Management Of Febrile Illness Research Articles

Frequency and Clinical Outcomes of Respiratory Infections in Children with Cancer Presenting with Febrile Illness

Objectives Fever is a known complication in pediatric cancer patients when on chemotherapy for which prompt initiation of empiric antibiotics is the single most important life-saving intervention. Nearly two-thirds of all children are treated without identifying the source of fever. Molecular diagnostics can improve management of febrile episodes and reduce unnecessary antibiotic use. The purpose of our study was to evaluate the pathogenic etiology of febrile episodes and analyze their clinical characteristics. Materials and Methods We conducted a prospective observational study at our tertiary care institution from January 2019 to March 2020, to identify the etiology of febrile episodes with or without neutropenia in pediatric cancer patients and to study their clinical outcomes. Results Forty febrile episodes were observed among 27 patients over a period of 15 months. The mean age group was 5 years. In 28 febrile episodes without a focus (70%), a respiratory organism (virus, bacteria, or coinfection) was detected. Rhinovirus was the most common single respiratory isolate (47.36%), followed by Streptococcus pneumoniae (21.05%) and six episodes had multiple viral isolates (21.42%). There was no prolonged hospitalization, need for intensive care unit or oxygen requirement, or mortality. The most common antibiotic used in empiric management was piperacillin–tazobactam. Aminoglycosides were added when there was a clinical suspicion of resistant organism. Conclusion Around 70% of febrile episodes without a focus or documented infection in cancer children had a respiratory pathogen identified in nasopharyngeal swab. Molecular diagnostics greatly enhances diagnostic sensitivity and thereby individualizes the management of febrile illness in these children.

33 Use of CHU Ste. Justine online resources prior to visiting the Emergency Department for less-urgent, acute febrile illness

Abstract Background Over the past 20 years, visits to paediatric emergency departments (EDs) across Canada have steadily increased, with a higher proportion of presentations for lower acuity symptoms. Many paediatric institutions’ websites now provide information and recommendations for caregivers on common illnesses and reasons for seeing healthcare providers or going to the ED. Increasing the use of internet resources may improve health literacy and hopefully decrease ED use for lower acuity presentations like uncomplicated viral illness. Objectives The objective of this study was to assess whether caregivers presenting with children with lower acuity at triage were aware of and using the online resources provided by our paediatric institution to help with at-home management of febrile illnesses and to guide their decision to present to the ED. Design/Methods This was a cross-sectional study in a tertiary care university-affiliated paediatric ED in an urban setting. Participants were a convenience sample of caregivers of children 6 months to 17 years old with a fever 72 hours or less and triaged low acuity (Canadian Triage and Acuity Scale levels 3 to 5). Caregivers of children with underlying significant systemic illness were excluded. Consenting participants completed two questionnaires. The first questionnaire included demographic data, information on baseline internet utilisation, use of general online health information and our institutions’ website specifically, and whether use of those resources influenced their decision to present to the ED. After browsing dedicated web materials developed by our institution (“Before going to the emergency room” and “Fever”), questionnaire 2 asked for feedback on the website. Results From April to July 2023, 100 caregivers participated in the study (response rates questionnaires 1 and 2: 80% and 70%, respectively) (Table 1). Half (49%) of caregivers researched their child’s symptoms prior to coming to the ED (Table 2). Approximately one third (39%) of respondents were aware that our institution provided online information for caregivers about common symptoms and when to present to the ED. Half (51%) of caregivers who completed questionnaire 2 said they would not have come to the ED if they had read these resources prior (Table 3). Many (66%) respondents reported they would be “likely/very likely” to look up their child’s symptoms on the institutional website before going to the ED in the future. Conclusion Half of caregivers presenting to the ED for their child’s lower-acuity febrile illness conducted research on their child’s symptoms prior to visiting the ED and most were influenced in their decision to come to ED by what they found. Most caregivers were not aware that our institution had online resources available. Promotion of the institutional resources available to parents may empower parents to manage common symptoms at home and prevent ED visits for lower-acuity illness.

