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Moorthy GS, Madut DB, Kilonzo KG, Lwezaula BF, Mbwasi R, Mmbaga BT, Ngocho JS, Saganda W, Bonnewell JP, Carugati M, Egger JR, Hertz JT, Tillekeratne LG, Maze MJ, Maro VP, Crump JA, Rubach MP. Antibacterial Utilization for Febrile Illnesses and Laboratory-Confirmed Bloodstream Infections in Northern Tanzania. Open Forum Infect Dis 2023; 10:ofad448. [PMID: 37663090 PMCID: PMC10468737 DOI: 10.1093/ofid/ofad448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 08/14/2023] [Indexed: 09/05/2023] Open
Abstract
Background We describe antibacterial use in light of microbiology data and treatment guidelines for common febrile syndromes in Moshi, Tanzania. Methods We compared data from 2 hospital-based prospective cohort studies, cohort 1 (2011-2014) and cohort 2 (2016-2019), that enrolled febrile children and adults. A study team member administered a standardized questionnaire, performed a physical examination, and collected blood cultures. Participants with bloodstream infection (BSI) were categorized as receiving effective or ineffective therapy based upon antimicrobial susceptibility interpretations. Antibacterials prescribed for treatment of pneumonia, urinary tract infection (UTI), or presumed sepsis were compared with World Health Organization and Tanzania Standard Treatment Guidelines. We used descriptive statistics and logistic regression to describe antibacterial use. Results Among participants, 430 of 1043 (41.2%) and 501 of 1132 (44.3%) reported antibacterial use prior to admission in cohorts 1 and 2, respectively. During admission, 930 of 1043 (89.2%) received antibacterials in cohort 1 and 1060 of 1132 (93.6%) in cohort 2. Inpatient use of ceftriaxone, metronidazole, and ampicillin increased between cohorts (P ≤ .002 for each). BSI was detected in 38 (3.6%) participants in cohort 1 and 47 (4.2%) in cohort 2. Of 85 participants with BSI, 81 (95.3%) had complete data and 52 (64.2%) were prescribed effective antibacterials. Guideline-consistent therapy in cohort 1 and cohort 2 was as follows: pneumonia, 87.4% and 56.8%; UTI, 87.6% and 69.0%; sepsis, 84.4% and 61.2% (P ≤ .001 for each). Conclusions Receipt of antibacterials for febrile illness was common. While guideline-consistent prescribing increased over time, more than one-third of participants with BSI received ineffective antibacterials.
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Affiliation(s)
- Ganga S Moorthy
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Duke University Medical Center, Durham, North Carolina, USA
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
| | - Deng B Madut
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
- Division of Infectious Diseases and International Health, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Kajiru G Kilonzo
- Kilimanjaro Christian Medical Centre-Duke University Collaboration, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Kilimanjaro Christian Medical University College, Tumaini University, Moshi, Tanzania
| | | | - Ronald Mbwasi
- Kilimanjaro Christian Medical Centre-Duke University Collaboration, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Blandina T Mmbaga
- Kilimanjaro Christian Medical Centre-Duke University Collaboration, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Kilimanjaro Christian Medical University College, Tumaini University, Moshi, Tanzania
| | - James S Ngocho
- Kilimanjaro Christian Medical Centre-Duke University Collaboration, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Kilimanjaro Christian Medical University College, Tumaini University, Moshi, Tanzania
| | - Wilbrod Saganda
- Kilimanjaro Christian Medical University College, Tumaini University, Moshi, Tanzania
| | - John P Bonnewell
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
- Division of Infectious Diseases and International Health, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Manuela Carugati
- Division of Infectious Diseases and International Health, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Joseph R Egger
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
| | - Julian T Hertz
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
| | - L Gayani Tillekeratne
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
