health, Boston, Massachusetts
| | - Terrie E Taylor
- College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan.,Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi
| | - Miriam K Laufer
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, Maryland
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15
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Sulis G, Adam P, Nafade V, Gore G, Daniels B, Daftary A, Das J, Gandra S, Pai M. Antibiotic prescription practices in primary care in low- and middle-income countries: A systematic review and meta-analysis. PLoS Med 2020; 17:e1003139. [PMID: 32544153 PMCID: PMC7297306 DOI: 10.1371/journal.pmed.1003139] [Citation(s) in RCA: 107] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 05/08/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The widespread use of antibiotics plays a major role in the development and spread of antimicrobial resistance. However, important knowledge gaps still exist regarding the extent of their use in low- and middle-income countries (LMICs), particularly at the primary care level. We performed a systematic review and meta-analysis of studies conducted in primary care in LMICs to estimate the prevalence of antibiotic prescriptions as well as the proportion of such prescriptions that are inappropriate. METHODS AND FINDINGS We searched PubMed, Embase, Global Health, and CENTRAL for articles published between 1 January 2010 and 4 April 2019 without language restrictions. We subsequently updated our search on PubMed only to capture publications up to 11 March 2020. Studies conducted in LMICs (defined as per the World Bank criteria) reporting data on medicine use in primary care were included. Three reviewers independently screened citations by title and abstract, whereas the full-text evaluation of all selected records was performed by 2 reviewers, who also conducted data extraction and quality assessment. A modified version of a tool developed by Hoy and colleagues was utilized to evaluate the risk of bias of each included study. Meta-analyses using random-effects models were performed to identify the proportion of patients receiving antibiotics. The WHO Access, Watch, and Reserve (AWaRe) framework was used to classify prescribed antibiotics. We identified 48 studies from 27 LMICs, mostly conducted in the public sector and in urban areas, and predominantly based on medical records abstraction and/or drug prescription audits. The pooled prevalence proportion of antibiotic prescribing was 52% (95% CI: 51%-53%), with a prediction interval of 44%-60%. Individual studies' estimates were consistent across settings. Only 9 studies assessed rationality, and the proportion of inappropriate prescription among patients with various conditions ranged from 8% to 100%. Among 16 studies in 15 countries that reported details on prescribed antibiotics, Access-group antibiotics accounted for more than 60% of the total in 12 countries. The interpretation of pooled estimates is limited by the considerable between-study heterogeneity. Also, most of the available studies suffer from methodological issues and report insufficient details to assess appropriateness of prescription. CONCLUSIONS Antibiotics are highly prescribed in primary care across LMICs. Although a subset of studies reported a high proportion of inappropriate use, the true extent could not be assessed due to methodological limitations. Yet, our findings highlight the need for urgent action to improve prescription practices, starting from the integration of WHO treatment recommendations and the AWaRe classification into national guidelines. TRIAL REGISTRATION PROSPERO registration number: CRD42019123269.
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Affiliation(s)
- Giorgia Sulis
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
- McGill International TB Centre, McGill University, Montreal, Quebec, Canada
| | - Pierrick Adam
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
- McGill International TB Centre, McGill University, Montreal, Quebec, Canada
| | - Vaidehi Nafade
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
- McGill International TB Centre, McGill University, Montreal, Quebec, Canada
| | - Genevieve Gore
- Schulich Library of Physical Sciences, Life Sciences and Engineering, McGill University, Montreal, Quebec, Canada
| | - Benjamin Daniels
- McCourt School of Public Policy, Georgetown University, Washington, District of Columbia, United States of America
| | - Amrita Daftary
- McGill International TB Centre, McGill University, Montreal, Quebec, Canada
- School of Health Policy and Management, Faculty of Health, York University, Toronto, Ontario, Canada
| | - Jishnu Das
- McCourt School of Public Policy, Georgetown University, Washington, District of Columbia, United States of America
| | - Sumanth Gandra
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, United States of America
| | - Madhukar Pai
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
- McGill International TB Centre, McGill University, Montreal, Quebec, Canada
- Manipal McGill Program for Infectious Diseases, Manipal Centre for Infectious Diseases, Manipal Academy of Higher Education, Manipal, Karnataka, India
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Klootwijk L, Chirwa AE, Kabaghe AN, van Vugt M. Challenges affecting prompt access to adequate uncomplicated malaria case management in children in rural primary health facilities in Chikhwawa Malawi. BMC Health Serv Res 2019; 19:735. [PMID: 31640676 PMCID: PMC6805512 DOI: 10.1186/s12913-019-4544-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 09/20/2019] [Indexed: 01/09/2023] Open
Abstract