Malaria Rapid Tests, Febrile Illness Management, and Child Mortality Across Sub-Saharan African Countries

A prompt malaria diagnosis is crucial for the management of children with febrile illness in sub-Saharan African countries, where malaria remains a leading cause of mortality among children younger than 5 years of age. The development and distribution of point-of-care rapid diagnostic tests (RDTs) for malaria has transformed practice, but limited systematic evidence exists on how malaria RDTs have affected the management of febrile illness and mortality for children younger than 5 years of age across sub-Saharan Africa countries. To evaluate the association between the distribution of malaria RDTs and the management of febrile illness and mortality among children younger than 5 years of age in sub-Saharan African countries. This quasi-experimental study used a novel dataset linking malaria RDT distribution to 165 nationally representative household surveys across 35 sub-Saharan African countries with mortality data. The sample comprised approximately 3.9 million child-year observations and approximately 260 000 febrile illness episodes in children younger than 5 years of age between 2000 and 2019. Fixed-effects linear probability models were used to analyze the association between variation in malaria RDTs distributed per child younger than 5 years of age (by country per year) and blood testing, antimalarial drug use, antibiotic use, use of symptomatic treatments, and mortality rates. Variation in the effects of testing and treatment was also assessed across the sub-Saharan African countries that had varying prevalence of malaria. The mortality sample included 1 317 866 children and the fever sample included 256 292 children. The mean age of the children with febrile illness was 2.4 years (SD, 1.3 years) and 49% were female. Each additional malaria RDT distributed per child younger than 5 years of age was associated with an increase of 3.5 percentage points (95% CI, 3.2-3.8 percentage points) in blood testing, an increase of 1.5 percentage points (95% CI, 1.2-1.8 percentage points) in the use of antimalarial drugs, an increase of 0.4 percentage points (95% CI, 0.1-0.6 percentage points) in antibiotic use, and a decrease of 0.4 percentage points (95% CI, 0.1-0.8 percentage points) in the use of treatments for symptoms. Each additional malaria RDT distributed per child younger than 5 years of age was associated with a reduction in child mortality of 0.34 deaths per 1000 child-years (95% CI, 0.15-0.52 deaths per 1000 child-years). The effects of malaria RDT distribution on medication use and child mortality varied across prevalence settings (low vs high) for malaria; there were survival improvements only in areas that had a high prevalence of malaria. Increasing distribution of malaria RDTs was associated with increased blood testing, increased use of antimalarial drugs, and modestly improved survival in children younger than 5 years of age in sub-Saharan African countries. However, malaria RDTs were associated with increases in the rates of antibiotic use that were already high, suggesting that more comprehensive approaches to case management of febrile illness are needed.

Cost-Effectiveness of Test-and-Treat Strategies to Reduce the Antibiotic Prescription Rate for Acute Febrile Illness in Primary Healthcare Clinics in Africa.

Inappropriate antibiotic use increases selective pressure, contributing to antimicrobial resistance. Point-of-care rapid diagnostic tests (RDTs) would be instrumental to better target antibiotic prescriptions, but widespread implementation of diagnostics for improved management of febrile illnesses is limited. Our study aims to contribute to evidence-based guidance to inform policymakers on investment decisions regarding interventions that foster more appropriate antibiotic prescriptions, as well as to address the evidence gap on the potential clinical and economic impact of RDTs on antibiotic prescription. A country-based cost-effectiveness model was developed for Burkina Faso, Ghana and Uganda. The decision tree model simulated seven test strategies for patients with febrile illness to assess the effect of different RDT combinations on antibiotic prescription rate (APR), costs and clinical outcomes. The incremental cost-effectiveness ratio (ICER) was expressed as the incremental cost per percentage point (ppt) reduction in APR. For Burkina Faso and Uganda, testing all patients with a malaria RDT was dominant compared to standard-of-care (SoC) (which included malaria testing). Expanding the test panel with a C-reactive protein (CRP) test resulted in an ICER of $0.03 and $0.08 per ppt reduction in APR for Burkina Faso and Uganda, respectively. For Ghana, the pairwise comparison with SoC-including malaria and complete blood count testing-indicates that both testing with malaria RDT only and malaria RDT + CRP are dominant. The use of RDTs for patients with febrile illness could effectively reduce APR at minimal additional costs, provided diagnostic algorithms are adhered to. Complementing SoC with CRP testing may increase clinicians' confidence in prescribing decisions and is a favourable strategy.

Typhus Fever- A Diagnosis Often Missed as A Cause of Fever.

