Objectives To examine the impact of use of rapid diagnostic tests for
malaria on prescribing of antimicrobials, specifically
antibiotics, for acute febrile illness in Africa and Asia.Design Analysisof nine preselected linked and codesigned observational and randomised studies (eight cluster or individually randomised trials and one observational study).Setting Public and private healthcare settings, 2007-13, in Afghanistan, Cameroon, Ghana, Nigeria, Tanzania, and Uganda.Participants 522 480 children and adults with acute febrile illness.Interventions Rapid diagnostic tests for
malaria.Main outcome measures Proportions of patients for whom an
antibiotic was prescribed in trial groups who had undergone rapid diagnostic testing compared with controls and in patients with negative test results compared with patients with positive results. A secondary aim compared classes of
antibiotics prescribed in different settings.Results Antibiotics were prescribed to 127 052/238 797 (53%) patients in control groups and 167 714/283 683 (59%) patients in intervention groups.
Antibiotics were prescribed to 40% (35 505/89 719) of patients with a positive test result for
malaria and to 69% (39 400/57 080) of those with a negative result. All but one study showed a trend toward more
antibiotic prescribing in groups who underwent rapid diagnostic tests. Random effects meta-analysis of the trials showed that the overall risk of
antibiotic prescription was 21% higher (95% confidence interval 7% to 36%) in intervention settings. In most intervention settings, patients with negative test results received more
antibiotic prescriptions than patients with positive results for all the most commonly used classes:
penicillins,
trimethoprim-sulfamethoxazole (one exception),
tetracyclines, and
metronidazole.Conclusions Introduction of rapid diagnostic tests for
malaria to reduce unnecessary use of
antimalarials-a beneficial public health outcome-could drive up untargeted use of
antibiotics. That 69% of patients were prescribed
antibiotics when test results were negative probably represents overprescription.This included
antibiotics from several classes, including those like
metronidazole that are seldom appropriate for febrile illness, across varied clinical, health system, and epidemiological settings. It is often assumed that better disease specific diagnostics will reduce antimicrobial overuse, but they might simply shift it from one antimicrobial class to another. Current global implementation of
malaria testing might increase untargeted
antibiotic use and must be examined.