Hopkins Heidi, Bruxvoort Katia J, Cairns Matthew E, Chandler Clare I R, Leurent Baptiste, Ansah Evelyn K, Baiden Frank, Baltzell Kimberly A, Björkman Anders, Burchett Helen E D, Clarke Siân E, DiLiberto Deborah D, Elfving Kristina, Goodman Catherine, Hansen Kristian S, Kachur S Patrick, Lal Sham, Lalloo David G, Leslie Toby, Magnussen Pascal, Jefferies Lindsay Mangham, Mårtensson Andreas, Mayan Ismail, Mbonye Anthony K, Msellem Mwinyi I, Onwujekwe Obinna E, Owusu-Agyei Seth, Reyburn Hugh, Rowland Mark W, Shakely Delér, Vestergaard Lasse S, Webster Jayne, Wiseman Virginia L, Yeung Shunmay, Schellenberg David, Staedke Sarah G, Whitty Christopher J M
London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK.
Ghana Health Service, Accra, Ghana.
BMJ. 2017 Mar 29;356:j1054. doi: 10.1136/bmj.j1054.
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. Analysisof nine preselected linked and codesigned observational and randomised studies (eight cluster or individually randomised trials and one observational study). Public and private healthcare settings, 2007-13, in Afghanistan, Cameroon, Ghana, Nigeria, Tanzania, and Uganda. 522 480 children and adults with acute febrile illness. Rapid diagnostic tests for malaria. 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. 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. 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.
为研究使用疟疾快速诊断检测对非洲和亚洲急性发热性疾病使用抗菌药物（特别是抗生素）的影响。对九项预先选定的关联并共同设计的观察性研究和随机研究（八项整群或个体随机试验和一项观察性研究）进行分析。研究对象为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立和私立医疗机构中522480名患有急性发热性疾病的儿童和成人。采用疟疾快速诊断检测。比较试验组中接受快速诊断检测的患者与对照组患者以及检测结果为阴性的患者与阳性患者中开具抗生素的比例。次要目的是比较不同环境中开具的抗生素类别。对照组中127052/238797（53%）的患者以及干预组中167714/283683（59%）的患者使用了抗生素。疟疾检测结果呈阳性的患者中有40%（35505/89719）使用了抗生素，检测结果呈阴性的患者中有69%（39400/57080）使用了抗生素。除一项研究外，所有研究均显示接受快速诊断检测的组中开具抗生素的趋势更为明显。对这些试验进行的随机效应荟萃分析表明，干预组中抗生素处方的总体风险高21%（95%置信区间为7%至36%）。在大多数干预环境中，对于所有最常用的抗生素类别：青霉素、甲氧苄啶 - 磺胺甲恶唑（有一个例外）、四环素和甲硝唑，检测结果为阴性的患者比阳性患者接受了更多的抗生素处方。引入疟疾快速诊断检测以减少抗疟药的不必要使用——这是一项有益的公共卫生成果——可能会导致抗生素的非针对性使用增加。检测结果为阴性时69%的患者被开具抗生素可能代表了过度处方。这包括来自几类抗生素，包括像甲硝唑这种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会减少抗菌药物的过度使用，但它们可能只是将其从一类抗菌药物转移到另一类。目前全球范围内疟疾检测的实施可能会增加抗生素的非针对性使用，必须对此进行研究。