Background Reducing the burden of malaria highly depends on access to prompt and effective malaria diagnosis and treatment. The aim of this study was to identify challenges affecting prompt access to effective uncomplicated malaria case management in children below 10 years old in rural primary health care facilities in Malawi. Methods A cross sectional health facility survey was conducted in six primary health facilities in Chikhwawa district, Malawi. Officers-in-charge of health facilities were interviewed on availability of staff, supplies and drugs. All consecutive children presenting at the facility with fever or suspected malaria, aged 6 months to 10 years old, were eligible to participate in exit interviews. Exit interviews with participants’ guardians assessed duration of illness, demographic information and distance travelled. Adherence to recommended malaria case management guidelines included performing malaria rapid diagnostic tests (mRDTs) in children with fever or suspected malaria and prescribing recommended weight-based dose of artemether-lumefantrine (AL) when mRDT was positive. Multivariate logistic regression was used to determine factors associated with prompt care seeking within 24 h of onset of illness. Results Health facilities were staffed by at least two health workers. Of 265 children screened, nine were excluded due to severe illness. Twenty-one percent of children presenting at a health facility with fever were not tested for malaria. Adherence to positive and negative mRDT results for those tested was 99.4, 95% CI [98.1–100] and 97, 95% CI [88.9–100], respectively. AL was prescribed as recommended by weight in 152 children (92.2%). Temporary stock outs of AL occurred in five of six facilities. In total, 146 (57, 95% CI [52.7–64.1]) guardians of patients sought care within 24 h after fever onset. Children aged 5 to 10 years were less likely to present within 24 h of fever onset than children below 5 years of age (unadjusted odds ratio 0.40, 95% CI [0.2–0.7]). Conclusion Adherence to malaria diagnosis and treatment guidelines was high. However, delayed care seeking and stock outs may affect prompt and effective malaria case management. Further qualitative work is required to determine, and address factors associated with delay in care seeking for fever.
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Affiliation(s)
- Larissa Klootwijk
- Academic Medical Centre, University of Amsterdam, Redemptoristenpad 18, 5211XR, Den Bosch, Amsterdam, Netherlands.
| | - Anthony Emeritus Chirwa
- Training and Research Unit of Excellence, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Alinune Nathanael Kabaghe
- Training and Research Unit of Excellence, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Michele van Vugt
- Department of Internal Medicine and Infectious Diseases, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
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17
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Ntamabyaliro NY, Burri C, Nzolo DB, Engo AB, Lula YN, Mampunza SM, Nsibu CN, Mesia GK, Kayembe JMN, Likwela JL, Kintaudi LM, Tona GL. Drug use in the management of uncomplicated malaria in public health facilities in the Democratic Republic of the Congo. Malar J 2018; 17:189. [PMID: 29724210 PMCID: PMC5934796 DOI: 10.1186/s12936-018-2332-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 04/25/2018] [Indexed: 02/04/2023] Open
Abstract
Background Malaria the first causes of death from parasitic infection worldwide. Interventions to reduce the burden of malaria have produced a tremendous drop in malaria morbidity and mortality. However, progress is slower in DRC, which shares with Nigeria 39% of deaths related to malaria globally. Inappropriate use of drugs may be one of the factors of this below-average performance. The aim of this study was to describe the use of drugs in the management of uncomplicated malaria in public health facilities in DRC. Methods A drug use study was carried out in DRC from January to March 2014. In each of the former 11 provinces of DRC, one Rural Health Centre, one Urban Health Centre and one General Hospital were selected. In each of them, 100 patient’s files containing prescription of anti-malarials from January to December 2013 were randomly selected. Among them, all of the files with diagnosis of uncomplicated malaria were included in this study. Prescribed anti-malarials, co-prescribed drugs and their indications were collected. Descriptive analyses were performed. Results A total of 2300 files out of 3300 (69.7%) concerned uncomplicated malaria and were included in analysis. Malaria treatment was initiated after a positive RDT or microscopy in 51.5% of cases, upon suspicion without requesting biological confirmation in 37% and despite negative results in 11%. Twenty-nine (29) different treatment regimens were used. The drugs recommended by the National Malaria Control Programme were used in 54.3% of cases (artesunate–amodiaquine 37.4% or artemether–lumefantrine 16.9%). The second most used anti-malarial was quinine (32.4%). Apart from anti-malarials, an average of 3.1 drugs per patient were prescribed, among which antibiotics (67.9%), analgesics and non-steroidal anti-inflammatory (NSAIDs) (all abbreviations to be explicated on first use) (70.6%), vitamins (29.1%), anaemia drugs, including blood transfusion (9.1%) and corticosteroids (5.7%), In 51.4% of cases there was no indication for the concomitant medication. Conclusion Management of uncomplicated malaria in DRC is characterized by a low adherence to treatment policy, numerous treatment regimens, and abundant concomitant medication potentially harmful to the patient. This may contribute to the low performance of DRC in malaria control. Determinant of this irrational use of drugs need to be assessed in order to formulate and implement efficient corrective measures.
