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Simple guidelines target antibiotic treatment in Kenyan children
id21 health
2006-03-20
Invasive bacterial infections are a significant cause of childhood illness and death worldwide. But clinical officers and doctors in African hospitals have few resources to diagnose and treat seriously ill children. Research in Kenya shows that simple rules based on current World Health Organisation guidelines effectively target antibiotic treatment.
The guidelines form part of the integrated management of childhood illness (IMCI)
approach. Health professionals diagnose and treat clinical syndromes groups
of signs and symptoms rather than individual diseases. But seriously ill
children often meet criteria for several clinical syndromes and different
diseases may cause the same syndrome. The signs and symptoms of malaria can
overlap with those of pneumonia, bacteraemia and meningitis. To test the
usefulness of the guidelines, researchers from Kenyas Centre for Geographic
Medicine Research used them to diagnose and treat 11,847 children admitted to
the Kilifi District Hospital, then checked the diagnosis using more
sophisticated techniques.
They found that:
- About half of the children had syndromes requiring antibiotics: sick young
infants, meningitis/encephalopathy severe malnutrition pneumonia and skin
or soft tissue infection. Of these, an invasive bacterial infection (bacteraemia
or meningitis) was identified in 11 percent of children.
- The guidelines identified four fifths of all children with invasive
bacterial infections and 93 percent of those who later died.
- Of 5,593 children without a syndrome requiring antibiotics, 171 (3.1
percent) had an invasive bacterial infection and 60 (1.1 percent) died.
- Among malaria-infected children meeting criteria for antibiotics, 4 to 8.8
percent had an invasive bacterial infection.
- A quarter of meningitis cases would not have received antibiotics if the
treatment rules had been followed strictly. They were only identified
following lumbar puncture.
- Only three quarters of bacterial samples from cases of meningitis/encephalopathy
were sensitive to penicillin or chloramphenicol (the currently recommended
treatment).
These results show that simple clinical syndromes effectively target children
with invasive bacterial infection and those at risk of death. However, there are
problems with recognition and treatment of meningitis. The researchers recommend
that antibiotic management of children admitted to hospital in settings with few
diagnostic tools should use a comprehensive assessment of the sick child and not
focus on single diseases. They provide a checklist for health professionals
using this approach. They also advise that:
- Separate decisions should be made about antibiotic, anti-malarial and
other treatments on the basis of defined clinical syndromes and the results
of reliable laboratory tests.
- If a child has malaria parasites in the blood, this does not justify
withholding antibiotics if they are indicated by a clinical syndrome,
especially as malaria microscopy can be unreliable in practice.
- On the other hand, children admitted to hospital with suspected or
confirmed malaria infection should be treated with anti-malarials regardless
of any antibiotic treatment.
- Lumbar puncture is critical for catching all cases of meningitis.
Contributor(s): James Berkley
Source(s):
Use of clinical syndromes to target antibiotic prescribing in seriously ill
children in malaria endemic area: observational study, British Medical
Journal 330(7498): 995, by James A. Berkley et al, 2005 More
information.
Funded by: Kenya Medical Research Institute Wellcome Trust
id21 Research Highlight: 30 November 2005
Further Information:
James Berkley
Kilifi KEMRI-Wellcome Trust Collaborative Programme
Centre for Geographic Medicine Research (coast)
PO Box 230
Kilifi
Kenya
Tel: +254 415 22353/22063
Fax: +254 415 22390
Contact the contributor: jberkley@kilifi.mimcom.net
Kenya Medical Research
Institute - Wellcome Trust Collaborative Programme
Other related links:
WHO
referral care guidelines
'Bacteremia among
children admitted to a rural hospital in Kenya', New England Journal of Medicine
352(1): 39-47, by James A. Berkley et al, 2005
'Hypothetical
performance of syndrome-based management of acute paediatric admissions of
children aged more than 60 days in a Kenyan district hospital', Bulletin of the
World Health Organisation 81(3): 166-173, by Mike English et al, 2003
'Prognostic
indicators of early and late death in children admitted to district hospital in
Kenya: cohort study', British Medical Journal 326(7385): 361, by James A.
Berkley et al, 2003
'Diagnosis
of acute bacterial meningitis in children at a district hospital in sub-Saharan
Africa', The Lancet. 357(9270): 1753-1757, by James A. Berkley et al, 2001
'Assessing the performance of
paediatric care in Kenyan district hospitals'
'Decisions, decisions
adapting the IMCI approach for Kenyan paediatric hospitals'
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