Background: In tropical countries epidemic and endemic typhus are sometimes missdiagnosed as typhoid fever. Typhus infection is emerging in the subcontinent and clinically presents as nonspecific febrile illness. So high index of clinical suspicion is essential and the objective of the study was to detect typhus infection as a cause of febrile illness. Materials &Method: This is a prospective observational study done from January to December 2019. A total 50 patients of different age groups were taken randomly who were suffering from fever for more than 7 days. All relevant investigations including CBC, Dengue serological test, Widal test, urine routine examination and C/S, blood C/S, chest x-ray were done. Patients not responding to conventional antibiotic therapy and having persistent fever were further investigated for typhus fever with Weil-Felix test. Results: Out of 50 patients 35 were male; age range was 2 to 12 years. Mean duration of fever was 10 days. Blood for CBC showed nonspecific findings, Blood culture and urine for c/s were negative for bacterial growth, dengue serological tests were negative, chest x-ray were normal (except 2 patients had pneumonia). Weil-Felix tests were positive in all cases. 12 cases were positive for both Widal test and Weil-Felix test and in 8 cases blood c/s were also positive with Weil-Felix test. Treatment changed to Doxycycline or Azithromycin in cases of typhus fever. Conclusion: Typhus fever should be taken into account in the management of febrile illness who were admitted without a confirmed cause of fever. BANGLADESH J CHILD HEALTH 2022; VOL 46 (2) : 54-57

Etiology of febrile illness among patients seeking care at a district hospital in Manyara, Tanzania

Managing febrile illness is complicated due to the increasing involvement of non-malarial pathogens. This hospital-based cross-sectional study was conducted in Kiteto District Hospital in Northern Western, Tanzania, between January and February 2019. Out-patients with a temperature ≥38°C were consecutively enrolled until the sample size was reached. Whole blood samples were collected aseptically and tested for 36 pathogens using a multiplex PCR. Out of the 426 febrile patients, 184 (43.2%) had pathogens detected in their bloodstream. Brucella spp. was isolated in 61 (14.3%) patients, followed by Dengue virus 51 (12.0%), Salmonella Typhi 39 (9.2%), Plasmodium falciparum 37(8.7%), Coxiella burnetii 23 (5.4%) and Leptospira spp., 17 (4.0%). Forty patients (21.7%) had more than one pathogen, whereby co-infection with Brucella spp. and C. burnetii was frequent among study participants. Dengue virus was the most frequent in children aged below 14 years, whereas Brucella spp. was the dominant agent in adults. The cause of fever was not identified in 242 (56.8%) of these patients. Houses surrounded by long grasses were risk factors for febrile illness caused by P. falciparum, consuming untreated milk and consuming sour milk were risk factors for febrile illness caused by bacteria zoonoses while not washing hands after visiting the toilet was a risk factor for febrile illness by S. Typhi. Regarding management, 143 (34.8%) were given anti-malaria despite malaria rapid diagnostic test (MRDT) negative results, while 26.5% were given both anti-malaria and antibiotics for febrile illness. In this study, the majority of febrile illness cases were due to non-malarial pathogens, with P. falciparum accounting for only 8.7% of the cases. We found that about one-third of the cases were wrongly treated for malaria, and more than a quarter were wrongly given antibiotics. A review of the management of febrile illnesses is warranted.

Etiology of febrile illness among patients seeking care at a district hospital in Manyara, Tanzania

Managing febrile illness is complicated due to the increasing involvement of non-malarial pathogens. This hospital-based cross-sectional study was conducted in Kiteto District Hospital in Northern Western, Tanzania, between January and February 2019. Out-patients with a temperature ≥38°C were consecutively enrolled until the sample size was reached. Whole blood samples were collected aseptically and tested for 36 pathogens using a multiplex PCR. Out of the 426 febrile patients, 184 (43.2%) had pathogens detected in their bloodstream. Brucella spp. was isolated in 61 (14.3%) patients, followed by Dengue virus 51 (12.0%), Salmonella Typhi 39 (9.2%), Plasmodium falciparum 37(8.7%), Coxiella burnetii 23 (5.4%) and Leptospira spp., 17 (4.0%). Forty patients (21.7%) had more than one pathogen, whereby co-infection with Brucella spp. and C. burnetii was frequent among study participants. Dengue virus was the most frequent in children aged below 14 years, whereas Brucella spp. was the dominant agent in adults. The cause of fever was not identified in 242 (56.8%) of these patients. Houses surrounded by long grasses were risk factors for febrile illness caused by P. falciparum, consuming untreated milk and consuming sour milk were risk factors for febrile illness caused by bacteria zoonoses while not washing hands after visiting the toilet was a risk factor for febrile illness by S. Typhi. Regarding management, 143 (34.8%) were given anti-malaria despite malaria rapid diagnostic test (MRDT) negative results, while 26.5% were given both anti-malaria and antibiotics for febrile illness. In this study, the majority of febrile illness cases were due to non-malarial pathogens, with P. falciparum accounting for only 8.7% of the cases. We found that about one-third of the cases were wrongly treated for malaria, and more than a quarter were wrongly given antibiotics. A review of the management of febrile illnesses is warranted.

