Discussion
typhoid
RTI, MALARIA, TYPHOID
This is the first study to assess the impact of access to CRP test kits—and staff training on how to use them in RTI management—on the non-prescription dispensation of antibiotics for RTI in PCPs, a situation that is largely seen in many resource-limited settings [This study shows that access to CRP test kits—and staff training on how to use them in RTI management—in PCPs reduces the non-prescription dispensation of antibiotics for RTI, as there was an absolute reduction—in the non-prescription dispensation of antibiotics—of 15.66% and 16%, based on the multiple imputation regarding the adjusted analysis and crude analysis respectively.Before making treatment decisions, PCPs in the intervention arm conducted CRP tests on simulated clients in 21.40% of visits and 21.67% of visits, based on the complete case analysis and multiple imputation analysis, respectively. No such tests were conducted in the control arm. The results of the CRP tests (that is, viral or bacterial or uncertain) were not explicitly assessed. However, considering that the simulated clients were healthy adults, they were all expected to have CRP levels of <30 mg/l (and hence the CRP tests should suggest that they require no antibiotics). Antibiotics were not dispensed in 43.75% of the visits in which CRP tests were conducted, based on the complete case analysis.Although the percentage of visits in which CRP tests were conducted is not quite high, the observed uptake of CRP testing suggests that CRP testing in PCPs is feasible. At the end of the trial, key pharmacy staff in the intervention arm were interviewed to ascertain any challenges they had regarding CRP testing. This will be reported separately and will, hopefully, provide insight into strategies that could be used to improve the uptake of CRP testing in future interventions of this kind.The findings of this trial are similar to that of a trial conducted in Vietnam, a resource-limited setting, to assess the impact of access to CRP test kits—and staff training on how to use them in RTI management—in primary healthcare centers on antibiotic use for RTI. In the trial, Do et al. Given that PCPs play an important role in the unnecessary use of antibiotics for RTI in resource-limited settings as they frequently dispense antibiotics to patients with RTI without prescriptions [Regarding generalisability, antibiotic dispensation for RTI in children was not captured as all the simulated clients were adult university students who were the only population group readily available to work as simulated clients within the resources available for the study. This may limit the generalizability of the findings of this study to the pediatric population. Additionally, it may be that PCPs that fail to meet the inclusion criteria differ significantly—with respect to blood testing experience—from those that were included in the study, thereby threatening the generalizability of the findings of this study to them. However, this is unlikely to be the case. Malaria and typhoid tests were preferentially used to assess blood testing experience solely because the concerned conditions are not sensitive as to make the individual who assessed eligibility uncomfortable. Most PCPs that fail to meet the inclusion criteria are likely to be equally experienced with blood testing by virtue of offering other blood test services, including blood glucose test, which is routinely offered by PCPs in Nigeria Regarding limitations, this study did not investigate what would happen if patients without prescriptions directly requested to be given antibiotics for their RTI rather than merely complaining about their RTI symptoms. This could be addressed in future trials. In addition, although pharmacy staff did not anticipate the visits by the simulated clients, it is not possible to say with certainty that there was no Hawthorne effect. Therefore, this effect may have contributed to some of the effects observed in this study.Access to CRP test kits—and staff training on how to use them in RTI management—in PCPs in Nigeria improved the objective assessment of antibiotic needs in patients with RTI without prescriptions and reduced the dispensation of antibiotics to such patients. All things being equal, if economic analysis shows that the cost of implementing this intervention in resource-limited settings is manageable, its implementation by relevant stakeholders in such settings is recommended, as this would help reduce the burden of antibiotic resistance.