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Integrated paediatric fever management and antibiotic over-treatment in Malawi health facilities: data mining a national facility census
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
Minist Hlth, Integrated Management Childhood Illness IMCI Unit, Lilongwe, Malawi..
Univ Oxford, Dept Zool, Spatial Ecol & Epidemiol Grp, Oxford, England..
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2016 (English)In: Malaria Journal, ISSN 1475-2875, E-ISSN 1475-2875, Vol. 15, 396Article in journal (Refereed) Published
Abstract [en]

Background: There 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.

Methods: A 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.

Results: Among 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.

Conclusions: Integrated 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.

Place, publisher, year, edition, pages
2016. Vol. 15, 396
Keyword [en]
Antibiotic resistance, IMCI, Malaria, Diagnosis, Child health, Fever case management
National Category
Health Sciences
Identifiers
URN: urn:nbn:se:uu:diva-302678DOI: 10.1186/s12936-016-1439-7ISI: 000380658800001PubMedID: 27488343OAI: oai:DiVA.org:uu-302678DiVA: diva2:970787
Funder
Forte, Swedish Research Council for Health, Working Life and Welfare
Available from: 2016-09-14 Created: 2016-09-08 Last updated: 2016-09-14Bibliographically approved

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Johansson, Emily WhiteSelling, Katarina EkholmPeterson, Stefan Swartling
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