The Question: Antibiotic resistance mechanisms originating in low- and middle- income countries are among the most common worldwide. Reducing unnecessary antibiotic use in India, the world’s largest antibiotic consumer, is crucial for controlling antimicrobial resistance globally. Diagnostic testing can improve antibiotic prescribing, but in many low-resource settings, rapid diagnostic tests for mosquito-borne illnesses, particularly malaria, have increased the rate of prescribed antibiotic consumption. Most prior studies were done in high-burden areas, where malaria is common. In this study, we examined the factors that were associated with empiric antibiotic initiation and discontinuation, focusing, especially, on the role of diagnostics for detecting mosquito-borne diseases.

What We Found: Our study included 1,486 patients in Pune, India who received empiric antibiotic therapy. We found that nearly all patients admitted with acute febrile illness were prescribed antibiotics. Patients suspected of having mosquito-borne disease were less likely to receive empiric antibiotics, and positive dengue or malaria test results were associated with antibiotic discontinuation. In addition, we found that positive bacteriology results were associated with antibiotic escalation, but negative bacteriology results were not associated with antibiotic discontinuation.

Why It Matters: Implementation of more sensitive and rapid identification of bacterial infection and antibiotic susceptibility has been discovered to be necessary to reduce antibiotic use. In settings like the United States, this has been found to be moderately effective. However, in this setting, negative diagnostic results did not result in discontinuation of antibiotics. This provides avenues for improvement in this area as well as further research to determine if this is common across other lower-resource settings. Additionally, we found that unlike high-burden malaria sites in other countries, diagnostic tests for mosquito-borne illnesses did not lead to a rise in antibiotic prescribing. Instead, these tests caused a decline. This suggests that in areas with a lower burden of malaria or other mosquito-borne diseases, clinicians do not assume that people who have a fever have malaria and thus, the use of rapid tests can provide beneficial therapy without propelling the use of antibiotics.