- Division of Infectious Diseases and International Health, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Michael J Maze
- Centre for International Health, University of Otago, Dunedin, New Zealand
- Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Venance P Maro
- Kilimanjaro Christian Medical Centre-Duke University Collaboration, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Kilimanjaro Christian Medical University College, Tumaini University, Moshi, Tanzania
| | - John A Crump
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
- Division of Infectious Diseases and International Health, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
- Kilimanjaro Christian Medical University College, Tumaini University, Moshi, Tanzania
- Centre for International Health, University of Otago, Dunedin, New Zealand
| | - Matthew P Rubach
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
- Division of Infectious Diseases and International Health, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
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Van Duffel L, Yansouni CP, Jacobs J, Van Esbroeck M, Ramadan K, Buyze J, Tsoumanis A, Barbé B, Boelaert M, Verdonck K, Chappuis F, Bottieau E. ACCURACY OF C-REACTIVE PROTEIN AND PROCALCITONIN FOR DIAGNOSING BACTERIAL INFECTIONS AMONG SUBJECTS WITH PERSISTENT FEVER IN THE TROPICS. Open Forum Infect Dis 2022; 9:ofac434. [PMID: 36092831 PMCID: PMC9454028 DOI: 10.1093/ofid/ofac434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 08/22/2022] [Indexed: 11/14/2022] Open
Abstract
Background In low-resource settings, inflammatory biomarkers can help identify patients with acute febrile illness who do not require antibiotics. Their use has not been studied in persistent fever (defined as fever lasting for ≥7 days at presentation). Methods C-reactive protein (CRP) and procalcitonin (PCT) levels were measured in stored serum samples of patients with persistent fever prospectively enrolled in Cambodia, the Democratic Republic of Congo, Nepal, and Sudan. Diagnostic accuracy was assessed for identifying all bacterial infections and the subcategory of severe infections judged to require immediate antibiotics. Results Among 1838 participants, CRP and PCT levels were determined in 1777 (96.7%) and 1711 (93.1%) samples, respectively, while white blood cell (WBC) count was available for 1762 (95.9%). Areas under the receiver operating characteristic curve for bacterial infections were higher for CRP (0.669) and WBC count (0.651) as compared with PCT (0.600; P <.001). Sensitivity for overall and severe bacterial infections was 76.3% (469/615) and 88.2% (194/220) for CRP >10 mg/L, 62.4% (380/609) and 76.8% (169/220) for PCT >0.1 µg/L, and 30.5% (184/604) and 43.7% (94/215) for WBC >11 000/µL, respectively. Initial CRP level was <10 mg/L in 45% of the participants who received antibiotics at first presentation. Conclusions In patients with persistent fever, CRP and PCT showed higher sensitivity for bacterial infections than WBC count, applying commonly used cutoffs for normal values. A normal CRP value excluded the vast majority of severe infections and could therefore assist in deciding whether to withhold empiric antibiotics after cautious clinical assessment.
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Affiliation(s)
- Lukas Van Duffel
- Infectious Diseases Unit, Morgagni-Pierantoni Hospital , AUSL of Romagna, Forlì , Italy
| | - Cedric P Yansouni
- JD MacLean Centre for Tropical Diseases, McGill University Health Centre , Montreal , Canada
| | - Jan Jacobs
- Department of Clinical Sciences, Institute of Tropical Medicine , Antwerp , Belgium
- Department of Microbiology, Immunology and Transplantation , KU Leuven, Leuven , Belgium
| | - Marjan Van Esbroeck
- Department of Clinical Sciences, Institute of Tropical Medicine , Antwerp , Belgium
| | - Kadrie Ramadan
- Department of Clinical Sciences, Institute of Tropical Medicine , Antwerp , Belgium
| | - Jozefien Buyze
- Department of Clinical Sciences, Institute of Tropical Medicine , Antwerp , Belgium
| | - Achilleas Tsoumanis
- Department of Clinical Sciences, Institute of Tropical Medicine , Antwerp , Belgium
| | - Barbara Barbé
- Department of Clinical Sciences, Institute of Tropical Medicine , Antwerp , Belgium
| | - Marleen Boelaert
