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Tolley A, Bansal A, Murerwa R, Howard Dicks J. Cost-effectiveness of point-of-care diagnostics for AMR: a systematic review. J Antimicrob Chemother 2024; 79:1248-1269. [PMID: 38498622 PMCID: PMC11144491 DOI: 10.1093/jac/dkae067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Accepted: 02/19/2024] [Indexed: 03/20/2024] Open
Abstract
BACKGROUND Antimicrobial resistance (AMR) is a major threat to global health. By 2050, it is forecast that AMR will cause 10 million deaths and cost 100 trillion USD annually. Point-of-care tests (POCTs) may represent a cost-effective approach to reduce AMR. OBJECTIVES We systematically reviewed which POCTs addressing AMR have undergone economic evaluation in primary and secondary healthcare globally, how these POCTs have been economically evaluated, and which are cost-effective in reducing antimicrobial prescribing or the burden of AMR. Clinical cost-effectiveness was additionally addressed. METHODS This systematic review, accordant with PRISMA guidelines, was pre-registered on PROSPERO (CRD42022315192). MEDLINE, PubMed, Embase, Cochrane Library, and Google Scholar were searched from 2000 to 2023 for relevant publications. Quality assessment was performed using the Consensus of Health Economic Criteria. RESULTS The search strategy identified 1421 studies, of which 20 met the inclusion criteria. The most common POCTs assessed were for respiratory infections (n = 10), STIs (n = 3), and febrile patients in low- and middle-income countries (n = 3). All studies assessed costs from a healthcare provider perspective; five additionally considered the societal cost of AMR.Eighteen studies identified POCT strategies that reduced antimicrobial prescribing. Of these, 10 identified POCTs that would be considered cost-effective at a willingness-to-pay (WTP) threshold of £33.80 per antibiotic prescription avoided. Most POCT strategies improved clinical outcomes (n = 14); the remainder were clinically neutral. CONCLUSIONS There is evidence that some POCTs are cost-effective in reducing antimicrobial prescribing, with potential concomitant clinical benefits. Such interventions-especially CRP POCTs in both high- and low-income settings-merit further, large-scale clinical evaluation.
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Affiliation(s)
- Abraham Tolley
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Akhil Bansal
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
- Department of Internal Medicine, St Vincent’s Hospital, Sydney, Australia
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Peters RPH, Klausner JD, Mazzola L, Mdingi MM, Jung H, Gigi RMS, Piton J, Daniels J, de Vos L, Adamson PC, Gleeson B, Ferreyra C. Novel lateral flow assay for point-of-care detection of Neisseria gonorrhoeae infection in syndromic management settings: a cross-sectional performance evaluation. Lancet 2024; 403:657-664. [PMID: 38335982 PMCID: PMC11246789 DOI: 10.1016/s0140-6736(23)02240-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 08/14/2023] [Accepted: 10/04/2023] [Indexed: 02/12/2024]
Abstract
BACKGROUND A rapid and affordable point-of-care test is a priority for Neisseria gonorrhoeae control. WHO and Foundation for Innovative New Diagnostics (FIND) have a target product profile for a non-molecular N gonorrhoeae rapid point-of-care test that requires a clinical sensitivity of greater than 80% and a specificity over 95% to be considered useful in syndromic management; test turnaround time should be 30 min or under, and the test should cost less than US$3. A novel lateral flow assay (LFA) was developed to achieve that profile. METHODS In this cross-sectional study we evaluated the performance of the novel N gonorrhoeae lateral flow assay (NG-LFA) at the primary health-care level in South Africa. Male patients with urethral discharge syndrome and female patients with vaginal discharge syndrome were recruited from five primary health-care facilities in the Buffalo City Metropolitan Municipality health district of South Africa. First-void urine specimens and nurse-collected vaginal swabs were tested in-facility with the NG-LFA and Xpert CT/NG PCR assay. N gonorrhoeae multi-antigen sequence typing (NG-MAST) was performed on all LFA positive specimens. FINDINGS Between March 7, and Sept 19, 2022, we enrolled 200 male patients with urethral discharge and 200 female patients with vaginal discharge. The median age of male patients was 24 years (IQR 21-31 years), and the median age of female patients was 25 years (IQR 21-32 years). In addition, 23 male patients and 12 female patients who presented at the facility with a partner notification slip were enrolled of whom one (4%) and five (42%) were symptomatic, respectively. NG-LFA and Xpert results were available for all participants. In urine specimens, NG-LFA sensitivity was 96·1% (Wilson 95% CI 91·2-98·3; 123 LFA-positive among 128 PCR-positive specimens) and 91·7% in vaginal swab specimens (78·2-97·1; 33 LFA-positive among 36 PCR-positive). The specificity was 97·2% in urine specimens (90·4-99·2; 70 LFA-negative among 72 PCR-negative) and 96·3% in vaginal specimens (92·2-98·3; 158 LFA-negative among 164 PCR-negative). In 156 LFA-positive specimens, NG-MAST showed 93 different sequence types. INTERPRETATION The novel NG-LFA had excellent clinical sensitivity and specificity in symptomatic male and female patients. The test met the optimal requirement for sensitivity and the minimal requirement for specificity specified in the target product profile. NG-LFA could provide an important tool to optimise clinical management and reduce excess antibiotic use in settings without direct access to laboratory testing. FUNDING Global Antimicrobial Resistance Innovation Fund (GAMRIF) via FIND and National Institutes of Health.
