Rapid Diagnostic Tests to Guide Case Management of and Improve Antibiotic Stewardship for Pediatric Acute Respiratory Illnesses in Resource-Constrained Settings: a Prospective Cohort Study in Southwestern Uganda.
Rapid Diagnostic Tests to Guide Case Management of and Improve Antibiotic Stewardship for Pediatric Acute Respiratory Illnesses in Resource-Constrained Settings: a Prospective Cohort Study in Southwestern Uganda.
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DOI：
10.1128/spectrum.01694-21
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发表时间：
2021-12-22
影响因子：
3.7
通讯作者：
Boyce RM
中科院分区：
文献类型：
--
作者：
Ciccone EJ;Kabugho L;Baguma E;Muhindo R;Juliano JJ;Mulogo E;Boyce RM
小儿急性呼吸道疾病（ARI）是撒哈拉以南非洲地区周边卫生中心评估的最常见原因之一，通常仅基于临床综合征进行管理。虽然大多数ARI发作可能是由自限性病毒感染引起的，但大多数都用抗生素治疗。这种过度使用有助于抗菌素耐药性的发展。为了评估将病原体特异性和临床生物标志物诊断检测添加到现有临床管理算法中的初步可行性和潜在影响，我们对2019年10月至2020年1月在乌干达西南部一家半城市周边卫生设施门诊部就诊的225名疟疾阴性、发热性ARI儿童进行了一项前瞻性、观察性队列研究。除了常规的临床评估外，我们还进行了流感和肺炎链球菌抗原检测，并在诊所实验室测量了C反应蛋白、降钙素原和乳酸水平，并在7天后通过电话进行了随访评估。近五分之一的参与者（40/225）流感检测呈阳性。临床生物标志物测量值较低，仅11%（13/222）的参与者C反应蛋白>40 mg/L，仅13%（16/125）的参与者降钙素原>0.25 ng/mL。除两名儿童外，所有儿童均接受抗生素治疗;仅3%（7/225）入院。在随访中，59%（118/201）的照顾者报告至少有一种持续症状，但所有儿童的发热均已消退。流感检测阳性与持续症状有关。总之，我们证明，简单，快速的病原体特异性检测和生物标志物测量在资源有限的环境中是可能的，可以改善综合征管理，进而改善抗生素管理。在全球范围内，呼吸道疾病是儿童寻求护理的最常见原因之一。它经常被不适当地用抗生素治疗，这可能会导致抗生素耐药性的发展。在资源丰富的环境中，检测特定病原体或测量临床生物标志物，如降钙素原和C反应蛋白，通常用于帮助确定哪些儿童应该接受抗生素。然而，关于在撒哈拉以南非洲资源有限的门诊患者中使用这些检测的数据有限。我们在乌干达西南部的一家诊所招募了患有呼吸道疾病的儿童，并在现场进行了流感、肺炎链球菌、C反应蛋白和降钙素原的检测。几乎所有的孩子都使用了抗生素。我们证明，采用包括流感和临床生物标志物检测在内的临床算法可以显着减少抗生素处方。因此，我们的研究提供了初步的数据，以支持诊断的可行性和潜在的效用，以改善管理呼吸系统疾病的资源有限的设置。
Pediatric acute respiratory illness (ARI) is one of the most common reasons for evaluation at peripheral health centers in sub-Saharan Africa and is frequently managed based on clinical syndrome alone. Although most ARI episodes are likely caused by self-limited viral infections, the majority are treated with antibiotics. This overuse contributes to the development of antimicrobial resistance. To evaluate the preliminary feasibility and potential impact of adding pathogen-specific and clinical biomarker diagnostic testing to existing clinical management algorithms, we conducted a prospective, observational cohort study of 225 children presenting with malaria-negative, febrile ARI to the outpatient department of a semi-urban peripheral health facility in southwestern Uganda from October 2019 to January 2020. In addition to routine clinical evaluation, we performed influenza and Streptococcus pneumoniae antigen testing and measured levels of C-reactive protein, procalcitonin, and lactate in the clinic’s laboratory, and conducted a follow-up assessment by phone 7 days later. Almost one-fifth of participants (40/225) tested positive for influenza. Clinical biomarker measurements were low with C-reactive protein of >40 mg/L in only 11% (13/222) of participants and procalcitonin >0.25 ng/mL in only 13% (16/125). All but two children received antibiotic treatment; only 3% (7/225) were admitted. At follow-up, 59% (118/201) of caregivers reported at least one persistent symptom, but fever had resolved for all children. Positive influenza testing was associated with persistent symptoms. In summary, we demonstrate that simple, rapid pathogen-specific testing and biomarker measurement are possible in resource-limited settings and could improve syndromic management and, in turn, antibiotic stewardship. IMPORTANCE Globally, respiratory illness is one of the most common reasons that children seek care. It is often treated inappropriately with antibiotics, which can drive the development of antibiotic resistance. In resource-rich settings, testing for specific pathogens or measurement of clinical biomarkers, such as procalcitonin and C-reactive protein, is often employed to help determine which children should receive antibiotics. However, there are limited data on the use of these tests in resource-constrained, outpatient contexts in sub-Saharan Africa. We enrolled children with respiratory illness presenting to a clinic in southwestern Uganda and performed testing for influenza, Streptococcus pneumoniae, C-reactive protein, and procalcitonin on-site. Almost all children received antibiotics. We demonstrate that employing clinical algorithms that include influenza and clinical biomarker testing could significantly decrease antibiotic prescriptions. Our study therefore provides preliminary data to support the feasibility and potential utility of diagnostics to improve management of respiratory illness in resource-constrained settings.