Impact of introduction of rapid diagnostic tests for malaria on antibiotic prescribing: analysis of observational and randomised studies in public and private healthcare settings.
Impact of introduction of rapid diagnostic tests for malaria on antibiotic prescribing: analysis of observational and randomised studies in public and private healthcare settings.
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DOI：
10.1136/bmj.j1054
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发表时间：
2017-03-29
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影响因子：
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通讯作者：
Whitty CJ
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作者：
Hopkins H;Bruxvoort KJ;Cairns ME;Chandler CI;Leurent B;Ansah EK;Baiden F;Baltzell KA;Björkman A;Burchett HE;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 CJ
目的研究在非洲和亚洲使用疟疾快速诊断检测方法对急性发热性疾病的抗菌剂，特别是抗生素处方的影响。设计分析9个预先选择的关联和共同设计的观察性和随机化研究（8个集群或单独随机化试验和1个观察性研究）。2007- 2013年，阿富汗、喀麦隆、加纳、尼日利亚、坦桑尼亚和乌干达的公共和私人医疗保健环境。参与者522480名患有急性发热性疾病的儿童和成人。干预措施疟疾快速诊断检测。主要结果测量：试验组中接受快速诊断检测的患者与对照组相比，接受抗生素处方的患者比例；检测结果阴性的患者与检测结果阳性的患者相比。第二个目的是比较不同情况下处方的抗生素种类。结果对照组使用抗生素127 052/238 797例（53%），干预组使用抗生素167 714/283 683例（59%）。40%（35 505/89 719）疟疾检测结果呈阳性的患者和69%（39 400/57 080）结果呈阴性的患者开了抗生素。除了一项研究外，所有的研究都表明，在接受快速诊断测试的人群中，抗生素处方有增加的趋势。试验的随机效应荟萃分析显示，在干预环境中，抗生素处方的总体风险高出21%（95%置信区间为7%至36%）。在大多数干预环境中，检测结果为阴性的患者比检测结果为阳性的患者获得的所有最常用类别的抗生素处方更多：青霉素、甲氧苄啶-磺胺甲恶唑（一个例外）、四环素和甲硝唑。结论：引入疟疾快速诊断检测以减少抗疟药的不必要使用——这是一个有益的公共卫生结果——可能会导致抗生素的非靶向使用。69%的患者在检测结果为阴性时开了抗生素，这可能代表了过度处方。这包括几类抗生素，包括甲硝唑等很少适用于发热性疾病的抗生素，涉及不同的临床、卫生系统和流行病学环境。人们通常认为，更好的疾病特异性诊断将减少抗生素的过度使用，但他们可能只是将其从一种抗生素类别转移到另一种抗生素类别。目前全球实施的疟疾检测可能会增加非靶向抗生素的使用，必须加以审查。
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.