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Randomized Controlled Trial
. 2020 Jul:96:334-342.
doi: 10.1016/j.ijid.2020.05.016. Epub 2020 May 11.

Causes of fever in primary care in Southeast Asia and the performance of C-reactive protein in discriminating bacterial from viral pathogens

Thomas Althaus  1 , Janjira Thaipadungpanit  2 , Rachel C Greer  3 , Myo Maung Maung Swe  4 , Sabine Dittrich  5 , Pimnara Peerawaranun  2 , Pieter W Smit  6 , Tri Wangrangsimakul  3 , Stuart Blacksell  3 , Jonas M Winchell  7 , Maureen H Diaz  7 , Nicholas P J Day  3 , Frank Smithuis  8 , Paul Turner  9 , Yoel Lubell  3
Affiliations
Randomized Controlled Trial

Causes of fever in primary care in Southeast Asia and the performance of C-reactive protein in discriminating bacterial from viral pathogens

Thomas Althaus et al. Int J Infect Dis. 2020 Jul.

Abstract

Objectives: This study investigated causes of fever in the primary levels of care in Southeast Asia, and evaluated whether C-reactive protein (CRP) could distinguish bacterial from viral pathogens.

Methods: Blood and nasopharyngeal swab specimens were taken from children and adults with fever (>37.5 °C) or history of fever (<14 days) in Thailand and Myanmar.

Results: Of 773 patients with at least one blood or nasopharyngeal swab specimen collected, 227 (29.4%) had a target organism detected. Influenza virus type A was detected in 85/227 cases (37.5%), followed by dengue virus (30 cases, 13.2%), respiratory syncytial virus (24 cases, 10.6%) and Leptospira spp. (nine cases, 4.0%). Clinical outcomes were similar between patients with a bacterial or a viral organism, regardless of antibiotic prescription. CRP was higher among patients with a bacterial organism compared with those with a viral organism (median 18 mg/L, interquartile range [10-49] versus 10 mg/L [≤8-22], p = 0.003), with an area under the curve of 0.65 (95% CI 0.55-0.75).

Conclusions: Serious bacterial infections requiring antibiotics are an exception rather than the rule in the first line of care. CRP testing could assist in ruling out such cases in settings where diagnostic uncertainty is high and routine antibiotic prescription is common. The original CRP randomised controlled trial was registered with ClinicalTrials.gov, number NCT02758821.

Keywords: Antibiotic prescription; C-reactive protein; Causes of fever; Primary care; Southeast Asia.

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Conflict of interest statement

The funders had no role in study design, data collection, data interpretation or writing the manuscript. The corresponding author had full access to all the data and took the final decision to submit for publication.

Figures

Figure 1
Figure 1
Study flowchart. RNP3, Ribonuclease P3 gene as an extraction and specimen integrity control.
Figure 2
Figure 2
C-reactive protein (CRP) concentration (mg/L) using a log scale per aetiological group in Chiang Rai, northern Thailand and Hlaing Tha Yar, Lower Myanmar, 2016–2017. CRP concentrations (all in log-scale) are coloured in blue for viruses, red for bacteria and in grey when no organisms were detected neither in blood specimens nor in nasopharyngeal (NP) swabs. Box boundaries show 25th and 75th percentiles of CRP concentrations and lines within the boxes show the medians. The whiskers indicate the 10th and 90th percentile of CRP concentrations.
Figure 3
Figure 3
Diagnostic accuracy of C-reactive protein (CRP)-testing for distinguishing bacterial from viral targeted organisms in Chiang Rai, northern Thailand and Hlaing Tha Yar, Lower Myanmar, 2016–2017.
See this image and copyright information in PMC

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