Assessment of the changing trends in maternal knowledge about management of fever and antibiotic use in the last decade in Türkiye.

The wrong attitudes of parents on fever create a basis for unnecessary drug use and increased workload. The study was conducted to evaluate the knowledge and attitudes concerning fever and antibiotic use and demonstrate the changes in the last decade. This cross-sectional study was composed of two parts, and a total of 500 participants were included. Group 1 (the new group, 50.0%) consisted of 250 participants who participated in the study between February 2020 and March 2020 and Group 2 (the old group, 50.0%) consisted of 250 participants who participated in the study between February 2010 and March 2010. All participants share the same ethnic properties and had been visiting the same center for similar reasons. A validated, structured questionnaire assessing the management of fever and antibiotic use was administered to all mothers. According to the fever assessment scoring, maternal knowledge of fever and its management in children significantly increased (p < 0.001). The antibiotic assessment score also increased in 2020 (p = 0.002). The public spotlight on the erroneous use of antibiotics and the management of febrile illnesses seems to be promising. Improving maternal/parental educational status and informational advertisements can enhance parental knowledge concerning fever and antibiotic use.

Could combined rapid diagnostic testing for malaria and c-reactive protein be helpful for the diagnosis and management of febrile illnesses in children under-5 years of age in rural Burkina Faso?

BackgroundFebrile illnesses are among the most important reasons for medical consultation in sub-Saharan Africa and are frequently treated with antimicrobials due to the unavailability of appropriate diagnostic tools. This practice leads to antimicrobial resistance, with increasing mortality and morbidity as result. One of the few accessible diagnostic tools available in low resource settings is malaria rapid diagnostic tests (mRDTs) which contributed to reducing the over-prescription of anti-malarials, but cannot guide antibiotic prescriptions. To circumvent this problem, we explored whether combined testing with mRDT and c-reactive protein (CRP) could improve the diagnosis of febrile illnesses and subsequent prescription of antibiotics.MethodsClinical specimens (blood, stool and urine) collected from 396 febrile children (axillary temperature of ≥ 37.5 °C) were analyzed with rapid diagnostic tests (malaria and CRP) and microbiology culture to establish the possible cause of fever. Actual antimicrobial prescriptions given to the children were compared with those that could be given based on combined CRP-malaria testing.ResultsIn total, 68.7% (272/396) of malaria cases were diagnosed by mRDT-Pf-HRP-2. CRP test was positive in 84.3% (334/396) of the children, but bacterial infections were confirmed in 12.4% (49/396) of them. A possible cause of fever could not be established in 20.5% (81/396) of cases. Based on the diagnostic practice in place, 265 of the children with a positive mRDT-Pf-HRP-2 received anti-malarial treatment. Furthermore, 89.5% (111/124) of negative mRDT results received antibiotic treatment and 37.1% (46/124) received antimalarial treatment. Of these 124 cases, 80 had positive CRP tests and 44 negative CRP tests. If the results of CRP testing are considered, 44 CRP/mRDT negative children would not get antibiotic treatment, resulting in a 35.5% reduction in antibiotic prescriptions. However, 2 cases with a bacterial infection would be denied appropriate treatment.ConclusionCombining mRDT-PfHRP2 with CRP testing is particularly useful in children for whom both tests are negative as it results in a reduction of antibiotics prescriptions. However, there is a risk to miss potential severe bacterial infections and a close follow-up of these cases is strongly recommended.

1164. Antibacterial Utilization for Febrile Illnesses and Laboratory-Confirmed Bloodstream Infections in Northern Tanzania

