title: Determinants of mortality, intensive care requirement and prolonged hospitalization in malaria - a tertiary care hospital based cohort study from South-Western India.
abstract: BACKGROUND
  There is a remarkable dearth of literature on less pronounced outcomes in malaria, namely prolonged hospitalization and intensive care requirement. Limitations on routine clinical applicability of the World Health Organization's (WHO) guidelines for determination of severity in malaria does result in underestimation of the true burden of clinicians' perceived severity in malaria. This study was conducted to evaluate the clinico-laboratory and malarial severity features to determine their association with mortality, prolonged hospitalization and requirement of intensive care outcomes.
  
  
  METHODS
  A tertiary care hospital based retrospective study was conducted from the year 2007 to 2011 among microscopically proven adult malaria patients. Logistic regression analysis was performed to determine the factors associated with mortality, more than seven days hospitalization, intensive care and other supportive requirements.
  
  
  RESULTS
  Of a total of 922 malaria cases studied, more than seven days of hospitalization was the most frequent outcome (21.8% (201), 95% CI=19.1-24.5%) followed by intensive care requirement (8.6% (79), 95% CI=6.8-10.4%) and in-hospital mortality (1.2% (11), 95% CI=0.5-1.9%). Odds of mortality were significantly higher with cerebral malaria, pulmonary oedema/acute respiratory distress syndrome (PE/ARDS), liver dysfunction, severe anaemia, renal failure, respiratory distress, metabolic acidosis and leucocytosis. More than seven days hospitalization had inverse association with mortality. Plasmodium falciparum infection, more than three days of history of fever, haemoglobinuria, renal failure, shock, leucocytosis, severe thrombocytopaenia and every 10 mmHg fall in systolic blood pressure were the independent predictors of more than seven days of hospitalization. More than three days of history of fever, cerebral malaria, PE/ARDS, renal failure, metabolic acidosis, hyperparasitaemia, leucocytosis and severe thrombocytopaenia were independently associated factors with intensive care requirement.
  
  
  CONCLUSIONS
  For routine clinical settings, severity definition for malaria needs to be redefined or modified from the existing WHO guidelines. Leucocytosis and severe thrombocytopaenia should be identified as severity determinant in malaria. Patients having more than three days history of fever, leucocytosis, severe thrombocytopaenia and renal failure are more likely to require either prolonged hospitalization and/or intensive care. PE/ARDS alone in Plasmodium vivax may result in mortality, whereas multiorgan involvement is common in P. falciparum related mortalities.
authors.affiliation: Department of Medicine, Kasturba Medical College, Manipal University, Manipal 576104, Karnataka, India. kavithasaravu@gmail.com.
authors.forename: Kavitha
authors.initials: K
authors.lastname: Saravu
authors.forename: Kumar
authors.initials: K
authors.lastname: Rishikesh
authors.forename: Asha
authors.initials: A
authors.lastname: Kamath
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D003422:Critical Care / Q000706:statistics & numerical data; D005260:Female; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D007194:India / Q000453:epidemiology; D007223:Infant; D007231:Infant, Newborn; D016778:Malaria, Falciparum / Q000453:epidemiology / Q000401:mortality* / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D063128:Tertiary Health Care; D016896:Treatment Outcome; D055815:Young Adult