Evaluation of C-reactive protein and myxovirus resistance protein A to guide the rational use of antibiotics among acute febrile adult patients in Northwest Ethiopia

OBJECTIVES

In low-resource settings, treatment is often given empirically without knowledge of the aetiology due to a lack of diagnostics. In the search for reliable rapid tests to guide treatment work-up, this study was performed to determine whether two biomarkers could differentiate bacterial from non-bacterial infections in acute febrile patients.

METHODS

Adults with acute fever were recruited at a referral hospital in Ethiopia. The QuikRead Go test was used to quantify C-reactive protein (qCRP) and the FebriDx test was used for combined qualitative detection of the bacterial CRP marker with myxovirus resistance protein A (MxA), a viral biomarker.

RESULTS

Of the 200 patients included in this study, most presented with 2-3 days of fever, headache, and joint pain. Antibiotics were prescribed for 83.5% and antimalarials for 36.5%, while a bacterial infection was only confirmed in 5% and malaria in 11%. The median qCRP level for confirmed bacterial infections was 128 mg/l. The FebriDx and QuikRead Go test had an overall agreement of 72.0%.

CONCLUSIONS

An over-prescription of antibiotics for febrile patients was observed, even for those with low CRP levels and without a confirmed bacterial infection. The added value of the FebriDx was limited, while the combined use of rapid tests for qCRP and malaria should be considered for the management of acute febrile illness and antibiotic stewardship.

Etiology of acute undifferentiated fever in patients presenting to the emergency department of a tertiary care center in Karachi, Pakistan

Objective:

Our study aimed at identifying the characteristics and etiology of various causes of acute undifferentiated fever in patients presenting to the emergency department of a tertiary care hospital.

Methods:

This was a retrospective study conducted at the department of emergency medicine, Aga Khan University Hospital from January to June 2016. Adult patients presenting to Emergency department with acute undifferentiated fever were enrolled. Descriptive statistics were calculated in terms of mean±SD for continuous variables like age of the patients and duration of fever, whereas frequency and percentage were computed for categorical variables like gender and causes of fever.

Results:

A total of one hundred and fifty five patients were included. Out of these 97 (62.6%) were males and 58 (37.4%) were females. Most patients (25.2%, n= 39) were diagnosed as malaria followed closely by dengue fever (n=33, 21.3%) and then enteric fever (n= 10, 6.5%). while 41.9% (n=65) were diagnosed as suspected viral fever based on clinical judgment and inconclusive laboratory results.

Conclusion:

Malaria was found to be the most common confirmed cause of acute undifferentiated fever followed by dengue and enteric fever. The provision of accurate epidemiological data will enable resources to be directed towards key areas and will be of practical importance to clinicians.

Outbreak of acute undifferentiated febrile illness in Kathmandu, Nepal: clinical and epidemiological investigation

Background

Outbreaks of acute undifferentiated febrile illness (AUFI) are common in Nepal, but the exact etiology or risk factors for them often go unrecognized. Diseases like influenza, enteric fever and rickettsial fevers account for majority of such outbreaks. Optimal diagnostic tests to inform treatment decisions are not available at the point-of-care. A proper epidemiological and clinical characterization of such outbreaks is important for appropriate treatment and control efforts.

Methods

An investigation was initiated as a response to increased presentation of patients at Patan Hospital from Chalnakhel locality in Dakchinkali municipality, Kathmandu with AUFI from June 10 to July 1, 2016. Focused group discussion with local inhabitants and the epidemiological curve of febrile patients at local primary health care centre confirmed the outbreak. The household-survey was conducted in the area with questionnaire administered on patients to characterize their illnesses and their medical records were reviewed. A different set of questionnaire was administered on the patients and controls to investigate the association with common risk factors. Water samples were collected and analyzed microbiologically.

Results

Eighty one patients from 137 households suffered from febrile illness within 6 weeks window before the investigation. All the 67 sampled patients with acute fever had a generalized illness without a discernible focus of infection. Only 38% of the patients had received a clinical diagnosis while the rest were treated empirically without a diagnosis. Three patients had blood culture confirmed enteric fever. Forty-two (63%) patients had been administered antibiotics, most commonly, ofloxacin, cefixime or azithromycin with a mean fever clearance time of 4 days. There was no definite association between several risk factors and fever. Fecal contamination was noted in tap water samples.

Conclusion

Based on the pattern of illness, this outbreak was most likely a mixture of self-limiting viral infections and enteric fever. This study shows that even in the absence of a confirmed diagnosis, a detailed characterization of the illness at presentation and the recovery course can suggest the diagnosis and help in formulating appropriate recommendation for treatment and control.