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Affiliation(s)
- Remco P H Peters
- Foundation for Professional Development, Research Unit, East London, South Africa; Department of Medical Microbiology, University of Pretoria, Pretoria, South Africa; Division of Medical Microbiology, University of Cape Town, Cape Town, South Africa.
| | - Jeffrey D Klausner
- Keck School of Medicine, Department of Population and Public Health Sciences, University of Southern California, Los Angeles, CA, USA
| | - Laura Mazzola
- Foundation for Innovative New Diagnostics (FIND), Geneva, Switzerland
| | - Mandisa M Mdingi
- Foundation for Professional Development, Research Unit, East London, South Africa
| | - Hyunsul Jung
- Department of Medical Microbiology, University of Pretoria, Pretoria, South Africa
| | - Ranjana M S Gigi
- Foundation for Professional Development, Research Unit, East London, South Africa; Department of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Jeremie Piton
- Foundation for Innovative New Diagnostics (FIND), Geneva, Switzerland
| | - Joseph Daniels
- Edson College of Nursing and Health Innovation, Arizona State University, Phoenix, AZ, USA
| | - Lindsey de Vos
- Foundation for Professional Development, Research Unit, East London, South Africa
| | - Paul C Adamson
- David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Birgitta Gleeson
- Foundation for Innovative New Diagnostics (FIND), Geneva, Switzerland
| | - Cecilia Ferreyra
- Foundation for Innovative New Diagnostics (FIND), Geneva, Switzerland
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Patel TS, Sati H, Lessa FC, Patel PK, Srinivasan A, Hicks LA, Neuhauser MM, Tong D, van der Heijden M, Alves SC, Getahun H, Park BJ. Defining access without excess: expanding appropriate use of antibiotics targeting multidrug-resistant organisms. THE LANCET. MICROBE 2024; 5:e93-e98. [PMID: 37837986 PMCID: PMC10789610 DOI: 10.1016/s2666-5247(23)00256-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 08/07/2023] [Accepted: 08/08/2023] [Indexed: 10/16/2023]
Abstract
Antimicrobial resistance remains a significant global public health threat. Although development of novel antibiotics can be challenging, several new antibiotics with improved activity against multidrug-resistant Gram-negative organisms have recently been commercialised. Expanding access to these antibiotics is a global public health priority that should be coupled with improving access to quality diagnostics, health care with adequately trained professionals, and functional antimicrobial stewardship programmes. This comprehensive approach is essential to ensure responsible use of these new antibiotics.
