title: Malaria investigation and treatment of children admitted to county hospitals in western Kenya.
abstract: BACKGROUND
  Up to 90 % of the global burden of malaria morbidity and mortality occurs in sub-Saharan Africa and children under-five bear a disproportionately high malaria burden. Effective inpatient case management can reduce severe malaria mortality and morbidity, but there are few reports of how successfully international and national recommendations are adopted in management of inpatient childhood malaria.
  
  
  METHODS
  A descriptive cross-sectional study of inpatient malaria case management practices was conducted using data collected over 24 months in five hospitals from high malaria risk areas participating in the Clinical Information Network (CIN) in Kenya. This study describes documented clinical features, laboratory investigations and treatment of malaria in children (2-59 months) and adherence to national guidelines.
  
  
  RESULTS
  A total of 13,014 children had a malaria diagnosis on admission to the five hospitals between March, 2014 and February, 2016. Their median age was 24 months (IQR 12-36 months). The proportion with a diagnostic test for malaria requested was 11,981 (92.1 %). Of 10,388 patients with malaria test results documented, 8050 (77.5 %) were positive and anti-malarials were prescribed in 6745 (83.8 %). Malaria treatment was prescribed in 1613/2338 (69.0 %) children with a negative malaria result out of which only 52 (3.2 %) had a repeat malaria test done as recommended in national guidelines. Documentation of clinical features was good across all hospitals, but quinine remained the most prescribed malaria drug (47.2 % of positive cases) although a transition to artesunate (46.1 %) was observed. Although documented clinical features suggested approximately half of positive malaria patients were not severe cases artemether-lumefantrine was prescribed on admission in only 3.7 % cases.
  
  
  CONCLUSIONS
  Despite improvements in inpatient malaria care, high rates of presumptive treatment for test negative children and likely over-use of injectable anti-malarial drugs were observed. Three years after national policy change, there is a gradual transition to artesunate. Continued efforts to support improved routine inpatient malaria care through dissemination and implementation of guidelines, and access to recommended drugs are needed together with improved capacity of hospitals to investigate other causes of severe illness in children. Efforts to improve clinical information could help track progress.
authors.affiliation: Kenya Medical Research Institute/Wellcome Trust Research Programme, P.O. Box 43640, Nairobi, 00100, Kenya. BAmboko@kemri-wellcome.org.
authors.forename: Beatrice I
authors.initials: BI
authors.lastname: Amboko
authors.affiliation: Kenya Medical Research Institute/Wellcome Trust Research Programme, P.O. Box 43640, Nairobi, 00100, Kenya.
authors.forename: Philip
authors.initials: P
authors.lastname: Ayieko
authors.affiliation: Kenya Medical Research Institute/Wellcome Trust Research Programme, P.O. Box 43640, Nairobi, 00100, Kenya.
authors.forename: Morris
authors.initials: M
authors.lastname: Ogero
authors.affiliation: Kenya Medical Research Institute/Wellcome Trust Research Programme, P.O. Box 43640, Nairobi, 00100, Kenya.
authors.forename: Thomas
authors.initials: T
authors.lastname: Julius
authors.affiliation: Kenya Medical Research Institute/Wellcome Trust Research Programme, P.O. Box 43640, Nairobi, 00100, Kenya.|Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya.
authors.forename: Grace
authors.initials: G
authors.lastname: Irimu
authors.affiliation: Kenya Medical Research Institute/Wellcome Trust Research Programme, P.O. Box 43640, Nairobi, 00100, Kenya.|Nuffield Department of Medicine, Oxford University, Oxford, UK.
authors.forename: Mike
authors.initials: M
authors.lastname: English
mesh_terms: D000962:Antimalarials / Q000627:therapeutic use*; D019090:Case Management / Q000458:organization & administration*; D002675:Child, Preschool; D003430:Cross-Sectional Studies; D004363:Drug Utilization; D005260:Female; D006302:Health Services Research; D006766:Hospitals, County; D006801:Humans; D007223:Infant; D007630:Kenya; D008288:Malaria / Q000175:diagnosis* / Q000188:drug therapy*; D008297:Male; D011803:Quinine / Q000627:therapeutic use
chemical_list: D000962:Antimalarials; D011803:Quinine
keywords: Anti-malarials; Children; Inpatient; Malaria; Malaria case management; Under-fives