WHO guidelines for antimicrobial treatment in children admitted to hospital in an area of intense Plasmodium falciparum transmission: prospective study.
OBJECTIVE
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.


METHODS
Prospective study.


METHODS
District hospital in Muheza, northeast Tanzania.


METHODS
Children aged 2 months to 13 years admitted to hospital for febrile illness.


METHODS
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.
Nadjm
Behzad
B
London School of Hygiene and Tropical Medicine, London WCIE 7HT.
Amos
Ben
B
Mtove
George
G
Ostermann
Jan
J
Chonya
Semkini
S
Wangai
Hannah
H
Kimera
Juma
J
Msuya
Walii
W
Mtei
Frank
F
Dekker
Denise
D
Malahiyo
Rajabu
R
Olomi
Raimos
R
Crump
John A
JA
Whitty
Christopher J M
CJ
Reyburn
Hugh
H
D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D001424:Bacterial Infections / Q000150:complications / Q000175:diagnosis* / Q000188:drug therapy / Q000401:mortality; D001431:Bacteriological Techniques; D002648:Child; D002675:Child, Preschool; D006679:HIV Seropositivity / Q000150:complications / Q000401:mortality; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D007223:Infant; D016778:Malaria, Falciparum / Q000150:complications* / Q000401:mortality; D017410:Practice Guidelines as Topic; D011446:Prospective Studies; D012680:Sensitivity and Specificity; D013636:Tanzania / Q000453:epidemiology
D000900:Anti-Bacterial Agents