Impact of introduction of rapid diagnostic tests for malaria on antibiotic prescribing: analysis of observational and randomised studies in public and private healthcare settingsBMJ 2017; 356 doi: https://doi.org/10.1136/bmj.j1054 (Published 29 March 2017) Cite this as: BMJ 2017;356:j1054
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Re: Impact of introduction of rapid diagnostic tests for malaria on antibiotic prescribing: analysis of observational and randomised studies in public and private healthcare settings
The authors show that RDT implementation to date, while reducing antimalarial overuse, might increase unwarranted antibiotic prescriptions. The paper focuses heavily on treatment outcomes, but it is ultimately a quality of care issue. Does RDT improve overall quality care that could in turn lead to more rational antimicrobial prescribing?
Our recent analysis based on a Malawi national facility census showed low quality fever care for pediatric outpatients in terms of completed fever assessments and antibiotic targeting despite common compliance to malaria treatment guidelines . In that study, most antibiotic prescriptions for pediatric fevers were unwarranted – rising to 82% with an RDT-negative result and cough or difficult breathing complaint! Our qualitative work from Uganda further suggested that health workers frequently felt unsupported especially when RDT results were negative and were uncertain about how to handle these cases . Indeed, the ultimate goal should be to empower health workers at peripheral clinics to manage non-severe non-malaria febrile illnesses without referral even within the context of a weak health system.
To this end, integrated, holistic treatment strategies (e.g. IMCI/iCCM with RDT for sick children) are critical for both patient care and antimicrobial resistance considerations. This requires funding initiatives beyond a singular disease focus to provide comprehensive support to health workers in terms of integrated guidance, commodities and training backed up by integrated procurement and supply chain mechanisms. IMCI guidelines should also be reviewed to clarify antibiotic prescriptions in the fever algorithm, which is currently unclear and could contribute to poor quality care and antibiotic over-treatment. Finally, improved overall clinical care, including adherence to malaria test results, requires stronger health systems and RDT deployment should be viewed as a unique opportunity to contribute to this effort. We were very glad to read your paper and hope it continues to advance discussion on this important topic.
 Johansson EW, Selling K, Nsona H, Mappin B, Gething P, Petzold M, Peterson S, Hildenwall H. Integrated pediatric fever management and antibiotic over-treatment in Malawi health facilities: data mining a national facility census. Malar J 2016;15:396.
 Johansson EW, Kitutu FE, Mayora C, Awor P, Peterson S, Wamani H, Hildenwall H. ‘It could be viral but you don’t know, you have not diagnosed it.’ Health worker challenges in managing non-malaria pediatric fevers in the low transmission setting of Mbarara District Uganda. Malar J 2016;15:197.
Competing interests: No competing interests