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Rapid malaria tests curb needless ACT, increase antibiotic use
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Rapid testing for malaria has decreased the unnecessary use of antimalarial drugs in a range of developing countries but increased the use of other antibiotics, according to researchers.
In addition, an alarming percentage of patients diagnosed with malaria using the rapid diagnostic tests (mRDTs) were not given antimalarials, and some who tested negative received the drugs anyway, they wrote in the American Journal of Tropical Medicine and Hygiene.
“Although mRDTs generally improve malaria case management, alone, they are not a panacea to solve the major challenge of effective fever management,” researcher Katia J. Bruxvoort, PhD, MPH, an assistant professor of epidemiology at the London School of Hygiene and Tropical Medicine in the United Kingdom, and colleagues wrote. “Simply providing mRDTs is insufficient if health workers continue prescribing antimalarials to test-negative patients, or if alternative treatments are not appropriate.”
The researchers focused in part on the use of artemisinin–based combination therapies (ACTs) and other types of antimalarials. They analyzed data from 10 studies conducted by the ACT Consortium, a group formed to help guide ACT use.
The studies included 18 settings in six countries — Afghanistan, Cameroon, Ghana, Nigeria, Tanzania and Uganda. The rates of ACT prescription for patients who underwent mRDT were compared with the rates of prescription for who did not. Overall, the use of mRDT was associated with fewer ACT prescriptions.
Bruxvoort and colleagues found that, in 10 of the studies’ 13 African settings, the mRDT-associated decreases in ACT due to negative test results were statistically significant. They included one in Uganda (Uga2/a), in which 95.1% of patients who were not tested with mRDT were prescribed ACT, compared with 8.2% of those who were tested (OR = 0).
In four of the five settings in Afghanistan, they said, “prescription of any antimalarial was much lower in scenarios with mRDT interventions than without.”
They included one in which 95.9% of patients who were not tested with mRDT received ACT, compared with 0.6% of those who were tested (OR = 0).
Patients who tested positive for malaria were not prescribed antimalarials consistently across settings. In 12 of 15 settings for which there were data on ACT prescriptions for mRDT positive results, ACT prescription ranged from 60.2% to 98%.
“Prescription of ACTs to test-positive patients was over 90% in six of these settings but was just 60.2% to 81.2% in another six settings, with 69.4% to 96.2% prescribed any antimalarial,” the researchers said.
Some mRDT scenarios had high rates of ACT prescription despite negative tests. In two Cameroon settings and two in Ghana, a range of 39.2% to 49.1% of patients testing negative for malaria were prescribed ACT. Less than 30% of patients with negative tests in other mRDT scenarios were prescribed ACT.
Another mRDT-associated effect, an increase in antibiotic use, concerned the researchers because of the possibility of worsening antimicrobial resistance.
The use of mRDT was associated with a significant increase in the prescribing of systemic antibiotics in seven settings — two in Afghanistan, four in Tanzania and one in Uganda. In those seven settings, increases in systemic antibiotic prescribing for patients who tested negative for malaria ranged from 46% to 77.7%. In 17 of the 18 total settings, that increase ranged from 40% to 79.9%.
The researchers concluded that mRDT has yielded improvements in how malaria is managed, but that further work is needed.
“Critically, challenges exist in ensuring that all patients who test positive for falciparum malaria are prescribed ACT,” they wrote. “Anything less endangers individual patients and the credibility of programs. It is also necessary to ensure that patients who test negative receive appropriate management, which may or may not include other antimicrobials.” – by Joe Green
Disclosure: The researchers report no relevant financial disclosures.
Perspective
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This study addressed the impacts of increased use of malaria rapid diagnostic tests (RDTs) in malaria-endemic countries. The WHO advocates use of RDTs to confirm the diagnosis before treating those with suspected malaria to avoid both inappropriate use of antimalarials and misdiagnosis of other important problems.
Important findings of the study were as follows. First, the use of RDTs led to decreased prescription of antimalarials, presumably because many patients with negative malaria tests were not treated. This is a desired outcome.
Second, decreased use of antimalarials was partly offset by increased use of antibiotics. As in other settings, it is difficult to provide no therapy for an ill individual, so clinicians may have felt compelled to prescribe antibiotics, even if the clinical scenario did not strongly suggest bacterial infection.
Third, clinicians did not always follow test results. Antimalarial therapy was provided to over 30% of those with negative malaria tests, and more alarmingly, it was not provided to over 20% of those with a positive malaria test.
Thus, although increased use of RDTs to diagnose malaria is a desired goal, we should work to improve management based on the diagnostic information afforded by RDTs.
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