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Affiliation(s)
- Nsengi Y Ntamabyaliro
- Unité de Pharmacologie Clinique, Faculté de Medicine, Université de Kinshasa, Kinshasa, Democratic Republic of the Congo.
| | - Christian Burri
- Division of Medicines Research, Swiss Tropical and Public Health Institute, Basel, Switzerland.,Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland
| | - Didier B Nzolo
- Unité de Pharmacologie Clinique, Faculté de Medicine, Université de Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Aline B Engo
- Unité de Pharmacologie Clinique, Faculté de Medicine, Université de Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Yves N Lula
- Unité de Pharmacologie Clinique, Faculté de Medicine, Université de Kinshasa, Kinshasa, Democratic Republic of the Congo.,Epidemiology for Global Health Institute, University of Antwerp, Antwerp, Belgium
| | - Samuel M Mampunza
- Unité de Pharmacologie Clinique, Faculté de Medicine, Université de Kinshasa, Kinshasa, Democratic Republic of the Congo.,Centre Neuropsychopathologique, Faculté de Médecine, Université de Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Célestin N Nsibu
- Unité de Pharmacologie Clinique, Faculté de Medicine, Université de Kinshasa, Kinshasa, Democratic Republic of the Congo.,Département de Pédiatrie, Faculté de Médecine, Université de Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Gauthier K Mesia
- Unité de Pharmacologie Clinique, Faculté de Medicine, Université de Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Jean-Marie N Kayembe
- Unité de Pharmacologie Clinique, Faculté de Medicine, Université de Kinshasa, Kinshasa, Democratic Republic of the Congo.,Département de Médecine Interne, Faculté de Médecine, Université de Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Joris L Likwela
- Programme National de Lutte Contre le Paludisme, Ministère de la Santé, RDC, Kinshasa, Democratic Republic of the Congo
| | | | - Gaston L Tona
- Unité de Pharmacologie Clinique, Faculté de Medicine, Université de Kinshasa, Kinshasa, Democratic Republic of the Congo
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18
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Guenther T, Sadruddin S, Finnegan K, Wetzler E, Ibo F, Rapaz P, Koepsell J, Khan IUH, Amouzou A. Contribution of community health workers to improving access to timely and appropriate case management of childhood fever in Mozambique. J Glob Health 2018; 7:010402. [PMID: 28400951 PMCID: PMC5344010 DOI: 10.7189/jogh.07.010402] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Background Large scale evaluations in several settings have demonstrated that lay community health workers can be trained to provide quality case management of childhood illnesses. In 2010, Mozambique introduced the integrated community case management (iCCM) strategy to reach children in remote areas with care provided through Agentes Polivalentes Elementares (APEs). We assessed the contribution of the program to improved care–seeking and appropriate treatment of childhood febrile illness in Nampula Province. Methods We used a post–test quasi–experimental design with three intervention and one comparison districts to compare access and appropriateness of care for sick children in Nampula province. We carried out a household survey in the study districts to measure levels of care–seeking and treatment of childhood fever after approximately two years of full implementation of the iCCM program in the intervention districts. We also assessed consistency of care with standard case management protocols comparing children receiving care from (APEs) to those receiving care from first–level health facilities. Results A total of 773 children 6–59 months with fever in the last two weeks were included in the study. In iCCM served areas, APEs were the predominant source of care and treatment; 87.1% (95% confidence interval CI 80.8–93.4) of children 6–59 months with fever who sought care were taken first to an APE and APEs accounted for 86.2% (95% CI 79.7–92.7) of all first–line antimalarial treatments. Public health facilities were the leading source of care in comparison areas, providing care to 86.1% (95% CI 79.0–93.3) of children with fever taken for care outside the home. Timeliness of treatment was significantly better in intervention areas, where 63.9% (95% CI 54.4–73.3) of children received treatment within 24 hours of symptom onset compared to 37.5% (95% CI 31.1–43.9) in comparison areas. Children taken first to an APE were more likely to receive a rapid diagnostic test (RDT) (68.1%; 95% CI 57.2–79.0) and to have their respiratory rate assessed (60.0%; 95% CI 45.4–74.6) compared to children taken to health facilities (41.4%; 95% CI33.7–49.2 and 19.4%; 95% CI 8.4–30.5, respectively). Overall, 61.3% (95% CI 51.5–71.0) of children with fever receiving care from APEs received the correct drug within 24 hours and for the correct duration compared to 26.0% (95% CI 18.2–33.9) of those receiving care from health facilities. Conclusion iCCM contributed to improved timely and appropriate treatment for fever for children living far from facilities. Trained, supplied and supervised APEs provided care consistent with iCCM protocols and performed significantly better than first level facilities on most measures of adherence to case management protocols. These findings reinforce the need for comprehensive efforts to strengthen the health system in Mozambique to enable reliable support for quality of case management of childhood illness at both health facility and community levels.