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Affiliation(s)
- Twisha S Patel
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | - Hatim Sati
- WHO AMR Division, WHO, Geneva, Switzerland
| | - Fernanda C Lessa
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Payal K Patel
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA; Division of Infectious Diseases, Intermountain Health, Salt Lake City, UT, USA
| | - Arjun Srinivasan
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Lauri A Hicks
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Melinda M Neuhauser
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | | | | | | | - Benjamin J Park
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
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Walia K, Mendelson M, Kang G, Venkatasubramanian R, Sinha R, Vijay S, Veeraraghavan B, Basnyat B, Rodrigues C, Bansal N, Ray P, Mathur P, Gopalakrishnan R, Ohri VC. How can lessons from the COVID-19 pandemic enhance antimicrobial resistance surveillance and stewardship? THE LANCET. INFECTIOUS DISEASES 2023; 23:e301-e309. [PMID: 37290476 DOI: 10.1016/s1473-3099(23)00124-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 02/27/2023] [Accepted: 02/27/2023] [Indexed: 06/10/2023]
Abstract
COVID-19 demanded urgent and immediate global attention, during which other public health crises such as antimicrobial resistance (AMR) increased silently, undermining patient safety and the life-saving ability of several antimicrobials. In 2019, WHO declared AMR a top ten global public health threat facing humanity, with misuse and overuse of antimicrobials as the main drivers in the development of antimicrobial-resistant pathogens. AMR is steadily on the rise, especially in low-income and middle-income countries across south Asia, South America, and Africa. Extraordinary circumstances often demand an extraordinary response as did the COVID-19 pandemic, underscoring the fragility of health systems across the world and forcing governments and global agencies to think creatively. The key strategies that helped to contain the increasing SARS-CoV-2 infections included a focus on centralised governance with localised implementation, evidence-based risk communication and community engagement, use of technological methods for tracking and accountability, extensive expansion of access to diagnostics, and a global adult vaccination programme. The extensive and indiscriminate use of antimicrobials to treat patients, particularly in the early phase of the pandemic, have adversely affected AMR stewardship practices. However, there were important lessons learnt during the pandemic, which can be leveraged to strengthen surveillance and stewardship, and revitalise efforts to address the AMR crisis.
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Affiliation(s)
- Kamini Walia
- Division of Epidemiology and Communicable Diseases, Indian Council of Medical Research, New Delhi 110029, India.
| | - Marc Mendelson
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Gagandeep Kang
- Department of Clinical Microbiology, Christian Medical College, Vellore, India
| | | | - Rina Sinha
- World Health Organization, Country Office for India, New Delhi, India
| | - Sonam Vijay
- Division of Epidemiology and Communicable Diseases, Indian Council of Medical Research, New Delhi 110029, India
| | | | - Buddha Basnyat
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Kathmandu, Nepal
| | - Camilla Rodrigues
- Department of Microbiology, PD Hinduja Hospital, Mumbai, Maharashtra, India
| | - Nitin Bansal
- Division of Infectious Diseases, Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India
| | - Pallab Ray
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Purva Mathur
- Department of Laboratory Medicine, Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India
| | | | - Vinod C Ohri
- Division of Epidemiology and Communicable Diseases, Indian Council of Medical Research, New Delhi 110029, India
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Moyo P, Moyo E, Mangoya D, Mhango M, Mashe T, Imran M, Dzinamarira T. Prevention of antimicrobial resistance in sub-Saharan Africa: What has worked? What still needs to be done? J Infect Public Health 2023; 16:632-639. [PMID: 36870230 DOI: 10.1016/j.jiph.2023.02.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 02/15/2023] [Accepted: 02/19/2023] [Indexed: 02/23/2023] Open
Abstract
Antibiotics help in preventing and treating infections and increasing life expectancy globally. Globally, many people's lives are being threatened by the emergence of antimicrobial resistance (AMR). The cost of treating and preventing infectious diseases has increased due to AMR. Bacteria can resist the effects of antibiotics by altering drug targets, inactivating drugs, and activating drug efflux pumps. According to estimates, five million individuals died in 2019 from AMR-related causes, wherein 1.3 million deaths were directly linked to bacterial AMR. Sub-Saharan Africa (SSA) experienced the greatest mortality rate from AMR in 2019. In this article, we discuss AMR's causes and challenges SSA faces in implementing AMR prevention measures and propose recommendations to address the challenges. Antibiotic misuse and overuse, widespread usage in agriculture, and the pharmaceutical industry's absence of new antibiotic development are the factors contributing to AMR. SSA's challenges in preventing AMR include poor AMR surveillance and lack of collaboration, irrational use of antibiotics, weak medicine regulatory systems, lack of infrastructural and institutional capacities, lack of human resources, and inefficient infection prevention and control (IPC) practices. The challenges faced by countries in SSA can be addressed by increasing the public's knowledge of antibiotics and AMR, promoting antibiotic stewardship, improving AMR surveillance, promoting collaboration within and beyond countries, antibiotics regulatory enforcement, and improving the practice of IPC measures at home, food handling establishments, and healthcare facilities.
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Affiliation(s)
- Perseverance Moyo
- College of Medicine and Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Enos Moyo
- College of Medicine and Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Derek Mangoya
- College of Medicine and Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Malizgani Mhango
- College of Medicine and Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | | | - Mohd Imran
- Department of Pharmaceutical Chemistry, Faculty of Pharmacy, Northern Border University, Saudi Arabia.
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