Abstract Background Antimicrobial resistance is an important cause of morbidity and mortality globally; low- and middle-income countries (LMICs) face an especially high burden. Ineffective antimicrobial prescriptions and use of broad-spectrum agents contribute to resistance. We describe antibacterial prescribing patterns in patients with febrile illnesses and bloodstream infections (BSI) in northern Tanzania. Methods We compared data from two hospital-based prospective cohort studies, cohort 1 (2011-2014) and cohort 2 (2016-2019), both enrolled febrile pediatric and adult inpatients in Moshi, Tanzania. Aerobic blood culture was obtained in all patients and standard methods were used to determine isolate antimicrobial susceptibility. To describe management of febrile illness, we analyzed antibacterial drug prescription prior to and after enrollment. Broad-spectrum antibacterials were categorized using published frameworks. Treatments were categorized as discordant if a blood culture isolate was not susceptible to the patient’s antibacterial regimen. We performed descriptive statistics and logistic regression to understand predictors of receiving an antibacterial. Results In total, 2,176 febrile inpatients were enrolled. Antibacterials were administered to 430 (42.0%) and 501 (45.1%) patients prior to enrollment, and 930 (89.1%) and 1,060 (93.6%) during admission in cohorts 1 and 2, respectively. Infancy and duration of fever were associated with higher antibacterial prescribing prior to enrollment (Table 2). Broad-spectrum antibacterials were administered to 548 (52.5%) in cohort 1 and 682 (60.2%) in cohort 2. Laboratory-confirmed bacteremia was detected in 87 (4%) patients. Susceptibility results were available in 73 patients; of these, 41 (56.2%) received discordant antibacterials. Conclusion Antibacterials were commonly administered for febrile illness in outpatient and inpatient settings; over half of patients received broad-spectrum antibacterials. A high proportion of patients with culture-positive BSI were treated with ineffective antimicrobials. Improved laboratory diagnostics for febrile illness, antimicrobial stewardship interventions, context-specific clinical guidelines, and provider education may improve prescribing practices. Disclosures Julian Hertz, MD, Roche Diagnostics: Grant/Research Support.

Febrile illness in high-risk children: a prospective, international observational study

To assess and describe the aetiology and management of febrile illness in children with primary or acquired immunodeficiency at high risk of serious bacterial infection, as seen in emergency departments in tertiary hospitals. Prospective data on demographics, presenting features, investigations, microbiology, management, and outcome of patients within the ‘Biomarker Validation in HR patients’ database in PERFORM, were analysed. Immunocompromised children (< 18 years old) presented to fifteen European hospitals in nine countries, and one Gambian hospital, with fever or suspected infection and clinical indication for blood investigations. Febrile episodes were assigned clinical phenotypes using the validated PERFORM algorithm. Logistic regression was used to assess the effect size of predictive features of proven/presumed bacterial or viral infection. A total of 599 episodes in 482 children were analysed. Seventy-eight episodes (13.0%) were definite bacterial, 67 episodes probable bacterial (11.2%), and 29 bacterial syndrome (4.8%). Fifty-five were definite viral (9.2%), 49 probable viral (8.2%), and 23 viral syndrome (3.8%). One hundred ninety were unknown bacterial or viral infections (31.7%), and 108 had inflammatory or other non-infectious causes of fever (18.1%). Predictive features of proven/presumed bacterial infection were ill appearance (OR 3.1 (95% CI 2.1–4.6)) and HIV (OR 10.4 (95% CI 2.0–54.4)). Ill appearance reduced the odds of having a proven/presumed viral infection (OR 0.5 (95% CI 0.3–0.9)). A total of 82.1% had new empirical antibiotics started on admission (N = 492); 94.3% proven/presumed bacterial (N = 164), 66.1% proven/presumed viral (N = 84), and 93.2% unknown bacterial or viral infections (N = 177). Mortality was 1.9% (N = 11) and 87.1% made full recovery (N = 522). Conclusion: The aetiology of febrile illness in immunocompromised children is diverse. In one-third of cases, no cause for the fever will be identified. Justification for standard intravenous antibiotic treatment for every febrile immunocompromised child is debatable, yet effective. Better clinical decision-making tools and new biomarkers are needed for this population.What is Known:• Immunosuppressed children are at high risk for morbidity and mortality of serious bacterial and viral infection, but often present with fever as only clinical symptom.• Current diagnostic measures in this group are not specific to rule out bacterial infection, and positivity rates of microbiological cultures are low.What is New:• Febrile illness and infectious complications remain a significant cause of mortality and morbidity in HR children, yet management is effective.• The aetiology of febrile illness in immunocompromised children is diverse, and development of pathways for early discharge or cessation of intravenous antibiotics is debatable, and requires better clinical decision-making tools and biomarkers.

Management of febrile illness in rural Guinea over a seven-year period: A retrospective study.

