Abstract
BackgroundIn 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.MethodsBetween 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.ResultsAmong 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).ConclusionsMalaria 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.
Highlights
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
While many countries, including Kenya, have adopted these guidelines with subsequent improvements in Onchiri et al Malaria Journal (2015) 14:97 malaria case-management practices [10], a considerable proportion of febrile patients still continue to be treated for malaria despite negative laboratory test [10,11,12]
This information will inform fever management and may improve understanding of guideline adherence in low-resource settings. Sites, and population This was a cross-sectional study nested within an ongoing surveillance study of febrile illnesses among children at Kisii Provincial Hospital and Homa Bay District Hospital, both in Western Kenya. These hospitals are situated in areas with historically different malaria endemicity: Kisii is hypo-endemic with annual entomologic inoculation rate (EIR) of
Summary
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. Malaria is a leading cause of morbidity and mortality among children in sub-Saharan Africa. Malaria overtreatment may result in the failure to treat other serious causes of fever, blood stream infections [7,8]. Because of the serious potential consequences of malaria overtreatment, it is important to understand why some children are inappropriately treated with anti-malarials. This information will inform fever management and may improve understanding of guideline adherence in low-resource settings
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