Abstract
BackgroundPrompt detection and appropriate treatment of malaria prevents severe disease and death. The quality of care for adult malaria in-patients is not well documented in sub-Saharan Africa, particularly in Uganda. The study sought to describe the patterns of malaria diagnosis and treatment among adult in-patients admitted to the medical and gynaecological wards of Uganda’s 1790-bed Mulago National Referral Hospital from December 2013 to April 2014.MethodsA prospective cohort of 762 consented in-patients aged ≥ 18 years was assembled. Proportions of in-patients who received preadmission and in-hospital anti-malarials, missed Day 1 dosing of hospital-initiated anti-malarials and/or had malaria microscopy done were determined. Multivariable logistic regression was used to identify risk-factors for missed Day 1 dosing of anti-malarials.ResultsOne in five (19%, 146/762) in-patients had an admission or discharge malaria diagnosis or both; with median age of 29 years (IQR, 22–42 years). Microscopy was requested in 77% (108/141) of in-patients with an admission malaria diagnosis; results were available for 46% (50/108), of whom 42% (21/50) tested positive for Plasmodium falciparum malaria parasitaemia. Only 13% (11/83) of in-patients who received in-hospital injectable artesunate (AS) or quinine (Q) received follow-up oral artemether-lumefantrine (AL); 2 of 18 severe malaria cases received follow-up oral AL. Injectable AS only (47%, 47/100) was the most frequent hospital-initiated anti-malarial treatment followed by injectable Q only (23%, 23/100) amongst in-patients who received in-hospital anti-malarials. A quarter (25%, 25/100; 95% CI: 17–35%) of in-patients missed Day 1 dosing of hospital-initiated anti-malarials. Each additional admission diagnosis was more than two-fold likely to increase the odds of missed Day 1 dosing of in-hospital anti-malarials (aOR = 2.6, 95% CI: 1.52–4.56; P-value = 0.001).ConclusionsHalf the malaria microscopy results were not available; yet, the rate of testing was high. The majority of in-patients initiated on injectable AS or Q did not receive the recommended follow-up oral AL. One in four in-patients delayed to initiate hospital anti-malarials by at least one calendar day. The hospital should encourage prompt availability of malaria test-results to promote the timely initiation and completion of anti-malarial treatment, thereby improving the quality of care for hospitalized malaria patients in Uganda.
Highlights
Prompt detection and appropriate treatment of malaria prevents severe disease and death
This study aims to describe the patterns of malaria diagnosis and treatment [i.e. anti-malarial use by extent of use, missed opportunity for treatment, frequency of administered-treatment, medication-usecycle, missed Day 1 dosing and mortality] among adult in-patients at Uganda’s 1790-bed Mulago National Referral Hospital
About one in five (19%, 141/762; 95% confidence intervals (CIs): 16–21%) in-patients had an admission malaria diagnosis, see Tables 1 & 2
Summary
Prompt detection and appropriate treatment of malaria prevents severe disease and death. Adults with severe malaria, including pregnant women in all trimesters and breast-feeding mothers, should be treated with three doses of injectable artesunate (AS) for 24 h minimum at 0, 12 and 24 h regardless of whether the patient can tolerate oral treatment earlier. Following injectable anti-malarials, a full 3-day course of oral artemisinin-based combination therapy (ACT)— mainly artemether-lumefantrine (AL) (six doses) for Uganda—should be administered if the patient is able to take oral medication [2, 4,5,6]. If full treatment for severe malaria is not possible at a given health facility but injectables are available, adults and children should be given one intramuscular dose of AS or Q and referred to a suitable facility for appropriate management [2]
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