Ameyaw Emmanuel, Nguah Samuel B, Ansong Daniel, Page Iain, Guillerm Martine, Bates Imelda
Department of Child Health, Komfo Anokye Teaching Hospital, Kumasi, Ghana.
Malar J. 2014 Nov 26;13:461. doi: 10.1186/1475-2875-13-461.
Over-diagnosis of malaria among African children results in mismanagement of non-malaria infections. Limited laboratory capacity makes it difficult to implement policies that recommend pre-treatment confirmation of infections so a new approach with a package for on-the-spot management of fevers was evaluated.
Febrile children presenting to outpatient clinic were randomized to receive either a 'test-treat' package (history with clinical examination; point-of-care tests; choice of artesunate-amodiaquine, co-amoxiclav and/or paracetamol) or routine outpatient care in a secondary health care facility in Kumasi, Ghana. A diagnosis of malaria, bacterial, viral or mixed malarial and bacterial infections was made using pre-defined criteria. Outcome was resolution of all symptoms including fever on day 7.
The median age of the patients was 37.5 months (IQR: 19 to 66 months), with 56.7% being males. Compared to routine care the test-treat package resulted in less diagnoses of malaria, (37.2% vs 46.2%, p = 0.190) and mixed malaria and bacterial infections (14.0% vs 53.8%, p < 0.001) but more diagnoses of viral (33.1% vs 0.0%, p < 0.001) and bacterial infections only (15.7% vs 0.0%, p < 0.001). Less anti-malarials (51.2% vs 100.0%, p < 0.001) and antibiotics (29.7% vs 48.7%, p < 0.001), were prescribed in the test-treat group on completion of study, more test-treat package patients were clinically well (99.2% vs 80.7%, p < 0.001) and febrile (0.8% vs 10.1%, p = 0.001) and less were admitted for inpatient care (0.0% vs 8.4% p = 0.001) compared to the routine care group.
Test-treat package improves the effectiveness of outpatient diagnosis and treatment of children with fever and reduces inappropriate prescribing of anti-malarials and antibiotics. The package provides clinicians with the option for immediate diagnosis and treatment of non-malaria fevers. The test-treat package now needs to be evaluated in other settings including primary health care facilities.
非洲儿童疟疾的过度诊断导致非疟疾感染的管理不当。实验室能力有限使得难以实施推荐在治疗前确认感染的政策，因此对一种用于现场管理发热的新方法及配套方案进行了评估。
在加纳库马西的一家二级医疗机构，将到门诊就诊的发热儿童随机分为两组，一组接受“检测-治疗”方案（病史及临床检查；即时检验；选择青蒿琥酯-阿莫地喹、阿莫西林克拉维酸和/或对乙酰氨基酚），另一组接受常规门诊护理。根据预先确定的标准对疟疾、细菌、病毒或疟疾与细菌混合感染进行诊断。观察指标为第7天时所有症状包括发热是否消退。
患者的中位年龄为37.5个月（四分位间距：19至66个月），其中56.7%为男性。与常规护理相比，“检测-治疗”方案导致疟疾诊断较少（37.2%对46.2%，p = 0.190）以及疟疾与细菌混合感染诊断较少（14.0%对53.8%，p < 0.001），但病毒感染（33.1%对0.0%，p < 0.001）和仅细菌感染（15.7%对0.0%，p < 0.001）的诊断较多。在研究结束时，“检测-治疗”组开具的抗疟药（51.2%对100.0%，p < 0.001）和抗生素（29.7%对48.7%，p < 0.001）较少，更多接受“检测-治疗”方案的患者临床状况良好（99.2%对80.7%，p < 0.001）且发热（0.8%对10.1%，p = 0.001），与常规护理组相比，住院治疗的患者较少（零对8.4%，p = 0.001）。
“检测-治疗”方案提高了门诊对发热儿童的诊断和治疗效果，并减少了抗疟药和抗生素的不恰当使用。该方案为临床医生提供了即时诊断和治疗非疟疾发热的选择。现在需要在包括初级卫生保健机构在内的其他环境中对“检测-治疗”方案进行评估。