Febrile illnesses constitute a major clinical challenge in tropical settings. We aimed to assess the frequency, presentation and management of febrile illness at two health facilities in Forécariah, Guinea, with a focus on appropriateness of antibiotic prescription. This was a retrospective study conducted in patient files in a health center and a district hospital. Proportions of antibiotic prescription were determined by age group and syndromes as well as appropriateness of antibiotic prescription using the WHO model list (2019). From 2014 to 2020, 23,583 of 62,185 (38.0%) visits were related to febrile illness. Most patients with fever were female (56.1%) and evaluated at the health center (81.0%). Gastrointestinal (40.6%) and respiratory syndromes (36.8%), and undifferentiated fever (30.0%) were the most common presentations. Malaria was confirmed in 61.3% of the cohort. Overall, the rate of antibiotic prescription was high (14,834/23,583, 62.9%), mostly among patients aged <5 years (5,285/7,566, 69.9%), those with respiratory (7,577/8,684, 87.3%) and gastrointestinal (6,324/9,585, 66.0%) syndromes. Moreover, 7,432/14,465 (51.4%) patients with malaria were also prescribed an antibiotic. Penicillin (42.0%), cotrimoxazole (26.3%) and quinolones (18.7%) were the most frequently prescribed antibiotics. Overall, appropriateness of antibiotic prescription was low (38.3%), and even more so in patients with respiratory (29.1%) and gastrointestinal (25.8%) syndromes. Febrile illness is a major cause of consultation in rural Guinea. Rate of antibiotic prescription was high, even in confirmed malaria and was often considered inappropriate. There is a pressing need to investigate the etiological spectrum and improve the diagnostic approach of febrile illness in Guinea.

Development and evaluation of an electronic algorithm using a combination of a two-step malaria RDT and other rapid diagnostic tools for the management of febrile illness in children under 5 attending outpatient facilities in Burkina Faso

BackgroundIn Sub-Saharan Africa (SSA), febrile illnesses remain a major public health problem in children. However, the persistence of hrp2 antigen and the low sensitivity of pLDH RDT negatively affect antimalarials and antibiotics prescription practices. These limitations lead to poor management of febrile diseases and antimicrobial resistance (AMR). To improve the diagnosis of these febrile diseases and subsequent prescription of antimicrobials, it is hypothesized that the implementation of an algorithm including a two-step malaria RDT PfHRP2/pLDH supported by point-of-care (PoC) tests for bacterial infections could significantly improve the management of febrile diseases and thereby tackling AMR.MethodsTo assess the value of the proposed algorithm, an open-label randomized controlled trial with three arms, enrolling febrile children from 6 to 59 months is proposed.In the control arm, febrile children will be managed according to the Integrated Management of Childhood Illnesses (IMCI), which is part of the standard of care in Burkina Faso. Treatment will be done according to national guidelines.In the RDT decisional algorithm (RDT-DA) arm (intervention), the clinical examination based on IMIC will be supported by a two-step malaria RDT and bacterial infections RDTs. Prescription will be left to the discretion of the healthcare workers based on clinical examination and PoC test results.In the e-algorithm arm (intervention), artificial intelligence integrating multiple layers of clinical information such as clinical examination, signs/symptoms and medical history, and biological information such as biomarkers (CRP and WBC) and pathogen-specific PoC tests, and oximetry will be developed. The e-algorithm will serve to guide the diagnostic and management of febrile infections in children.In the 3 arms, the case report forms will be digitalized. A final follow-up visit (day 7) will be scheduled for all participants. Patients will be asked to come back to the health facilities before the scheduled visit if the symptoms persist or in case of health condition worsening.DiscussionIf successful, this study could contribute to improve the management of febrile diseases and reduce inappropriate use of antimicrobials.Trial registrationThe trial is registered at ClinicalTrial.gov, NCT05285657. Enrolment started on 4 March 2022 with long-term outcome being assessed completely by 2023.

Clinical management and outcomes of acute febrile illness in children attending a tertiary hospital in southern Ethiopia

