Antibiotic Use Prior to Hospital Presentation Among Individuals With Suspected Enteric Fever in Nepal, Bangladesh, and Pakistan

Abstract

Background Antibiotic use prior to seeking care at a hospital may reduce the sensitivity of blood culture for enteric fever, with implications for both clinical care and surveillance. The Surveillance for Enteric Fever in Asia Project (SEAP) is a prospective study of enteric fever incidence in Nepal, Bangladesh, and Pakistan. Nested within SEAP, we evaluated the accuracy of self-reported antibiotic use and investigated the association between antibiotic use and blood culture positivity. Methods Between November 2016 and April 2019, we collected urine samples among a subset of SEAP participants to test for antibiotic use prior to the hospital visit using an antibacterial activity assay. All participants were asked about recent antibiotic use and had a blood culture performed. We used mixed-effect logit models to evaluate the effect of antimicrobial use on blood culture positivity, adjusted for markers of disease severity. Results We enrolled 2939 patients with suspected enteric fever. Antibiotics were detected in 39% (1145/2939) of urine samples. The correlation between measured and reported antibiotic use was modest (κ = 0.72). After adjusting for disease severity, patients with antibiotics in their urine were slightly more likely to be blood culture positive for enteric fever; however, the effect was not statistically significant (prevalence ratio, 1.22 [95% confidence interval, .99–1.50]). Conclusions The reliability of self-reported prior antibiotic use was modest among individuals presenting with fever to tertiary hospitals. While antibiotics are likely to reduce the sensitivity of blood culture, our findings indicate that there is still considerable value in performing blood culture for individuals reporting antibiotic use.

Illness Severity and Outcomes Among Enteric Fever Cases From Bangladesh, Nepal, and Pakistan: Data From the Surveillance for Enteric Fever in Asia Project, 2016–2019

“…We observed that hospitalization was associated with antimicrobial use and resistance, especially in Pakistan, which is currently experiencing an ongoing outbreak of XDR typhoid [ 12 ]. Delayed care-seeking and self-reported prior antibiotic use, while only moderately reliable [ 27 ], were also associated with higher odds of severe disease, consistent with previous findings [ 8 , 28 ]. Reasons for delayed care-seeking are unknown; possibly some patients presented to the study sites only after treatment failure, especially in cases of drug resistance [ 29 ].…”

Antibiotic Use before, during, and after Seeking Care for Acute Febrile Illness at a Hospital Outpatient Department: A Cross-Sectional Study from Rural India

“…Antibiotic use before seeking outpatient care for AFI was similar to reports of 5% from Thailand and Myanmar [15], and 8% in Tanzania [14], but less than the 42% reported in Bangladesh and Nepal [24], and 46% in Pakistan [24]. The variation between settings could be due to differences in epidemiology, access to antibiotics, and severity and length of the fever, compared to the other two studies.…”

Incidence of typhoid and paratyphoid fever in Bangladesh, Nepal, and Pakistan: results of the Surveillance for Enteric Fever in Asia Project

“… 22 Data on previous antibiotic use from within the SEAP sites are published elsewhere . 31 To address this limitation, we included the estimated sensitivity of blood culture (59%) in our incidence adjustments. Lastly, we annualised incidence rates and therefore did not capture seasonality of typhoid transmission.…”