- Department of Public Health, Institute of Tropical Medicine , Antwerp , Belgium
| | - Kristien Verdonck
- Department of Public Health, Institute of Tropical Medicine , Antwerp , Belgium
| | - Francois Chappuis
- Division of Tropical and Humanitarian Medicine, Geneva University Hospitals and University of Geneva , Geneva , Switzerland
| | - Emmanuel Bottieau
- Department of Clinical Sciences, Institute of Tropical Medicine , Antwerp , Belgium
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C-Reactive Protein for the Early Assessment of Non-Malarial Febrile Patients: A Retrospective Diagnostic Study. Diagnostics (Basel) 2021; 11:diagnostics11091728. [PMID: 34574070 PMCID: PMC8469932 DOI: 10.3390/diagnostics11091728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 09/17/2021] [Accepted: 09/17/2021] [Indexed: 12/04/2022] Open
Abstract
Biomarkers, especially CRP, have demonstrated their relevance to differentiate viral from bacterial infection, even though a reliable threshold is far to being found. In low- and middle-income countries, affordable and user-friendly rapid diagnostic tests based on biomarkers can be widely adopted to help health workers in the management of non-malarial fever. The primary objective of this study is to assess the best CRP cut-off to distinguish viral from bacterial infections. Other biomarkers were evaluated for the same purpose, alone or in combination with CRP. We retrospectively collected data from two referral hospital departments for infectious and tropical diseases in Italy. Areas under the ROC curve (AUC) were calculated and then compared using the DeLong test. Overall, we included 1193 febrile cases (viral 20.74% vs. bacterial 79.25%). We also collected malaria (n = 202) and intestinal parasite (n = 186) cases to establish their impact on biomarkers. CRP had the best accuracy in differentiating viral from bacterial infections. The best performance of CRP was a cut-off of 11 mg/L. All other biomarkers studied had significantly lower accuracy. Median CRP values were within the normal ranges in parasitic infections, while they were higher in malaria. None of the combinations of CRP with other biomarkers significantly increased the accuracy of CRP alone.
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Otten T, de Mast Q, Koeneman B, Althaus T, Lubell Y, van der Ven A. Value of C-reactive protein in differentiating viral from bacterial aetiologies in patients with non-malaria acute undifferentiated fever in tropical areas: a meta-analysis and individual patient data study. Trans R Soc Trop Med Hyg 2021; 115:1130-1143. [PMID: 33644814 DOI: 10.1093/trstmh/traa186] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 11/23/2020] [Accepted: 12/22/2020] [Indexed: 12/21/2022] Open
Abstract
C-reactive protein (CRP) is used to discriminate common bacterial and viral infections, but its utility in tropical settings remains unknown. We performed a meta-analysis of studies performed in Asia and Africa. First, mean CRP levels for specific tropical infections were calculated. Thereafter, individual patient data (IPD) from patients with non-malarial undifferentiated fever (NMUF) who were tested for viral and bacterial pathogens were analysed, calculating separate cut-off values and their performance in classifying viral or bacterial disease. Mean CRP levels of 7307 patients from 13 countries were dengue 12.0 mg/l (standard error [SE] 2.7), chikungunya 41.0 mg/l (SE 19.5), influenza 15.9 mg/l (SE 6.3), Crimean-Congo haemorrhagic fever 9.7 mg/l (SE 4.7), Salmonella 61.9 mg/l (SE 5.4), Rickettsia 61.3 mg/l (SE 8.8), Coxiella burnetii 98.7 mg/l (SE 44.0) and Leptospira infections 113.8 mg/l (SE 23.1). IPD analysis of 1059 NMUF patients ≥5 y of age showed CRP <10 mg/l had 52% sensitivity (95% confidence interval [CI] 48 to 56) and 95% specificity (95% CI 93 to 97) to detect viral infections. CRP >40 mg/l had 74% sensitivity (95% CI 70 to 77) and 84% specificity (95% CI 81 to 87) to identify bacterial infections. Compared with routine care, the relative risk for incorrect classification was 0.64 (95% CI 0.55 to 0.75) and the number needed to test for one extra correctly classified case was 8 (95% CI 6 to 12). A two cut-off value CRP test may help clinicians to discriminate viral and bacterial aetiologies of NMUF in tropical areas.