Causes of fever in pregnant women with acute undifferentiated fever: a prospective multicentric study

The etiologies of undifferentiated fever in pregnant women have not been studied thoroughly. Because of its non-specific presentation but severe prognosis, listeriosis is often suspected in this setting, but in most cases not confirmed. We studied the causes of undifferentiated fever in pregnant women who received preemptive listeriosis treatment. We conducted from November 1, 2011, to June 30, 2013, a prospective multicentric observational cohort study of pregnant women referred to obstetrical wards with undifferentiated fever and who received listeriosis preemptive treatment. Clinical and biological features, treatment, outcome, and final diagnosis were collected. We enrolled 103 febrile pregnant women. A cause was identified in 77/103 (75%): viral infection in 52/103 (50%, influenza in 21 (20%)), bacterial infection in 22 (21%, including 16 pyelonephritis (16%) and 3 pneumonias (3%)), and TORCH infection in 3 (3%, varicella, toxoplasmosis, and cytomegalovirus primo-infections, n=1, each). Viral infections collected during influenza outbreaks (December-March) accounted for 43/57 (75%) cases. Two fetal losses were reported in the context of febrile pneumonia. Final diagnoses required adapting medical care in 46/77 (60%) of cases, for bacterial, influenza, or TORCH infections. A large array of benign to potentially severe infections manifests as acute undifferentiated fever in pregnant women, requiring careful repeated evaluation.

How are the village health volunteers deliver malaria testing and treatment services and what are the challenges they are facing? A mixed methods study in Myanmar

Background

Village health volunteers (VHVs) play a key role in delivering community-based malaria care especially in the hard-to-reach areas in Myanmar. It is necessary to assess their performance and understand the challenges encountered by them for effective community management of malaria. This mixed methods study was conducted to (i) understand the cascade of malaria services (testing, diagnosis, referral, and treatment of malaria) provided by the VHVs under the National Malaria Control Programme (NMCP) in Myanmar in 2016 and compare with other health care providers and (ii) explore the challenges in the delivery of malaria services by VHVs.

Methods

A sequential mixed methods study was designed with a quantitative followed by a descriptive qualitative component. The quantitative study was a cohort design involving analysis of secondary data available from NMCP database whereas the qualitative part involved 16 focus group discussions (eight each with community and VHVs) and 14 key informant interviews with program stakeholders in four selected townships.

Results

Among 444,268 cases of undifferentiated fever identified by VHVs in 2016, 444,190 were tested using a rapid diagnostic test. Among those tested, 20,375 (4.6%) cases of malaria were diagnosed, of whom 16,910 (83.0%) received appropriate treatment, with 7323 (35.9%) receiving treatment within 24 h. Of all malaria cases, 296 (1.5%) were complicated, of whom 79 (26.7%) were referred to the higher facility. More than two thirds of all cases were falciparum malaria (13,970, 68.6%) followed by vivax (5619, 27.6%). Primaquine was given to 83.6% of all cases. VHVs managed 34.0% of all undifferentiated fever cases, 35.9% of all malaria cases, and identified 38.0% of all Plasmodium falciparum cases reported under NMCP. The key barriers identified are work-related (challenges in reporting, referral, management of malaria especially primaquine therapy, and lack of community support) and logistics related (challenges in transportation, financial constraints, time and shortage of drugs, and test kits). On the other hand, they also enjoy good community support and acceptance in most areas.

Conclusion

VHVs play an important role in malaria care in Myanmar, especially in the hard-to-reach areas. More programmatic support is needed in terms of logistics, transportation allowance, and supervision to improve their performance.

Characteristics of acute febrile illness and determinants of illness recovery among adults presenting to Singapore primary care clinics

Background

Undifferentiated acute febrile illness (AFI) is a common presentation among adults in primary care settings in Singapore but large gaps exist in the understanding of the characteristics of these patients. We studied clinical and epidemiological characteristics of AFI patients and factors associated with delayed recovery from AFI.

Methods

We performed a secondary data analysis using data from the Early DENgue infection and outcome (EDEN) study on 2046 adult patients presenting at 5 Singapore polyclinics between December 2007 and February 2013 with a history of fever (≥38 °C) for less than 72 h. We used an accelerated failure time model to investigate factors associated with delayed recovery from AFI.

