Rapid clinical assessment to facilitate the triage of adults with falciparum malaria, a retrospective analysis.
BACKGROUND
Most adults dying from falciparum malaria will die within 48 hours of their hospitalisation. An essential component of early supportive care is the rapid identification of patients at greatest risk. In resource-poor settings, where most patients with falciparum malaria are managed, decisions regarding patient care must frequently be made using clinical evaluation alone.


METHODS
We retrospectively analysed 4 studies of 1801 adults with severe falciparum malaria to determine whether the presence of simple clinical findings might assist patient triage.


RESULTS
If present on admission, shock, oligo-anuria, hypo- or hyperglycaemia, an increased respiratory rate, a decreased Glasgow Coma Score and an absence of fever were independently predictive of death. The variables were used to construct a simple clinical algorithm. When applied to the 1801 patients, this algorithm's positive predictive value for survival to 48 hours was 99.4 (95% confidence interval (CI) 97.8-99.9) and for survival to discharge 96.9% (95% CI 94.3-98.5). In the 712 patients receiving artesunate, the algorithm's positive predictive value for survival to 48 hours was 100% (95% CI 97.3-100) and to discharge was 98.5% (95% CI 94.8-99.8).


CONCLUSIONS
Simple clinical findings are closely linked to the pathophysiology of severe falciparum malaria in adults. A basic algorithm employing these indices can facilitate the triage of patients in settings where intensive care services are limited. Patients classified as low-risk by this algorithm can be safely managed initially on a general ward whilst awaiting senior clinical review and laboratory data.
Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand ; Global Health Division, Menzies School of Health Research, Darwin, Australia.
Josh
J
Hanson
Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand ; Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, Churchill Hospital, Oxford, United Kingdom.
Sue J
SJ
Lee
Department of Medicine, Ispat Hospital, Rourkela, Orissa, India.
Sanjib
S
Mohanty
Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand ; Dev Care Foundation, Dhaka, Bangladesh.
M Abul
MA
Faiz
Global Health Division, Menzies School of Health Research, Darwin, Australia.
Nicholas M
NM
Anstey
Global Health Division, Menzies School of Health Research, Darwin, Australia ; Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, Churchill Hospital, Oxford, United Kingdom.
Ric N
RN
Price
Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand.
Prakaykaew
P
Charunwatthana
Chittagong Medical College, Chittagong, Bangladesh.
Emran Bin
EB
Yunus
Department of Medicine, Ispat Hospital, Rourkela, Orissa, India.
Saroj K
SK
Mishra
National Institute of Health Research and Development, Ministry of Health, Jakarta, Indonesia.
Emiliana
E
Tjitra
Shaheed Sharwardhy Medical College, Dhaka, Bangladesh.
Ridwanur
R
Rahman
Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand ; Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, Churchill Hospital, Oxford, United Kingdom ; Shoklo Malaria Research Unit, Mae Sot, Thailand.
Francois
F
Nosten
Department of Medical Research, Lower Myanmar, Ministry of Health, Yangon, Myanmar.
Ye
Y
Htut
Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand ; Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, Churchill Hospital, Oxford, United Kingdom.
Richard J
RJ
Maude
Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam.
Tran Thi Hong
TT
Chau
Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam.
Nguyen Hoan
NH
Phu
Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam.
Tran Tinh
TT
Hien
Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand ; Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, Churchill Hospital, Oxford, United Kingdom.
Nicholas J
NJ
White
Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand ; Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, Churchill Hospital, Oxford, United Kingdom.
Nicholas P J
NP
Day
Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand ; Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, Churchill Hospital, Oxford, United Kingdom.
Arjen M
AM
Dondorp
D000208:Acute Disease; D000328:Adult; D000465:Algorithms; D000962:Antimalarials / Q000627:therapeutic use; D037621:Artemisinins / Q000627:therapeutic use; D000077332:Artesunate; D042241:Early Diagnosis; D005260:Female; D006801:Humans; D006943:Hyperglycemia / Q000473:pathology; D007003:Hypoglycemia / Q000473:pathology; D016778:Malaria, Falciparum / Q000175:diagnosis* / Q000188:drug therapy / Q000401:mortality / Q000473:pathology*; D008297:Male; D008875:Middle Aged; D009846:Oliguria / Q000473:pathology; D018579:Patient Selection; D010963:Plasmodium falciparum / Q000187:drug effects / Q000302:isolation & purification*; D056152:Respiratory Rate; D012720:Severity of Illness Index; D012769:Shock / Q000473:pathology
D000962:Antimalarials; D037621:Artemisinins; D000077332:Artesunate