title: Integrated paediatric fever management and antibiotic over-treatment in Malawi health facilities: data mining a national facility census.
abstract: There are growing concerns about irrational antibiotic prescription practices in the era of test-based malaria case management. This study assessed integrated paediatric fever management using malaria rapid diagnostic tests (RDT) and Integrated Management of Childhood Illness (IMCI) guidelines, including the relationship between RDT-negative results and antibiotic over-treatment in Malawi health facilities in 2013-2014.
  
  
  
  A Malawi national facility census included 1981 observed sick children aged 2-59 months with fever complaints. Weighted frequencies were tabulated for other complaints, assessments and prescriptions for RDT-confirmed malaria, IMCI-classified non-severe pneumonia, and clinical diarrhoea. Classification trees using model-based recursive partitioning estimated the association between RDT results and antibiotic over-treatment and learned the influence of 38 other input variables at patient-, provider- and facility-levels.
  
  
  
  Among 1981 clients, 72 % were tested or referred for malaria diagnosis and 85 % with RDT-confirmed malaria were prescribed first-line anti-malarials. Twenty-eight percent with IMCI-pneumonia were not prescribed antibiotics (under-treatment) and 59 % 'without antibiotic need' were prescribed antibiotics (over-treatment). Few clients had respiratory rates counted to identify antibiotic need for IMCI-pneumonia (18 %). RDT-negative children had 16.8 (95 % CI 8.6-32.7) times higher antibiotic over-treatment odds compared to RDT-positive cases conditioned by cough or difficult breathing complaints.
  
  
  
  Integrated paediatric fever management was sub-optimal for completed assessments and antibiotic targeting despite common compliance to malaria treatment guidelines. RDT-negative results were strongly associated with antibiotic over-treatment conditioned by cough or difficult breathing complaints. A shift from malaria-focused 'test and treat' strategies toward 'IMCI with testing' is needed to improve quality fever care and rational use of both anti-malarials and antibiotics in line with recent global commitments to combat resistance.
authors.affiliation: Department of Women's and Children's Health, International Maternal and Child Health, Uppsala University, Uppsala, Sweden. emily.johansson@kbh.uu.se.
authors.forename: Emily White
authors.initials: EW
authors.lastname: Johansson
authors.affiliation: Department of Women's and Children's Health, International Maternal and Child Health, Uppsala University, Uppsala, Sweden.
authors.forename: Katarina Ekholm
authors.initials: KE
authors.lastname: Selling
authors.affiliation: Integrated Management of Childhood Illness (IMCI) Unit, Ministry of Health, Lilongwe, Malawi.
authors.forename: Humphreys
authors.initials: H
authors.lastname: Nsona
authors.affiliation: Spatial Ecology and Epidemiology Group, Department of Zoology, University of Oxford, Oxford, UK.
authors.forename: Bonnie
authors.initials: B
authors.lastname: Mappin
authors.affiliation: Spatial Ecology and Epidemiology Group, Department of Zoology, University of Oxford, Oxford, UK.
authors.forename: Peter W
authors.initials: PW
authors.lastname: Gething
authors.affiliation: The Sahlgrenska Academy, Center for Applied Biostatistics, University of Gothenburg, Gothenburg, Sweden.
authors.forename: Max
authors.initials: M
authors.lastname: Petzold
authors.affiliation: Department of Women's and Children's Health, International Maternal and Child Health, Uppsala University, Uppsala, Sweden.|Global Health-Health Systems and Policy Research Group, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.|School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda.
authors.forename: Stefan Swartling
authors.initials: SS
authors.lastname: Peterson
authors.affiliation: Global Health-Health Systems and Policy Research Group, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.
authors.forename: Helena
authors.initials: H
authors.lastname: Hildenwall
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D019352:Censuses; D002648:Child; D002675:Child, Preschool; D057225:Data Mining; D019033:Delivery of Health Care, Integrated; D003955:Diagnostic Tests, Routine / Q000706:statistics & numerical data*; D004363:Drug Utilization; D005260:Female; D005334:Fever / Q000175:diagnosis* / Q000188:drug therapy*; D006302:Health Services Research; D006801:Humans; D007223:Infant; D008288:Malaria / Q000175:diagnosis / Q000188:drug therapy; D008295:Malawi; D008297:Male; D008875:Middle Aged; D055815:Young Adult
chemical_list: D000900:Anti-Bacterial Agents
keywords: Antibiotic resistance; Child health; Diagnosis; Fever case management; IMCI; Malaria