Background: Acute!febrile!respiratory!illnesses,!including!influenza,!account!for!
a!large!proportion!of!ambulatory!care!visits!worldwide.!In!the!developed!world,!these!
encounters!commonly!result!in!unwarranted!antibiotic!prescriptions;!data!from!more!
resource-limited settings!are!lacking.!!The!purpose!of!this!study!was!to!describe!the!
epidemiology of!influenza!among!outpatients!in!southern!Sri!Lanka and!to!determine!if!
access!to!rapid!influenza!test!results!was associated!with!decreased antibiotic!
prescriptions.
Methods: In!this!pretest- posttest!study,!consecutive!patients!presenting!from!
March!2013- April!2014!to!the!Outpatient!Department!of!the!largest!tertiary!care!hospital!
in!southern!Sri!Lanka!were!surveyed!for!influenza-like!illness!(ILI).!Patients!meeting!
World!Health!Organization!criteria!for!ILI-- acute!onset!of!fever!≥38.0°C!and!cough!in!
the!prior!7!days—were!enrolled.!Consenting!patients!were!administered!a!structured!
questionnaire,!physical!examination, and!nasal/nasopharyngeal!sampling. Rapid!
influenza A/B testing (Veritor!System,!Becton!Dickinson) was!performed!on!all!patients,!
but!test!results!were!only!released!to!patients!and!clinicians!during!the!second!phase!of!
the!study!(December 2013- April!2014).!
Results:!!We!enrolled 397!patients!with!ILI,!with!217 (54.7%)!adults!≥12 years!and!
188 (47.4%)!females.!A!total!of!179!(45.8%)!tested!positive!for!influenza!by!rapid!testing,!
v
with!April- July!2013!and!September- November!2013 being!the!periods!with!the!highest!
proportion!of!ILI!due!to!influenza.!A!total!of!310!(78.1%)!patients with!ILI received!a!
prescription!for!an!antibiotic!from!their!outpatient!provider.!The!proportion!of!patients!
prescribed!antibiotics decreased from!81.4%!in!the!first!phase!to!66.3%!in the!second!
phase!(p=.005); among rapid!influenza-positive!patients, antibiotic!prescriptions!
decreased!from!83.7%!in!the!first!phase!to!56.3%!in!the!second!phase!(p=.001).!On!
multivariable analysis,!having!a!positive!rapid!influenza!test!available to!clinicians was!
associated!with!decreased!antibiotic!use!(OR!0.20,!95%!CI!0.05- 0.82).
Conclusions: Influenza!virus!accounted!for!almost!50% of!acute!febrile!
respiratory!illness!in!this!study,!but!most!patients!were!prescribed!antibiotics.!Providing!
rapid!influenza!test!results!to clinicians was!associated!with!fewer antibiotic!
prescriptions,!but!overall!prescription!of!antibiotics!remained!high.!In!this!developing
country setting,!a!multi-faceted!approach!that!includes improved access!to!rapid!
diagnostic!tests!may!help!decrease!antibiotic!use and!combat antimicrobial!resistance.