BackgroundThe management of febrile illnesses is challenging in settings where diagnostic laboratory facilities are limited, and there are few published longitudinal data on children presenting with fever in such settings. We have previously conducted the first comprehensive study of infectious aetiologies of febrile children presenting to a tertiary care facility in Ethiopia. We now report on clinicians’ prescribing adherence with guidelines and outcomes of management in this cohort.MethodsWe consecutively enrolled febrile children aged 2 months and under 13 years, who were then managed by clinicians based on presentation and available laboratory and radiologic findings on day of enrolment. We prospectively collected outcome data on days 7 and 14, and retrospectively evaluated prescribing adherence with national clinical management guidelines.ResultsOf 433 children enrolled, the most common presenting syndromes were pneumonia and acute diarrhoea, diagnosed in 177 (40.9%) and 82 (18.9%), respectively. Antibacterial agents were prescribed to 360 (84.7%) of 425 children, including 36 (34.0%) of 106 children without an initial indication for antibacterials according to guidelines. Antimalarial drugs were prescribed to 47 (11.1%) of 425 children, including 30 (7.3%) of 411 children with negative malaria microscopy. Fever had resolved in 357 (89.7%) of 398 children assessed at day 7, and in-hospital death within 7 days occurred in 9 (5.9%) of 153 admitted patients. Among children with pneumonia, independent predictors of persisting fever or death by 7 days were young age and underweight for age. Antibacterial prescribing in the absence of a guideline-specified indication (overprescribing) was more likely among infants and those without tachypnea, while overprescribing antimalarials was associated with older age, anaemia, absence of cough, and higher fevers.ConclusionOur study underscores the need for improving diagnostic support to properly guide management decisions and enhance adherence by clinicians to treatment guidelines.

Viral haemorrhagic fevers and malaria co-infections among febrile patients seeking health care in Tanzania

BackgroundIn recent years there have been reports of viral haemorrhagic fever (VHF) epidemics in sub-Saharan Africa where malaria is endemic. VHF and malaria have overlapping clinical presentations making differential diagnosis a challenge. The objective of this study was to determine the prevalence of selected zoonotic VHFs and malaria co-infections among febrile patients seeking health care in Tanzania.MethodsThis facility-based cross-sectional study was carried out between June and November 2018 in Buhigwe, Kalambo, Kyela, Kilindi, Kinondoni, Kondoa, Mvomero, and Ukerewe districts in Tanzania. The study involved febrile patients seeking health care from primary healthcare facilities. Blood samples were collected and tested for infections due to malaria, Crimean-Congo haemorrhagic fever (CCHF), Ebola virus disease (EVD), Marburg virus disease (MVD), Rift Valley fever (RVF) and yellow fever (YF). Malaria infections were tested using rapid diagnostics tests while exposure to VHFs was determined by screening for immunoglobulin M antibodies using commercial enzyme-linked immunosorbent assays. The Chi-square test was used to compare the proportions.ResultsA total of 308 participants (mean age = 35 ± 19 years) were involved in the study. Of these, 54 (17.5%) had malaria infection and 15 (4.8%) were positive for IgM antibodies against VHFs (RVF = 8; CCHF = 2; EBV = 3; MBV = 1; YF = 1). Six (1.9%) individuals had both VHF (RVF = 2; CCHF = 1; EVD = 2; MVD = 1) and malaria infections. The highest co-infection prevalence (0.6%) was observed among individuals aged 46‒60 years (P < 0.05). District was significantly associated with co-infection (P < 0.05) with the highest prevalence recorded in Buhigwe (1.2%) followed by Kinondoni (0.9%) districts. Headache (100%) and muscle, bone, back and joint pains (83.3%) were the most significant complaints among those infected with both VHFs and malaria (P = 0.001).ConclusionsCo-infections of VHF and malaria are prevalent in Tanzania and affect more the older than the younger population. Since the overlapping symptoms in co-infected individuals may challenge accurate diagnosis, adequate laboratory diagnosis should be emphasized in the management of febrile illnesses.

"There are many fevers": Communities' perception and management of Febrile illness and its relationship with human animal interactions in South-Western Uganda.

Diagnosing the causative agent of febrile illness in resource-limited countries is a challenge in part due to lack of adequate diagnostic infrastructure to confirm cause of infection. Most febrile illnesses (>60%) are non-malarial, with a significant proportion being zoonotic and likely from animal origins. To better characterize the pathways for zoonotic disease transmission and control in vulnerable communities, adequate information on the communities’ experiences and lexicon describing fever, and their understanding and perceptions of risk pathways is required. We undertook an ethnographic study to understand behaviors, exposures, and attitudes toward fever at the community level. Our hope is to better elucidate areas of priority surveillance and diagnostic investment. A focused ethnography consisting of participant observation, informal conversations, 4 barazas (community meetings), and formal ethnographic interviews (13 Focus group discussions and 17 Key informant interviews) was conducted between April and November 2015 in Kasese and Hoima Districts in Uganda. Perception of illness and associated risk factors was heavily influenced by the predominant livelihood activity of the community. The term “fever” referred to multiple temperature elevating disease processes, recognized as distinct pathological occurrences. However, malaria was the illness often cited, treated, or diagnosed both at the health facilities and through self-diagnosis and treatment. As expected, fever is as an important health challenge affecting all ages. Recognition of malarial fever was consistent with a biomedical model of disease while non-malarial fevers were interpreted mainly through ethno etiological models of explanation. These models are currently being used to inform education and prevention strategies and treatment regimens toward the goal of improving patients’ outcomes and confidence in the health system. Development of treatment algorithms that consider social, cultural, and economic contexts, especially where human-animal interaction is prevalent, should factor animal exposure and zoonotic illnesses as important differentials.

