A simple score to predict the outcome of severe malaria in adults.
BACKGROUND
World Health Organization treatment guidelines recommend that adults with severe malaria be admitted to an intensive care unit (ICU). However, ICU facilities are limited in the resource-poor settings where most malaria occurs. Identification of patients at greater risk of complications may facilitate their triage and resource allocation.


METHODS
With use of data from a trial conducted in Southeast Asia (n=868), a logistic regression model was built to identify independent predictors of mortality among adults with severe malaria. A scoring system based on this model was tested in the original dataset and then validated in 2 series from Bangladesh (n=188) and Vietnam (n=292).


RESULTS
Acidosis (base deficit) and cerebral malaria (measured as Glasgow Coma Score) were the main independent predictors of outcome. The 5-point Coma Acidosis Malaria (CAM) score was simply derived from these 2 variables. Mortality increased steadily with increasing score. A CAM score <2 predicted survival with a positive predictive value (PPV) of 95.8% (95% confidence interval [CI], 93%- 97.7%). Of the 14 of 331 patients who died with a CAM score <2, 11 (79%) had renal failure and death occurred late after hospital admission (median, 108 h; range, 40-360 h). Substitution of plasma bicarbonate as the measure of acidosis only slightly reduced the prognostic value of the model. Use of respiratory rate was inferior, but a score <2 still predicted survival with a PPV of 92.2% (95% CI, 89.1%-94.7%).


CONCLUSIONS
Patients with a CAM score <2 at hospital admission may be safely treated in a general ward, provided that renal function can be monitored.
Hanson
Josh
J
Mahidol University, Bangkok, Thailand. drjoshhanson@gmail.com
Lee
Sue J
SJ
Mohanty
Sanjib
S
Faiz
M A
MA
Anstey
Nicholas M
NM
Charunwatthana
Prakaykaew
P
Yunus
Emran Bin
EB
Mishra
Saroj K
SK
Tjitra
Emiliana
E
Price
Ric N
RN
Rahman
Ridwanur
R
Nosten
Francois
F
Htut
Ye
Y
Hoque
Gofranul
G
Hong Chau
Tran Thi
TT
Hoan Phu
Nguyen
N
Hien
Tran Tinh
TT
White
Nicholas J
NJ
Day
Nicholas P J
NP
Dondorp
Arjen M
AM
D000138:Acidosis / Q000473:pathology; D000328:Adult; D001459:Bangladesh; D003128:Coma / Q000473:pathology; D005260:Female; D006801:Humans; D008288:Malaria / Q000175:diagnosis* / Q000401:mortality / Q000473:pathology*; D008297:Male; D011379:Prognosis; D012720:Severity of Illness Index; D014744:Vietnam