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Affiliation(s)
| | | | - Karen Finnegan
- Johns Hopkins University, Institute of International Programs, Baltimore, Maryland, USA
| | | | - Fatima Ibo
- Save the Children International, Maputo, Mozambique
| | - Paulo Rapaz
- Save the Children International, Maputo, Mozambique
| | | | | | - Agbessi Amouzou
- Johns Hopkins University, Institute of International Programs, Baltimore, Maryland, USA
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19
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Chem ED, Anong DN, Akoachere JFKT. Prescribing patterns and associated factors of antibiotic prescription in primary health care facilities of Kumbo East and Kumbo West Health Districts, North West Cameroon. PLoS One 2018; 13:e0193353. [PMID: 29505584 PMCID: PMC5837085 DOI: 10.1371/journal.pone.0193353] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Accepted: 01/31/2018] [Indexed: 11/18/2022] Open
Abstract
Background Inappropriate use of antibiotics is a global public health challenge and has been associated with antibiotic resistance. WHO reports show that efforts to promote rational antibiotic use in developing countries are poor. With the growing number of infections with antibiotic resistant bacteria, rational drug use becomes imperative and studies that promote rational drug use are highly necessary. Considering this, we investigated prescribing patterns and predictors of antibiotic prescription in primary health care facilities in Kumbo East (KE) and Kumbo West (KW) health districts in North West Cameroon, to contribute data which could influence policy on antibiotic use. Methods and findings A cross sectional retrospective study was conducted from April 2014 to April 2015 in 26 randomly selected primary care facilities. Questionnaires were administered to 59 antibiotic prescribers to determine factors that predict antibiotic prescribing. Data on antibiotic prescription were collected by review of consultation registers. Prescription rates and demographics, prescriber and institution factors were analyzed using ANOVA. The best predictor of prescription was determined using multiple linear regression analysis. Results A total of 30,096 prescriptions were reviewed. Overall antibiotic prescription rate was 36.71%, with a mean of 1.14 antibiotics prescribed per patient. Amoxicillin was the most prescribed (29.9%). The most prevalent indications for prescribing were respiratory tract infections (21.27%). All antibiotics prescribed were broad-spectrum. Antibiotics were prescribed for patients with malaria and also in situations where diagnosis was uncertain. Prescribing by generic name was 98.36% while 99.87% was from Essential Drug List. Use of laboratory results, patient turnout and Performance Based Financing (PBF) were significantly associated with antibiotic prescribing rates (p < 0.05). PBF moderated prescribing. Conclusion There was misuse of antibiotics in primary care facilities in study area. We recommend all primary care health facilities in study area to be included in the PBF scheme and that prescribing should only be done by physicians as the have adequate training.