Assessment of Antipyretics Usage in Pediatric Inpatients

ABSTRACT Parents often misinterpret fever as being harmful. Fear of fever results in excessive use of antipyretics, unnecessary emergency department visits and financial burden. The aims of the study were to determine the utilization pattern of antipyretics and assess the knowledge and practice (KP) of parents on antipyretics usage. One part of the study design was interventional and the other was cross-sectional, conducted for a period of 6 months. Study included inpatients from pediatric department who were receiving antipyretic medications to determine the utilization pattern of antipyretics. A validated questionnaire was administered to the enrolled subject’s parents to assess their KP on antipyretic usage. Among the 250 study population enrolled, paracetamol was found to be the most commonly used antipyretic. 90% of the enrolled study population were mothers. 95.20% of parents believed fever was harmful, 81.6% considered a temperature of 38°C as fever and would start antipyretics. Only 38.4% had a thermometer at home, 73.20% administered antipyretics without prescription. About 62% believed drowsiness was a complication of antipyretics. The level of education of parents showed a positive impact on the perception of fever. Knowledge score based on socioeconomic status was also found to be significant. The lack of digital thermometer and inaccurate measurement of temperature has led to fever phobia, and the correct management of febrile illness remains unclear among the parents. Educating parents may positively influence their approach to fever and antipyretic usage.

Seroprevalence and associated risk factors of selected zoonotic viral hemorrhagic fevers in Tanzania

ObjectiveTo determine the seroprevalence of selected zoonotic viral hemorrhagic fevers (VHFs) and their associated risk factors in Tanzania. MethodsBlood samples were collected from consenting outpatients and community members in eight districts selected from five ecological zones of Tanzania. Serum was harvested and tested for the presence of immunoglobulin G (IgG) and M (IgM) antibodies against Crimean-Congo hemorrhagic fever (CCHF), Ebola virus disease (EVD), Marburg virus disease (MVD), Rift Valley fever (RVF), and yellow fever (YF). ResultsThe presence of IgM and IgG antibodies against CCHF, EVD, MVD, RVF, and YF was detected in 64 of 500 samples (12.8%). The prevalences of IgM and IgG antibodies to CCHF, EVD, MVD, RFV, and YF were 2.0%, 3.4%, 1.2%, 4.8%, and 1.4%, respectively. Contact with wild animals (OR = 1.2, CI = 1.3–1.6) and keeping goats (OR = 1.3, CI = 1.5–1.9) were significantly associated with RVF, while contact with bats (OR = 1.2, CI = 1.1–1.5) was associated with MVD. ConclusionThe findings of this study provide evidence of exposure to CCHF, EVD, MVD, RVF, and YF in Tanzania. Since most of these VHFs occurred without apparent clinical forms of the disease, these findings call for the need to strengthen the surveillance system and management of febrile illnesses in Tanzania.

Anticipating the future: prognostic tools as a complementary strategy to improve care for patients with febrile illnesses in resource-limited settings

In low-income and middle-income countries, most patients with febrile illnesses present to peripheral levels of the health system where diagnostic capacity is very limited. In these contexts, accurate risk stratification...

A rare case of an imported typhoid fever caused by extensively drug-resistant salmonella typhi in the UAE

The emergence of extensively drug-resistant (XDR) strains of Salmonella enterica serovar Typhi-resistant to multiple first-line antibiotics started in the Sindh Province in Pakistan is a cause of concern in the management of typhoid fever. Recently, we experienced a case of XDR typhoid fever in a 4-year-old unvaccinated girl who contracted it during her visit to Pakistan in the summer of 2019, improved with meropenem and azithromycin. This is the first reported case of paediatric XDR typhoid diagnosed and treated in the UAE. Awareness of the on-going outbreak of XDR typhoid fever in Pakistan is very important for clinicians in the evaluation and management of febrile illnesses in a child with a history of travel to Pakistan.