Thomas Althaus: Antibiotic prescription in primary care
Prescription of antibiotics at the point of care is very high in Southeast Asia. Simple tests can help health workers determine which patients actually need antibiotics, but we need to ensure that the benefits and advantages are clearly explained. In the long term, those tests could represent a sustainable alternative to the massive prescription of antibiotics in developing countries.
My name is Thomas Althaus, I’m a DPhil candidate at Oxford University but based in Southeast Asia. I’ve been mainly involved in a clinical trial based in Myanmar and northern Thailand with the objective to guide antibiotic prescription in primary care.
Prescription of antibiotics in Southeast Asia is major. We consider this region the epicentre of antibiotic prescription in the world and the immediate consequence of this massive antibiotic prescription is the mutation of bacteria to resistant strains. Primary care represents the major source of this antibiotic prescription and this is the reason why I was so interested in targeting primary care because it reaches a large amount of people in the community and at the same time there is no tool available to identify patients in need of antibiotics.
You have to understand that a typical health worker in primary care isn’t a doctor: it’s a nurse with limited clinical training, with probably more than one hundred patients a day. Health workers are facing a difficult, challenging question and they have no tool to answer this question. Fever can be caused by different pathogens. When a fever is caused by a virus, it doesn’t need an antibiotic to be treated. We call this treatment symptomatic, it means that you only need, for example, some paracetamol to control the fever and the body will handle the viral infection itself. On the opposite way, we also need to help identify patients who have an infection that requires an antibiotic, bacterial infection for example; you can die from a bacterial infection if you do not have antibiotics.
The CRP rapid test is very simple per se. It’s a test that tells you when to give an antibiotic or not. You can however imagine that patients might not be willing to comply to this test if they do not understand what it is. As an example, we were extremely surprised to see a patient asking for an antibiotic despite a negative test, because it took him a day to reach the facility and in terms of cost of transportation that was also very high for him. You cannot just simply expect people to comply to your prescription without explaining the test. What are the benefits and advantages of what we are doing, and this implies to know and to understand our population. It’s not about saying that antibiotics are bad; antibiotics are extremely useful but they’re precious and it’s a scarce resource we need to control. So it’s not a race to find new drugs, it’s a race to slow down the pace of antibiotic prescription.
Diagnosing malaria is extremely simple and cheap. We have rapid tests available everywhere for almost nothing and because of those tests being more and more negative because the disease is getting eliminated, we are now facing this new challenge that is once my malaria test is negative, what do I do with my patients? How can I manage a patient without malaria, with a fever? How can I figure out without having any access to laboratory if this patient needs an antibiotic or not? We also know that the most effective and funded research project trying to screen and to look for every pathogen do not discover more than let’s say 50% of the causes of fever. This means that even though you use your best diagnostic tool to investigate those causes of fever, in 50% of the cases you will never know what they have.
We know that antibiotic prescription in primary care is around 70% in Asia on average and bacterial infections should represent around 20%, so there’s a huge potential impact to have on health at this level of care. With such impact for such small investments, we could also allocate a bit of it to these no specific illness tests that could save a lot of lives and at the same time immediately impact antibiotic prescription at the point of care.