Abstract
BackgroundThere 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.MethodsA 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.ResultsAmong 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.ConclusionsIntegrated 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.Electronic supplementary materialThe online version of this article (doi:10.1186/s12936-016-1439-7) contains supplementary material, which is available to authorized users.
Highlights
There are growing concerns about irrational antibiotic prescription practices in the era of test-based malaria case management
In 2010, World Health Organization (WHO) revised malaria treatment guidelines to recommend diagnosis of all suspected malaria cases prior to treatment given the increasing availability of malaria rapid diagnostic tests (RDT) [4]. This policy shift has great potential to improve rational drug use and quality fever care [5], studies indicate common inappropriate treatment of RDT-negative patients with anti-malarial or antibiotic drugs [6]. These findings suggest poor integration of RDT into the Integrated Management of Childhood Illness (IMCI) framework, few studies have explicitly examined integrated paediatric fever management and available evidence is largely derived from limited hospital settings [7,8,9,10,11,12]
There is limited understanding of factors associated with non-adherence to clinical guidelines, notably antibiotic over-treatment, which is a particular concern in the era of test-based malaria case management [13]
Summary
There are growing concerns about irrational antibiotic prescription practices in the era of test-based malaria case management. In 2010, WHO revised malaria treatment guidelines to recommend diagnosis of all suspected malaria cases prior to treatment given the increasing availability of malaria rapid diagnostic tests (RDT) [4] This policy shift has great potential to improve rational drug use and quality fever care [5], studies indicate common inappropriate treatment of RDT-negative patients with anti-malarial or antibiotic drugs [6]. These findings suggest poor integration of RDT into the IMCI framework, few studies have explicitly examined integrated paediatric fever management and available evidence is largely derived from limited hospital settings [7,8,9,10,11,12]. This concern reflects studies showing widespread antibiotic prescriptions for test-negative cases and not according to established clinical guidelines [1, 6, 8]
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