WHO guidelines for antimicrobial treatment in children admitted to hospital in an area of intense Plasmodium falciparum transmission: prospective study.
Abstract
OBJECTIVES: To assess the performance of WHO's "Guidelines for care at the first-referral
level in developing countries" in an area of intense malaria transmission and identify
bacterial infections in children with and without malaria. DESIGN: Prospective study.
SETTING: District hospital in Muheza, northeast Tanzania. PARTICIPANTS: Children aged
2 months to 13 years admitted to hospital for febrile illness. MAIN OUTCOME MEASURES:
Sensitivity and specificity of WHO guidelines in diagnosing invasive bacterial disease;
susceptibility of isolated organisms to recommended antimicrobials. RESULTS: Over
one year, 3639 children were enrolled and 184 (5.1%) died; 2195 (60.3%) were blood
slide positive for Plasmodium falciparum, 341 (9.4%) had invasive bacterial disease,
and 142 (3.9%) were seropositive for HIV. The prevalence of invasive bacterial disease
was lower in slide positive children (100/2195, 4.6%) than in slide negative children
(241/1444, 16.7%). Non-typhi Salmonella was the most frequently isolated organism
(52/100 (52%) of organisms in slide positive children and 108/241 (45%) in slide negative
children). Mortality among children with invasive bacterial disease was significantly
higher (58/341, 17%) than in children without invasive bacterial disease (126/3298,
3.8%) (P<0.001), and this was true regardless of the presence of P falciparum parasitaemia.
The sensitivity and specificity of WHO criteria in identifying invasive bacterial
disease in slide positive children were 60.0% (95% confidence interval 58.0% to 62.1%)
and 53.5% (51.4% to 55.6%), compared with 70.5% (68.2% to 72.9%) and 48.1% (45.6%
to 50.7%) in slide negative children. In children with WHO criteria for invasive bacterial
disease, only 99/211(47%) of isolated organisms were susceptible to the first recommended
antimicrobial agent. CONCLUSIONS: In an area exposed to high transmission of malaria,
current WHO guidelines failed to identify almost a third of children with invasive
bacterial disease, and more than half of the organisms isolated were not susceptible
to currently recommended antimicrobials. Improved diagnosis and treatment of invasive
bacterial disease are needed to reduce childhood mortality.
Type
Journal articleSubject
Anti-Bacterial AgentsBacterial Infections
Bacteriological Techniques
Child
Child, Preschool
HIV Seropositivity
Hospitalization
Humans
Infant
Malaria, Falciparum
Practice Guidelines as Topic
Prospective Studies
Sensitivity and Specificity
Tanzania
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Jan Ostermann
Adjunct Associate Professor of Global Health

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