comparison of rates of antimicrobial use in febrile patients with or without the use of c-reactive protein blood test

Conditions: Acute Febrile Illness; Use of Antimicrobial Agents; C-reactive Protein Level

Summary: in health posts of rural areas operated by the government of nepal, there are limitations of tests to differentiate between bacterial and viral infections. due to this, health workers are obliged to prescribe antimicrobials (antibacterials) just on the basis of clinical features. this can lead to irrational use of antimicrobials, consequently contributing to antimicrobial resistance. c-reactive protein is the marker of inflammation which rises during bacterial infection but rarely rises during viral infection. the investigators wish to compare the effect on antimicrobial usage of using crp(c-reactive protein) test, a rapid diagnostic test used to differentiate bacterial and viral infection, with usual standard of care, by carrying out a cluster-randomized controlled trial. the investigators plan to carry out this study in eight health posts of resunga, dhurkot and gulmi-durbar municipalities of gulmi district. the investigators will randomly allocate four health posts (clusters) to the intervention arm- crp tests in addition to usual standard of care, and four health posts (clusters) to the control arm- usual standard of care alone. the investigators plan to study all patients above one year of age presenting with fever or a history of reported fever with a duration of up to 7 days in health posts. primarily, the investigators will assess the rates of antimicrobial use per patient who presents with febrile illness. secondarily, the investigators will also assess the outcome of illness of the patient such as need for subsequent hospital admission or severe or complicated illness. this testing method will supplement the existing methods to differentiate bacterial and viral infections based on history and clinical examination by health professionals as a part of usual standard of care in the health posts included in this study.

the world health organization (who) defines antimicrobial resistance (amr) as a situation where drugs used to treat microbial infection caused by bacteria, viruses, fungi and parasites no longer work to treat infection because of the changes in these microbes over time. though this process of development of amr is a natural process, it is accelerated by the overuse and misuse of antimicrobials (mladenovic-antic et al, 2016, pp.532-537). there were an estimated 1.27 million deaths attributable to bacterial amr globally in 2019 (murray et al, 2022). it is estimated that in india every year around sixty thousand newborns die due to amr (laxminarayan et al, 2013, pp.1057-1098). as big as the death toll due to amr is, the economic costs are also significant. even in a setting of a developed country like the us, direct healthcare cost of amr is over 6 billion us dollars (cdc, 2019). nepal is one of the developing countries of the world located in south asia between india and china. amr is an increasing problem in nepal and some of the most common causes for it are excessive use of antimicrobials in animal husbandry and unnecessary use of antimicrobials for treatment of febrile illness (rijal et al, 2021, pp. 1-14; acharya and wilson, 2021, p.105). currently, bacteria like escherichia coli, klebsiella pneumoniae, streptococcus pneumoniae, shigella spp., vibrio cholera, neisseria gonorrheae and staphylococcus aureus are increasingly resistant to the most first-line and some second-line antimicrobials (acharya and wilson, 2021 p.105; basnyat et al, 2015, pp.102-111). thus antimicrobial resistance (amr) presents a great threat to public health. nepal has its own national antibiotic treatment guideline and according to this even the smallest government healthcare units like health posts can prescribe antimicrobials. these health posts lack microbiology laboratory access and the health worker has to prescribe antimicrobials based upon their history and examination findings which may lead to unnecessary prescription of antimicrobials against viral illness. this challenge of unavailability of laboratory tests can be tackled by introducing point-of-care rapid diagnostic test to detect c-reactive protein to differentiate between bacterial and viral infections. c-reactive protein is the marker of inflammation which rises in blood during bacterial infection but rarely rises during viral infection (phommasone et al, 2015, pp.1-6). this method has already been used in other developing countries like laos, thailand, myanmar, malaysia and vietnam, which have similar socio-economic conditions like that of nepal (phommasone et al, 2015, pp.1-6; althaus et al, 2019, pp.e119-e131; lubell et al, 2018, pp.1-6; haenssgen et al, 2018, pp.1-12). antimicrobials are rarely prescribed based on an absolute certainty of a bacterial infection. the use of point-of-care rapid diagnostic test offers an easy, affordable and a working solution to this problem and helps in judicial use of antimicrobials (o'neill, 2016). although it is known that crp testing can differentiate bacterial and viral infections, the extent to which it can reduce antimicrobial use in a rural health-post setting of nepal and thus play a role in limiting the emergence of antimicrobial resistance is not known. if this study shows significant reduction in antimicrobial prescription without any adverse clinical outcome, the test kit can be implemented nationally in all low resource health care settings in nepal.

Eligibility criteria:
inclusion criteria: * history of reported fever or fever greater than 100.4◦f (38◦c) with duration of illness up to 7 days * duration of fever less than or equal to 7 days * can connect with mobile phone for follow up exclusion criteria: * child younger than 1 year * main complaint being trauma or injury * symptoms requiring hospital referral * impaired consciousness * inability to take oral medication * convulsions * confirmed malaria * confirmed urinary tract infection * local skin infection * dental abscess or infection * suspicion of tuberculosis * any symptom other than fever present for more than 14 days * any bleeding such as from skin, nose and gums.

Keywords: c-reactive protein acute febrile illness viral infection bacterial infection antimicrobial drug crp rapid test