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Affiliation(s)
- Elvis Dzelamonyuy Chem
- Department of Microbiology and Parasitology, Faculty of Science, University of Buea, Buea, Cameroon
| | - Damian Nota Anong
- Department of Microbiology and Parasitology, Faculty of Science, University of Buea, Buea, Cameroon
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20
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Kabaghe AN, Phiri MD, Phiri KS, van Vugt M. Challenges in implementing uncomplicated malaria treatment in children: a health facility survey in rural Malawi. Malar J 2017; 16:419. [PMID: 29047388 PMCID: PMC5648442 DOI: 10.1186/s12936-017-2066-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Accepted: 10/16/2017] [Indexed: 11/10/2022] Open
Abstract
Background Prompt and effective malaria treatment are key in reducing transmission, disease severity and mortality. With the current scale-up of artemisinin-based combination therapy (ACT) coverage, there is need to focus on challenges affecting implementation of the intervention. Routine indicators focus on utilization and coverage, neglecting implementation quality. A health system in rural Malawi was assessed for uncomplicated malaria treatment implementation in children. Methods A cross-sectional health facility survey was conducted in six health centres around the Majete Wildlife Reserve in Chikwawa district using a health system effectiveness approach to assess uncomplicated malaria treatment implementation. Interviews with health facility personnel and exit interviews with guardians of 120 children under 5 years were conducted. Results Health workers appropriately prescribed an ACT and did not prescribe an ACT to 73% (95% CI 63–84%) of malaria rapid diagnostic test (RDT) positive and 98% (95% CI 96–100%) RDT negative children, respectively. However, 24% (95% CI 13–37%) of children receiving artemisinin–lumefantrine had an inappropriate dose by weight. Health facility findings included inadequate number of personnel (average: 2.1 health workers per 10,000 population), anti-malarial drug stock-outs or not supplied, and inconsistent health information records. Guardians of 59% (95% CI 51–69%) of children presented within 24 h of onset of child’s symptoms. Conclusion The survey presents an approach for assessing treatment effectiveness, highlighting bottlenecks which coverage indicators are incapable of detecting, and which may reduce quality and effectiveness of malaria treatment. Health service provider practices in prescribing and dosing anti-malarial drugs, due to drug stock-outs or high patient load, risk development of drug resistance, treatment failure and exposure to adverse effects.
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Affiliation(s)
- Alinune N Kabaghe
- Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Division of Internal Medicine, Academic Medical Center, University of Amsterdam, Meibergdreef 9, PO Box 22700, 1100 DE, Amsterdam, The Netherlands. .,Public Health Department, College of Medicine, Private Bag 360, Blantyre, Malawi.
| | - Mphatso D Phiri
- Ministry of Health, Queen Elizabeth Central Hospital, P.O. Box 95, Blantyre, Malawi.,Malawi-Liverpool Wellcome Trust, P.O Box 30096, Blantyre, Malawi
| | - Kamija S Phiri
- Public Health Department, College of Medicine, Private Bag 360, Blantyre, Malawi
| | - Michèle van Vugt
- Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Division of Internal Medicine, Academic Medical Center, University of Amsterdam, Meibergdreef 9, PO Box 22700, 1100 DE, Amsterdam, The Netherlands
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21
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Robinson ML, Manabe YC. Reducing Uncertainty for Acute Febrile Illness in Resource-Limited Settings: The Current Diagnostic Landscape. Am J Trop Med Hyg 2017; 96:1285-1295. [PMID: 28719277 DOI: 10.4269/ajtmh.16-0667] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
AbstractDiagnosing the cause of acute febrile illness in resource-limited settings is important-to give the correct antimicrobials to patients who need them, to prevent unnecessary antimicrobial use, to detect emerging infectious diseases early, and to guide vaccine deployment. A variety of approaches are yielding more rapid and accurate tests that can detect more pathogens in a wider variety of settings. After decades of slow progress in diagnostics for acute febrile illness in resource-limited settings, a wave of converging advancements will enable clinicians in resource-limited settings to reduce uncertainty for the diagnosis of acute febrile illness.
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Affiliation(s)
- Matthew L Robinson
- Division of Infectious Disease, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Yukari C Manabe
- Division of Infectious Disease, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
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22
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Hanson K, Goodman C. Testing times: trends in availability, price, and market share of malaria diagnostics in the public and private healthcare sector across eight sub-Saharan African countries from 2009 to 2015. Malar J 2017; 16:205. [PMID: 28526075 PMCID: PMC5438573 DOI: 10.1186/s12936-017-1829-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 04/19/2017] [Indexed: 12/13/2022] Open
Abstract
