title: Frequency and correlates of malaria over-treatment in areas of differing malaria transmission: a cross-sectional study in rural Western Kenya.
abstract: BACKGROUND
  In 2010, the World Health Organization shifted its malaria guidelines from recommending the empiric treatment of all febrile children to treating only those with laboratory-confirmed malaria. This study evaluated the frequency and predictors of malaria over-treatment among febrile malaria-negative children in Kenya.
  
  
  METHODS
  Between 2012 and 2013, 1,362 children presenting consecutively with temperature ≥37.5°C to Kisii and Homa Bay hospitals were enrolled in a cross-sectional study evaluating causes of fever. Children were screened for malaria using smear microscopy and rapid diagnostic tests and managed according to standard of care at the hospitals. The frequency of anti-malarial prescriptions among children with laboratory-confirmed malaria negative children (malaria over-treatment) was determined; and clinical and demographic correlates of overtreatment evaluated using logistic regression. Because of differences in malaria endemicity, analyses were stratified and compared by site.
  
  
  RESULTS
  Among 1,362 children enrolled, 46 (7%) of 685 children in Kisii, and 310 (45.8%) of 677 in Homa Bay had laboratory-confirmed malaria; p < 0.001. Among malaria-negative children; 210 (57.2%) in Homa Bay and 45 (7.0%) in Kisii received anti-malarials; p < 0.001. Predictors of over-treatment in Homa Bay included ≥ one integrated management of childhood illness (IMCI) danger sign (aOR = 8.47; 95% CI: 4.81-14.89), fever lasting ≥ seven days (aOR = 4.94; 95% CI: 1.90-12.86), and fever ≥39°C (aOR = 3.07; 95% CI: 1.58-5.96). In Kisii, only fever ≥39°C predicted over-treatment (aOR = 2.13; 95% CI: 1.02-4.45).
  
  
  CONCLUSIONS
  Malaria over-treatment was common, particularly in Homa Bay, where the prevalence of malaria was extremely high. Severe illness and high or prolonged fever were associated with overtreatment. Overtreatment may result in failure to treat other serious causes of fever, drug resistance, and unnecessarily treatment costs.
authors.affiliation: Department of Epidemiology, University of Washington, 325 Ninth Avenue, Box 359909, Seattle, WA, 98104, USA. fonchiri@gmail.com.|Kenya Medical Research Institute, Centre for Clinical Research, Nairobi, Kenya. fonchiri@gmail.com.
authors.forename: Frankline M
authors.initials: FM
authors.lastname: Onchiri
authors.affiliation: Department of Epidemiology, University of Washington, 325 Ninth Avenue, Box 359909, Seattle, WA, 98104, USA. ppav@u.washington.edu.
authors.forename: Patricia B
authors.initials: PB
authors.lastname: Pavlinac
authors.affiliation: Kenya Medical Research Institute, Centre for Clinical Research, Nairobi, Kenya. singabo2008@gmail.com.
authors.forename: Benson O
authors.initials: BO
authors.lastname: Singa
authors.affiliation: Kenya Medical Research Institute, Centre for Clinical Research, Nairobi, Kenya. jngarayi@gmail.com.|Department of Pediatrics, University of Washington, Seattle, USA. jngarayi@gmail.com.
authors.forename: Jacqueline M
authors.initials: JM
authors.lastname: Naulikha
authors.affiliation: Walter Reed Project, United States Army Medical Research Unit, Kericho, Kenya. Elizabeth.Odundo@usamru-k.org.
authors.forename: Elizabeth A
authors.initials: EA
authors.lastname: Odundo
authors.affiliation: Department of Epidemiology, University of Washington, 325 Ninth Avenue, Box 359909, Seattle, WA, 98104, USA. cfarq@uw.edu.|Department of Global Health, University of Washington, Seattle, USA. cfarq@uw.edu.|Department of Medicine, University of Washington, Seattle, USA. cfarq@uw.edu.
authors.forename: Carey
authors.initials: C
authors.lastname: Farquhar
authors.affiliation: Department of Biostatistics, University of Washington, Seattle, USA. barbrar@uw.edu.|Department of Global Health, University of Washington, Seattle, USA. barbrar@uw.edu.|Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, USA. barbrar@uw.edu.
authors.forename: Barbra A
authors.initials: BA
authors.lastname: Richardson
authors.affiliation: Department of Epidemiology, University of Washington, 325 Ninth Avenue, Box 359909, Seattle, WA, 98104, USA. gjohn@uw.edu.|Department of Pediatrics, University of Washington, Seattle, USA. gjohn@uw.edu.|Department of Global Health, University of Washington, Seattle, USA. gjohn@uw.edu.|Department of Medicine, University of Washington, Seattle, USA. gjohn@uw.edu.
authors.forename: Grace
authors.initials: G
authors.lastname: John-Stewart
authors.affiliation: Department of Epidemiology, University of Washington, 325 Ninth Avenue, Box 359909, Seattle, WA, 98104, USA. walson@uw.edu.|Department of Pediatrics, University of Washington, Seattle, USA. walson@uw.edu.|Department of Global Health, University of Washington, Seattle, USA. walson@uw.edu.|Department of Medicine, University of Washington, Seattle, USA. walson@uw.edu.
authors.forename: Judd L
authors.initials: JL
authors.lastname: Walson
mesh_terms: D000293:Adolescent; D000962:Antimalarials / Q000494:pharmacology / Q000627:therapeutic use*; D002648:Child; D002675:Child, Preschool; D003430:Cross-Sectional Studies; D005260:Female; D005334:Fever / Q000453:epidemiology / Q000469:parasitology; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D007630:Kenya / Q000453:epidemiology; D008288:Malaria / Q000188:drug therapy* / Q000453:epidemiology* / Q000469:parasitology; D008297:Male; D010963:Plasmodium falciparum / Q000187:drug effects*
chemical_list: D000962:Antimalarials