title: The outcome of a test-treat package versus routine outpatient care for Ghanaian children with fever: a pragmatic randomized control trial.
abstract: BACKGROUND
  Over-diagnosis of malaria among African children results in mismanagement of non-malaria infections. Limited laboratory capacity makes it difficult to implement policies that recommend pre-treatment confirmation of infections so a new approach with a package for on-the-spot management of fevers was evaluated.
  
  
  METHODS
  Febrile children presenting to outpatient clinic were randomized to receive either a 'test-treat' package (history with clinical examination; point-of-care tests; choice of artesunate-amodiaquine, co-amoxiclav and/or paracetamol) or routine outpatient care in a secondary health care facility in Kumasi, Ghana. A diagnosis of malaria, bacterial, viral or mixed malarial and bacterial infections was made using pre-defined criteria. Outcome was resolution of all symptoms including fever on day 7.
  
  
  RESULTS
  The median age of the patients was 37.5 months (IQR: 19 to 66 months), with 56.7% being males. Compared to routine care the test-treat package resulted in less diagnoses of malaria, (37.2% vs 46.2%, p = 0.190) and mixed malaria and bacterial infections (14.0% vs 53.8%, p < 0.001) but more diagnoses of viral (33.1% vs 0.0%, p < 0.001) and bacterial infections only (15.7% vs 0.0%, p < 0.001). Less anti-malarials (51.2% vs 100.0%, p < 0.001) and antibiotics (29.7% vs 48.7%, p < 0.001), were prescribed in the test-treat group on completion of study, more test-treat package patients were clinically well (99.2% vs 80.7%, p < 0.001) and febrile (0.8% vs 10.1%, p = 0.001) and less were admitted for inpatient care (0.0% vs 8.4% p = 0.001) compared to the routine care group.
  
  
  CONCLUSIONS
  Test-treat package improves the effectiveness of outpatient diagnosis and treatment of children with fever and reduces inappropriate prescribing of anti-malarials and antibiotics. The package provides clinicians with the option for immediate diagnosis and treatment of non-malaria fevers. The test-treat package now needs to be evaluated in other settings including primary health care facilities.
authors.affiliation: Department of Child Health, Komfo Anokye Teaching Hospital, Kumasi, Ghana. ekameyaw@yahoo.com.
authors.forename: Emmanuel
authors.initials: E
authors.lastname: Ameyaw
authors.forename: Samuel B
authors.initials: SB
authors.lastname: Nguah
authors.forename: Daniel
authors.initials: D
authors.lastname: Ansong
authors.forename: Iain
authors.initials: I
authors.lastname: Page
authors.forename: Martine
authors.initials: M
authors.lastname: Guillerm
authors.forename: Imelda
authors.initials: I
authors.lastname: Bates
mesh_terms: D000553:Ambulatory Care / Q000379:methods; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D000962:Antimalarials / Q000627:therapeutic use*; D002648:Child; D002675:Child, Preschool; D015510:Clinical Medicine / Q000379:methods*; D003955:Diagnostic Tests, Routine / Q000379:methods*; D005260:Female; D005335:Fever of Unknown Origin / Q000175:diagnosis* / Q000188:drug therapy*; D005869:Ghana; D006801:Humans; D007223:Infant; D008297:Male; D019095:Point-of-Care Systems; D016896:Treatment Outcome
chemical_list: D000900:Anti-Bacterial Agents; D000962:Antimalarials