Background The World Health Organization guidelines have recommended that all cases of suspected malaria should receive a confirmatory test with microscopy or a malaria rapid diagnostic test (RDT), however evidence from sub-Saharan Africa (SSA) illustrates that only one-third of children under five with a recent fever received a test. The aim of this study was to evaluate availability, price and market share of microscopy and RDT from 2009/11 to 2014/15 in 8 SSA countries, to better understand barriers to improving access to malaria confirmatory testing in the public and private health sectors. Results Repeated national cross-sectional quantitative surveys were conducted among a sample of outlets stocking anti-malarial medicines and/or diagnostics. In total, 169,655 outlets were screened. Availability of malaria blood testing among all screened public health facilities increased significantly between the first survey wave in 2009/11 and the most recent in 2014/15 in Benin (36.2, 85.4%, p < 0.001), Kenya (53.8, 93.0%, p < 0.001), mainland Tanzania (46.9, 89.9%, p < 0.001), Nigeria (28.5, 86.2%, p < 0.001), Katanga, the Democratic Republic of the Congo (DRC) (76.0, 88.2%, p < 0.05), and Uganda (38.9, 95.6%, p < 0.001). These findings were attributed to an increase in availability of RDTs. Diagnostic availability remained high in Kinshasa (the DRC) (87.6, 97.6%) and Zambia (87.9, 91.6%). Testing availability in public health facilities significantly decreased in Madagascar (88.1, 73.1%, p < 0.01). In the most recent survey round, the majority of malaria testing was performed in the public sector in Zambia (90.9%), Benin (90.3%), Madagascar (84.5%), Katanga (74.3%), mainland Tanzania (73.5%), Uganda (71.8%), Nigeria (68.4%), Kenya (53.2%) and Kinshasa (51.9%). In the anti-malarial stocking private sector, significant increases in availability of diagnostic tests among private for-profit facilities were observed between the first and final survey rounds in Kinshasa (82.1, 94.0%, p < 0.05), Nigeria (37.0, 66.0%, p < 0.05), Kenya (52.8, 74.3%, p < 0.001), mainland Tanzania (66.8, 93.5%, p < 0.01), Uganda (47.1, 70.1%, p < 0.001), and Madagascar (14.5, 45.0%, p < 0.01). Blood testing availability remained low over time among anti-malarial stocking private health facilities in Benin (33.1, 20.7%), and high over time in Zambia (94.4, 87.5%), with evidence of falls in availability in Katanga (72.7, 55.6%, p < 0.05). Availability among anti-malarial stocking pharmacies and drug stores—which are the most common source of anti-malarial medicines—was rare in all settings, and highest in Uganda in 2015 (21.5%). Median private sector price of RDT for a child was equal to the price of pre-packaged quality-assured artemisinin-based combination therapy (QAACT) treatment for a two-year old child in some countries, and 1.5–2.5 times higher in others. Median private sector QAACT price for an adult varied from having parity with an RDT for an adult to being up to 2 times more expensive. The exception was in both Kinshasa and Katanga, where the median price of QAACT was less expensive than RDTs. Conclusions Significant strides have been made in the availability of testing, mainly through the widespread distribution of RDT, and especially in public health facilities. Significant barriers to universal coverage of diagnostic testing can be attributed to very low availability in the private sector, particularly among pharmacies and drug stores, which are responsible for most anti-malarial distribution. Where tests are available, price may serve as a barrier to uptake, particularly for young children. Several initiatives that have introduced RDT into the private sector can be modified and expanded as a means to close this gap in malaria testing availability and promote universal diagnosis. Electronic supplementary material The online version of this article (doi:10.1186/s12936-017-1829-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Kara Hanson
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
| | - Catherine Goodman
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
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23
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Lunze K, Biemba G, Lawrence JJ, MacLeod WB, Yeboah-Antwi K, Musokotwane K, Ajayi T, Mutembo S, Puta C, Earle D, Steketee R, Hamer DH. Clinical management of children with fever: a cross-sectional study of quality of care in rural Zambia. Bull World Health Organ 2017; 95:333-342. [PMID: 28479634 PMCID: PMC5418822 DOI: 10.2471/blt.16.170092] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Revised: 01/10/2017] [Accepted: 01/10/2017] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To evaluate current practices and standards of evaluation and treatment of childhood febrile illness in Southern Province, Zambia. METHODS From November to December 2013, we conducted a cross-sectional survey of facilities and health workers and we observed the health workers' interactions with febrile children and their caregivers. The facility survey recorded level of staffing, health services provided by the facility, availability and adequacy of medical equipment, availability of basic drugs and supplies and availability of treatment charts and guidelines. The health worker survey assessed respondents' training, length of service, access to national guidelines and job aids for managing illnesses, and their practice and knowledge on management of neonatal and child illnesses. We also conducted exit interviews with caregivers to collect information on demographic characteristics, chief complaints, counselling and drug dispensing practices. FINDINGS This study included 24 health facilities, 53 health workers and 161 children presenting with fever. Facilities were insufficiently staffed, stocked and equipped to adequately manage childhood fever. Children most commonly presented with upper respiratory tract infections (46%; 69), diarrhoea (31%; 27) and malaria (10%; 16). Health workers insufficiently evaluated children for danger signs, and less than half (47%; 9/19) of children with pneumonia received appropriate antibiotic treatment. Only 57% (92/161) were tested for malaria using either rapid diagnostic tests or microscopy. CONCLUSION Various health system challenges resulted in a substantial proportion of children receiving insufficient management and treatment of febrile illness. Interventions are needed including strengthening the availability of commodities and improving diagnosis and treatment of febrile illness.
