Abstract
Background: Across Southeast Asia, declining malaria incidence poses a challenge for healthcare providers, in how best to manage the vast majority of patients with febrile illnesses who have a negative malaria test. In rural regions, where the majority of the population reside, empirical treatment guidelines derived from central urban hospitals are often of limited relevance. In these settings, relatively untrained health workers deliver care, often without any laboratory diagnostic support. In this paper, our aim was to model the impact on mortality from febrile illness of using point-of-care C-reactive protein testing to inform the decision to prescribe antibiotics and regional surveillance data to inform antibiotic selection, rooted in the real-world context of rural Savannakhet province, southern Laos. Methods: Our model simulates 100 scenarios with varying quarterly incidence of six key pathogens known to be prevalent in rural Laos. In the simulations, community health workers either prescribe antibiotics in-line with current practice as documented in health facilities in rural Laos, or with the aid of the two interventions. We provide cost-effectiveness estimates for each strategy alone and then for an integrated approach using both interventions. Results: We find that each strategy alone is predicted to be highly cost-effective, and that the combined approach is predicted to result in the biggest reduction in mortality (averting a predicted 510 deaths per year in rural Savannakhet, a 28% reduction compared to standard practice) and is highly cost-effective, with an incremental cost-effectiveness ratio of just $66 per disability-adjusted life year averted. Conclusions: Substantial seasonal variation in the predicted optimal empirical antibiotic treatment for febrile illness highlights the benefits of up-to-date information on regional causes of fever. In this modelling analysis, an integrated system incorporating point-of-care host biomarker testing and regional surveillance data appears highly cost-effective, and may warrant piloting in a real-life setting.
Highlights
There is a growing body of evidence that host biomarker tests, including commercially available low-cost point-of-care varieties, can help health workers identify patients with febrile illnesses who might benefit from antibiotic treatment1,2
The use of C-reactive protein (CRP)-guided antibiotic therapy, without the surveillance data, would avert an additional 325 deaths due to identification of a greater proportion of patients with bacterial infections whom may benefit from antibiotic treatment
Use of the regional surveillance data alone would have a lower impact than CRP-guided antibiotic therapy alone, reducing mortality by an additional 192 deaths compared with current prescribing practice
Summary
There is a growing body of evidence that host biomarker tests, including commercially available low-cost point-of-care varieties, can help health workers identify patients with febrile illnesses who might benefit from antibiotic treatment. There is a growing body of evidence that host biomarker tests, including commercially available low-cost point-of-care varieties, can help health workers identify patients with febrile illnesses who might benefit from antibiotic treatment1,2 These tests have the potential to improve rational antibiotic prescribing, increasing the proportion of patients with bacterial infections that receive antibiotics, and diminishing overall drug pressure through fewer antibiotic prescriptions for patients with viral infections. In rural regions, where the majority of the population reside, empirical treatment guidelines derived from central urban hospitals are often of limited relevance In these settings, health workers with limited training deliver care, often without any laboratory diagnostic support. Conclusions: Substantial seasonal variation in the predicted optimal version 2 (revision)
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