Results

The mean age of patients was 36.6 years, 65 % were male, 51 % were of Chinese ethnicity, and 75 % lived in public housing. Median illness duration was 5 days (interquartile range, 3–7). In multivariable analysis, the unemployed and white collar workers had longer illness duration compared with blue collar workers (time ratio (TR), 1.10; 95 % confidence interval (CI), 1.03–1.17 and TR, 1.08; 95 % CI, 1.02–1.15, respectively). Patients with more symptoms at initial consultation had slower recovery (TR, 1.03 per additional symptom; 95 % CI, 1.02–1.03). Other clinical factors were also associated with longer duration of illness, including use of analgesics (TR, 1.21; 95 % CI, 1.15–1.28); use of cough medicines (TR, 1.14; 95 % CI, 1.08–1.20); use of antibiotics (TR, 1.14; 95 % CI, 1.07–1.21); and hospitalization (TR, 1.59; 95 % CI, 1.39–1.82). Compared to patients with normal WBC count at first consultation, those with low WBC count had slower recovery (TR, 1.14; 95 % CI, 1.07–1.21), while the reverse was observed among patients with high WBC count (TR, 0.94; 95 % CI, 0.88–1.00).

Conclusions

Differences in illness duration among different types of employment may reflect differences in their underlying general health status. Early identification of factors delaying recovery could help triage management in a primary care setting. In-depth characterization of fever etiology in Singapore will improve surveillance and control activities.

Non-inferiority of nitric oxide releasing intranasal spray compared to sub-therapeutic antibiotics to reduce incidence of undifferentiated fever and bovine respiratory disease complex in low to moderate risk beef cattle arriving at a commercial feedlot

Undifferentiated fever, or bovine respiratory disease complex (BRDc), is a challenging multi-factorial health issue caused by viral/bacterial pathogens and stressors linked to the transport and mixing of cattle, negatively impacting the cattle feedlot industry. Common practice during processing at feedlots is administration of antibiotic metaphylaxis to reduce the incidence of BRDc. Nitric oxide (NO) is a naturally occurring nano-molecule with a wide range of physiological attributes. This study evaluated the metaphylactic use of intranasal NO releasing spray (NORS) to control BRDc incidence in calves at low-moderate risk of developing BRDc, arriving at a commercial feedlot as compared to conventional antibiotic metaphylaxis. One thousand and eighty crossbred, multiple-sourced, commingled, commercial, weaned beef calves were screened, enrolled, randomized and treated upon arrival. Animals appearing sick were pulled (from their pen) by blinded pen keepers then assessed for BRDc symptoms; blood samples were taken for haptoglobin quantification and the animals were rescued with an antibiotic. After 35 days both groups showed no significant difference in BRDc incidence (5.2% of animals from NORS group and 3.2% from antibiotic group). Average daily weight gain of animals at day 150 for the NORS cohort was 1.17kg compared to 1.18kg for the antibiotic group (p>0.05). There was no significant difference in mortality in the first 35 days (p=0.7552), however, general mortality over 150 days trended higher in the antibiotic cohort. NORS treatment was shown to be safe, causing neither distress nor adverse effects on the animals. This large randomized controlled study in low-moderate BRDc incidence risk calves demonstrates that NORS treatment, as compared to conventional metaphylactic antibiotics, is non-inferior based on BRDc incidence and other metrics like weight and mortality. These data justify further studies in higher BRDc incidence risk populations to evaluate NORS as an alternative strategy to reduce sub-therapeutic metaphylaxis antibiotic use in beef cattle production.

Prophylactic nitric oxide treatment reduces incidence of bovine respiratory disease complex in beef cattle arriving at a feedlot

Bovine respiratory disease complex (BRDc), is a challenging multi-factorial health issue caused by viral/bacterial pathogens and stressors linked with the transport and mixing of cattle, negatively impacting the cattle feedlot industry. Nitric oxide (NO) is a naturally occurring molecule with antimicrobial attributes. This study tests whether NO can prevent the symptoms associated with BRDc. Eighty-five, crossbred, multiple-sourced, commingled commercial weaned beef calves were monitored and scored for temperature, white blood count, clinical score, hematology, cortisol levels and neutrophil/lymphocyte ratio. NO treatment or placebo were given once on arrival to the stockyard. After one week 87.5% of sick animals were from the control while 12.5% from treatment groups and after two weeks 72% and 28% respectively. Treatment was shown to be safe, causing neither distress nor adverse effects on the animals. These data show that NO treatment on arrival to the feedlot significantly decreased the incidence of BRDc in this study.