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Affiliation(s)
- Karsten Lunze
- Department of Medicine, Boston University Medical School, 801 Massachusetts Ave, Boston MA 02119, United States of America (USA)
| | - Godfrey Biemba
- Zambian Centre for Applied Health Research and Development, Lusaka, Zambia
| | - J Joseph Lawrence
- Global Health Corps Fellowship, Zambian Centre for Applied Health Research and Development, Lusaka, Zambia
| | - William B MacLeod
- Center for Global Health and Development, Boston University School of Public Health, Boston, USA
| | - Kojo Yeboah-Antwi
- Center for Global Health and Development, Boston University School of Public Health, Boston, USA
| | | | | | - Simon Mutembo
- Southern Provincial Medical Office, Ministry of Health, Choma, Zambia
| | | | | | - Rick Steketee
- Malaria Control and Elimination Partnership in Africa Program, PATH, Seattle, USA
| | - Davidson H Hamer
- Center for Global Health and Development, Boston University School of Public Health, Boston, USA
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Hopkins H, Bruxvoort KJ, Cairns ME, Chandler CIR, Leurent B, Ansah EK, Baiden F, Baltzell KA, Björkman A, Burchett HED, Clarke SE, DiLiberto DD, Elfving K, Goodman C, Hansen KS, Kachur SP, Lal S, Lalloo DG, Leslie T, Magnussen P, Jefferies LM, Mårtensson A, Mayan I, Mbonye AK, Msellem MI, Onwujekwe OE, Owusu-Agyei S, Reyburn H, Rowland MW, Shakely D, Vestergaard LS, Webster J, Wiseman VL, Yeung S, Schellenberg D, Staedke SG, Whitty CJM. Impact of introduction of rapid diagnostic tests for malaria on antibiotic prescribing: analysis of observational and randomised studies in public and private healthcare settings. BMJ 2017; 356:j1054. [PMID: 28356302 PMCID: PMC5370398 DOI: 10.1136/bmj.j1054] [Citation(s) in RCA: 87] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/06/2017] [Indexed: 01/21/2023]
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.
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Affiliation(s)
- Heidi Hopkins
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | | | - Matthew E Cairns
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | | | - Baptiste Leurent
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | | | | | | | | | | | - Siân E Clarke
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | | | | | | | - Kristian S Hansen
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
- University of Copenhagen, Copenhagen, DK1014, Denmark
| | | | - Sham Lal
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | | | - Toby Leslie
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
- Health Protection Research Organisation, Kabul, Afghanistan
| | - Pascal Magnussen
- Centre for Medical Parasitology, University of Copenhagen and Copenhagen University Hospital, and Department for Veterinary Disease Biology, University of Copenhagen, Copenhagen, Denmark
| | | | | | - Ismail Mayan
- Health Protection Research Organisation, Kabul, Afghanistan
| | - Anthony K Mbonye
- Ministry of Health, Kampala, Uganda
- Makerere University School of Public Health, Kampala, Uganda
| | | | - Obinna E Onwujekwe
- Department of Pharmacology and Therapeutics, University of Nigeria, Enugu, Nigeria
| | - Seth Owusu-Agyei
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
- Kintampo Health Research Centre, Kintampo, Ghana
| | - Hugh Reyburn
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - Mark W Rowland
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - Delér Shakely
- Centre for Malaria Research, Karolinska Institutet, Stockholm, Sweden, and Health Metrics at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Lasse S Vestergaard
- Department of Infectious Disease Epidemiology, Statens Serum Institut, Copenhagen, Denmark
| | - Jayne Webster
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - Virginia L Wiseman
- 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
| | - Shunmay Yeung
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | | | - Sarah G Staedke
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
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Dittrich S, Tadesse BT, Moussy F, Chua A, Zorzet A, Tängdén T, Dolinger DL, Page AL, Crump JA, D’Acremont V, Bassat Q, Lubell Y, Newton PN, Heinrich N, Rodwell TJ, González IJ. Target Product Profile for a Diagnostic Assay to Differentiate between Bacterial and Non-Bacterial Infections and Reduce Antimicrobial Overuse in Resource-Limited Settings: An Expert Consensus. PLoS One 2016; 11:e0161721. [PMID: 27559728 PMCID: PMC4999186 DOI: 10.1371/journal.pone.0161721] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 08/09/2016] [Indexed: 11/30/2022] Open
Abstract
