Treatment guided by rapid diagnostic tests for malaria in Tanzanian children: safety and alternative bacterial diagnoses

Hendriksen, Mrema Hedwiga, Manjurano Alphaxard, Sykes Alma, Whitty, Mtove George, Amos Ben, Mandia Victor, Muro Florida, Hildenwall Helena, Reyburn Hugh

Description

WHO guidelines for the treatment of young children with suspected malaria have recently changed from presumptive treatment to anti-malarial treatment guided by a blood slide or malaria rapid diagnostic test (RDT). However, there is limited evidence of the safety of this policy in routine outpatient settings in Africa. Methods Children 3-59 months of age with a non-severe febrile illness and no obvious cause were enrolled over a period of one year in a malaria endemic area of Tanzania. Treatment was determined by the results of a clinical examination and RDT result, and blood culture and serum lactate were also collected. RDT-negative children were followed up over 14 days. Results Over the course of one year, 965 children were enrolled; 158 (16.4%) were RDT-positive and treated with artemether-lumefantrine and 807 (83.4%) were RDT-negative and treated with non-anti-malarial medicines. Compared with RDT-positives, RDT-negative children were on average younger with a lower axillary temperature and more likely to have a history of cough or difficulty in breathing. Six (0.6%) children became RDT-positive after enrolment, all of whom were PCR-negative for Plasmodium falciparum DNA at enrolment. In addition, 12 (1.2%) children were admitted to hospital, one with possible malaria, none of whom died. A bacterial pathogen was identified in 9/965 (0.9%) children, eight of whom were RDT-negative and one was RDT-positive, but slide-negative. Excluding three children with Salmonella typhi , all of the children with bacteraemia were ≤12 months of age. Compared to double-read research slide results RDTs had a sensitivity of 97.8% (95%CI 96.9-98.7) and specificity of 96.3% (95%CI 96.3-98.4). Conclusions Use of RDTs to direct the use of anti-malarial drugs in young children did not result in any missed diagnoses of malaria although new infections soon after a consultation with a negative RDT result may undermine confidence in results. Invasive bacterial disease is uncommon in children with non-severe illness and most cases occurred in infants with a current fever.

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• Publié par: biomed
• Publié le: 01 janvier 2011
• Nombre de lectures: 4
• Langue: English

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Mtoveet al.Malaria Journal2011,10:290 http://www.malariajournal.com/content/10/1/290

R E S E A R C HOpen Access Treatment guided by rapid diagnostic tests for malaria in Tanzanian children: safety and alternative bacterial diagnoses 1 23 33†4 George Mtove , Ilse CE Hendriksen , Ben Amos , Hedwiga Mrema , Victor Mandia, Alphaxard Manjurano , 4 35 66,7* Florida Muro , Alma Sykes , Helena Hildenwall , Christopher JM Whittyand Hugh Reyburn

Abstract Background:WHO guidelines for the treatment of young children with suspected malaria have recently changed from presumptive treatment to antimalarial treatment guided by a blood slide or malaria rapid diagnostic test (RDT). However, there is limited evidence of the safety of this policy in routine outpatient settings in Africa. Methods:Children 359 months of age with a nonsevere febrile illness and no obvious cause were enrolled over a period of one year in a malaria endemic area of Tanzania. Treatment was determined by the results of a clinical examination and RDT result, and blood culture and serum lactate were also collected. RDTnegative children were followed up over 14 days. Results:Over the course of one year, 965 children were enrolled; 158 (16.4%) were RDTpositive and treated with artemetherlumefantrine and 807 (83.4%) were RDTnegative and treated with nonantimalarial medicines. Compared with RDTpositives, RDTnegative children were on average younger with a lower axillary temperature and more likely to have a history of cough or difficulty in breathing. Six (0.6%) children became RDTpositive after enrolment, all of whom were PCRnegative forPlasmodium falciparumDNA at enrolment. In addition, 12 (1.2%) children were admitted to hospital, one with possible malaria, none of whom died. A bacterial pathogen was identified in 9/965 (0.9%) children, eight of whom were RDTnegative and one was RDTpositive, but slidenegative. Excluding three children withSalmonella typhi, all of the children with bacteraemia were≤12 months of age. Compared to doubleread research slide results RDTs had a sensitivity of 97.8% (95%CI 96.998.7) and specificity of 96.3% (95%CI 96.398.4). Conclusions:Use of RDTs to direct the use of antimalarial drugs in young children did not result in any missed diagnoses of malaria although new infections soon after a consultation with a negative RDT result may undermine confidence in results. Invasive bacterial disease is uncommon in children with nonsevere illness and most cases occurred in infants with a current fever.

Background The features of malaria overlap with those of other common illnesses and, where diagnosis is based on clin ical history and examination alone, this often results in a large degree of overtreatment for malaria [1]. For many years this has been considered as a price worth paying to ensure prompt treatment of malaria in young

* Correspondence: [e-mail] †Contributed equally 6 London School of Hygiene and Tropical Medicine, Keppel St, London WCIE7HT, UK Full list of author information is available at the end of the article

children, but over the last decade a number of impor tant trends have driven a movement towards parasitolo gical testing to guide the use of antimalarial drugs [2]. These include the replacement of older antimalarial drugs with the more expensive artemisinin combination therapy (ACT), the need to minimize selection pressure for drugresistant strains ofPlasmodium falciparum, the need for more reliable surveillance data as malaria has declined in many areas of Africa, and the relative neglect of alternative diagnoses to malaria [37].

© 2011 Mtove et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.