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Affiliation(s)
- Twan Otten
- Department of International Health and Infectious Diseases, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Quirijn de Mast
- Department of International Health and Infectious Diseases, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Bouke Koeneman
- Department of International Health and Infectious Diseases, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Thomas Althaus
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, 10400, Thailand
| | - Yoel Lubell
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, 10400, Thailand
| | - André van der Ven
- Department of International Health and Infectious Diseases, Radboud University Medical Centre, Nijmegen, The Netherlands
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Akelew Y, Derbew A, Lemma M, Negash M, Bewket G, Belay G, Pollmann J, Adriaensen W, Adane A, Mohammed R, van Griensven J, Cnops L. 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. Int J Infect Dis 2020; 101:276-282. [PMID: 33002622 DOI: 10.1016/j.ijid.2020.09.1444] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 09/22/2020] [Accepted: 09/22/2020] [Indexed: 10/23/2022] Open
Abstract
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.
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Affiliation(s)
- Yibeltal Akelew
- Department of Medical Laboratory Sciences, College of Medicine and Health Sciences, Debre Markos University, Debre Markos, Ethiopia; Department of Immunology and Molecular Biology, College of Medicine and Health Sciences, University of Gondar, Debre Markos, Ethiopia
| | - Agegnehu Derbew
- Department of Internal Medicine, University of Gondar, Debre Markos, Ethiopia
| | - Mulualem Lemma
- Department of Immunology and Molecular Biology, College of Medicine and Health Sciences, University of Gondar, Debre Markos, Ethiopia
| | - Markos Negash
- Department of Immunology and Molecular Biology, College of Medicine and Health Sciences, University of Gondar, Debre Markos, Ethiopia
| | - Gezahegn Bewket
- Department of Immunology and Molecular Biology, College of Medicine and Health Sciences, University of Gondar, Debre Markos, Ethiopia
| | - Gizeaddis Belay
- Department of Medical Microbiology, University of Gondar, Debre Markos, Ethiopia
| | - Julia Pollmann
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Wim Adriaensen
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Aynishet Adane
- Department of Internal Medicine, University of Gondar, Debre Markos, Ethiopia
| | - Rezika Mohammed
- Department of Internal Medicine, University of Gondar, Debre Markos, Ethiopia; Leishmaniasis Research and Treatment Centre, University of Gondar, Debre Markos, Ethiopia
| | - Johan van Griensven
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Lieselotte Cnops
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium.
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van Griensven J, Cnops L, De Weggheleire A, Declercq S, Bottieau E. Point-of-Care Biomarkers to Guide Antibiotic Prescription for Acute Febrile Illness in Sub-Saharan Africa: Promises and Caveats. Open Forum Infect Dis 2020; 7:ofaa260. [PMID: 32818139 PMCID: PMC7423291 DOI: 10.1093/ofid/ofaa260] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 06/26/2020] [Indexed: 01/21/2023] Open
Abstract
Empiric malaria treatment in Sub-Saharan Africa has significantly decreased with the scaling-up of malaria rapid diagnostic tests; this coincided with a pronounced increase in empiric antibiotic prescriptions. In high-income countries, guidance for antibiotic prescriptions using biomarkers such as C-reactive protein (CRP) and procalcitonin (PCT) has reduced antibiotic use while safe-guarding patient safety. Importantly, several low-cost point-of-care CRP/PCT tests are currently available. However, only a few studies on the role of CRP/PCT in differentiating bacterial vs viral infections in acute febrile illness have been conducted in Sub-Saharan Africa. Studies from Central and West Africa (most of which is malaria-endemic) are particularly scarce, and only 1 has included adults. The evidence base for point-of-care use of CRP/PCT biomarkers in acute fever in Sub-Saharan Africa should be urgently built. Before engaging in clinical trials to assess clinical impact, pilot studies should be conducted to address key knowledge gaps including recommended CRP/PCT cutoff values and the effect of malaria coinfection.
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