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Antimicrobial stewardship in tropical fever — DTM&H MCQ

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HardEpidemiology and public healthAntimicrobial stewardship in tropical feverDTM&H

A clinic in rural Cambodia gives ceftriaxone to nearly every patient with fever despite negative malaria tests and no sepsis signs. Blood cultures are rarely taken, and resistant enteric fever has increased locally. What is the most important service improvement?

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Correct answer: C — Introduce fever algorithms with diagnostics, cultures and antibiotic review

The correct answer is C, introduce fever algorithms with diagnostics, cultures and antibiotic review. Blanket ceftriaxone use without confirmatory testing is exactly the practice pattern that drives resistant enteric fever, and the core stewardship fix is a structured clinical pathway that mandates appropriate diagnostics (malaria testing, blood cultures where facilities allow) before empirical antibiotics are started, with a formal review of the ongoing need for that antibiotic once results return. NICE guidance on antimicrobial stewardship sets out that services should review the clinical diagnosis and the continuing need for antibiotics, with a clear documented plan of action, rather than continuing therapy by default. Applying this systems approach in a resource-limited fever clinic targets the actual failure (undifferentiated empirical prescribing without diagnostic confirmation or review), rather than removing diagnostics or intensifying antibiotic use, and is the only option that simultaneously improves diagnosis of enteric fever and slows further resistance selection. Why the other options are wrong: D. Stop malaria testing to reduce cost: removing malaria testing abolishes the only tool distinguishing malaria from bacterial causes of fever, increasing missed or delayed antimalarial treatment and worsening indiscriminate antibiotic use. B. Use ceftriaxone earlier for every fever: this is the practice already causing harm; earlier, undifferentiated ceftriaxone use accelerates selection of ceftriaxone-resistant Salmonella Typhi/Paratyphi and other enteric pathogens. E. Replace blood culture with eosinophil count: eosinophilia reflects helminth or allergic disease, not bacteraemia, and has no role in diagnosing or excluding enteric fever; this removes the diagnostic test needed for antimicrobial confirmation and susceptibility data. A. Give ivermectin with each antibiotic dose: ivermectin treats parasitic infestations such as strongyloidiasis, not bacterial enteric fever, and has no mechanism to address antibiotic misuse or resistance. Key point: Fever management in areas with rising resistant enteric fever needs diagnosis-led algorithms (testing, cultures, structured antibiotic review) rather than default broad-spectrum antibiotics for every febrile patient.

Reference: NICE Quality Standard QS61, Infection prevention and control, Statement 1: Antimicrobial stewardship, review the clinical diagnosis and continuing need for antibiotics with a documented Antimicrobial Prescribing Decision (https://www.nice.org.uk/guidance/qs61/chapter/quality-statement-1-antimicrobial-stewardship)