Acute fever is one of the most common presenting symptoms globally. In order to reduce the empiric use of antimicrobial drugs and improve outcomes, it is essential to improve diagnostic capabilities. In the absence of microbiology facilities in low-income settings, an assay to distinguish bacterial from non-bacterial causes would be a critical first step. To ensure that patient and market needs are met, the requirements of such a test should be specified in a target product profile (TPP). To identify minimal/optimal characteristics for a bacterial vs. non-bacterial fever test, experts from academia and international organizations with expertise in infectious diseases, diagnostic test development, laboratory medicine, global health, and health economics were convened. Proposed TPPs were reviewed by this working group, and consensus characteristics were defined. The working group defined non-severely ill, non-malaria infected children as the target population for the desired assay. To provide access to the most patients, the test should be deployable to community health centers and informal health settings, and staff should require <2 days of training to perform the assay. Further, given that the aim is to reduce inappropriate antimicrobial use as well as to deliver appropriate treatment for patients with bacterial infections, the group agreed on minimal diagnostic performance requirements of >90% and >80% for sensitivity and specificity, respectively. Other key characteristics, to account for the challenging environment at which the test is targeted, included: i) time-to-result <10 min (but maximally <2 hrs); ii) storage conditions at 0–40°C, ≤90% non-condensing humidity with a minimal shelf life of 12 months; iii) operational conditions of 5–40°C, ≤90% non-condensing humidity; and iv) minimal sample collection needs (50–100μL, capillary blood). This expert approach to define assay requirements for a bacterial vs. non-bacterial assay should guide product development, and enable targeted and timely efforts by industry partners and academic institutions.
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Affiliation(s)
- Sabine Dittrich
- Foundation for Innovative New Diagnostics (FIND), 9 Chemin des Mines, 1202 Geneva, Switzerland
- * E-mail:
| | - Birkneh Tilahun Tadesse
- Foundation for Innovative New Diagnostics (FIND), 9 Chemin des Mines, 1202 Geneva, Switzerland
- Special Programme for Research & Training in Tropical Diseases (TDR), World Health Organization, Avenue Appia 20, 1211, Geneva 27, Switzerland
- Hawassa University, College of Medicine and Health Sciences, Department of Pediatrics, Hawassa, Ethiopia
| | - Francis Moussy
- World Health Organization, 20 Avenue Appia, 1211, Geneva 27, Switzerland
| | - Arlene Chua
- Institute of Infectious Diseases and Epidemiology, Tan Tock Seng Hospital, Singapore, Singapore
| | - Anna Zorzet
- ReAct Europe, Uppsala University, Box 256, 751 05, Uppsala, Sweden
| | - Thomas Tängdén
- ReAct Europe, Uppsala University, Box 256, 751 05, Uppsala, Sweden
| | - David L. Dolinger
- Foundation for Innovative New Diagnostics (FIND), 9 Chemin des Mines, 1202 Geneva, Switzerland
- World Health Organization, 20 Avenue Appia, 1211, Geneva 27, Switzerland
- Institute of Infectious Diseases and Epidemiology, Tan Tock Seng Hospital, Singapore, Singapore
| | - Anne-Laure Page
- Epidemiology and Population Health, Epicentre, Paris, France
| | - John A. Crump
- Centre for International Health, University of Otago, PO Box 56, Dunedin, 9054, New Zealand
- Duke Global Health Institute, Box 90519, Duke University, Durham, NC, 27708, United States of America
- Division of Infectious Diseases and International Health, Box 102359, Duke University Medical Center, Durham, NC, 27710, United States of America
| | - Valerie D’Acremont
- Swiss Tropical and Public Health Institute, 4002 Basel, Switzerland
- Department of Ambulatory Care and Community Medicine, University of Lausanne, Bugnon 44, 1011, Lausanne, Switzerland
| | - Quique Bassat
- ISGlobal, Barcelona Ctr. Int. Health Res. (CRESIB), Hospital Clínic—Universitat de Barcelona, Barcelona, Spain
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | - Yoel Lubell
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Paul N. Newton
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Vientiane, Lao PDR
| | - Norbert Heinrich
- Division for Infectious Diseases and Tropical Medicine, Medical Center of the University of Munich (LMU), Munich, Germany; German Center for Infection Research, Munich partner site, Leopoldstr 5, D-80802, Munich, Germany
| | - Timothy J. Rodwell
- Foundation for Innovative New Diagnostics (FIND), 9 Chemin des Mines, 1202 Geneva, Switzerland
| | - Iveth J. González
- Foundation for Innovative New Diagnostics (FIND), 9 Chemin des Mines, 1202 Geneva, Switzerland
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