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WHO guidelines for antimicrobial treatment in children admitted to hospital in an area of intense Plasmodium falciparum transmission: prospective study.
BMJ. British Medical Journal. 2010; 340:c1350.OBJECTIVES: To assess the performance of WHO's "Guidelines for care at the first-referral level in developing countries" in an area of intense malaria transmission and identify bacterial infections in children with and without malaria. DESIGN: Prospective study. SETTING: District hospital in Muheza, northeast Tanzania. PARTICIPANTS: Children aged 2 months to 13 years admitted to hospital for febrile illness. MAIN OUTCOME MEASURES: Sensitivity and specificity of WHO guidelines in diagnosing invasive bacterial disease; susceptibility of isolated organisms to recommended antimicrobials. RESULTS: Over one year, 3639 children were enrolled and 184 (5.1%) died; 2195 (60.3%) were blood slide positive for Plasmodium falciparum, 341 (9.4%) had invasive bacterial disease, and 142 (3.9%) were seropositive for HIV. The prevalence of invasive bacterial disease was lower in slide positive children (100/2195, 4.6%) than in slide negative children (241/1444, 16.7%). Non-typhi Salmonella was the most frequently isolated organism (52/100 (52%) of organisms in slide positive children and 108/241 (45%) in slide negative children). Mortality among children with invasive bacterial disease was significantly higher (58/341, 17%) than in children without invasive bacterial disease (126/3298, 3.8%) (P<0.001), and this was true regardless of the presence of P falciparum parasitaemia. The sensitivity and specificity of WHO criteria in identifying invasive bacterial disease in slide positive children were 60.0% (95% confidence interval 58.0% to 62.1%) and 53.5% (51.4% to 55.6%), compared with 70.5% (68.2% to 72.9%) and 48.1% (45.6% to 50.7%) in slide negative children. In children with WHO criteria for invasive bacterial disease, only 99/211(47%) of isolated organisms were susceptible to the first recommended antimicrobial agent. CONCLUSIONS: In an area exposed to high transmission of malaria, current WHO guidelines failed to identify almost a third of children with invasive bacterial disease, and more than half of the organisms isolated were not susceptible to currently recommended antimicrobials. Improved diagnosis and treatment of invasive bacterial disease are needed to reduce childhood mortality.
Antimicrobial and support therapy for bacterial meningitis in children. Report of the meeting of 18- 20 June 1997, Geneva, Switzerland.
Geneva, Switzerland, WHO, Division of Emerging and Other Communicable Diseases Surveillance and Control, 1998.  p. (WHO/CHD/98.6; WHO/EMC/BAC/98.2)WHO and UNICEF have developed an integrated approach to address the major life-threatening illnesses of children known as Integrated Management of Childhood Illness (IMCI). Lessons learned from disease-specific programmes have been applied to promote co-ordination and integration of the activities to improve the prevention and management of childhood illness. Apart from five major killer diseases of children under five years (acute respiratory infections - mostly pneumonia, diarrhoea, measles, malaria and malnutrition) bacterial meningitis is an important cause of childhood morbidity and mortality. (excerpt)
Diagnosis and management of febrile children using the WHO / UNICEF guidelines for IMCI in Dhaka, Bangladesh.
Bulletin of the World Health Organization. 2001; 79(12):1096-105.In Dhaka, Bangladesh, a study was conducted to determine the effectiveness of WHO’s integrated management of childhood illnesses (IMCI) guidelines in identifying children with bacterial infections in need of antibiotics. A systematic sample of 669 sick children aged 2-59 months was enrolled in the study. Weight, tactile, measured temperature, and respiratory rate were obtained from each patient. The study revealed that had IMCI guidelines been used to evaluate the subjects, 78% of those with bacterial infections would have received antibiotics, including the majority of children with meningitis (100%), pneumonia (95%), otitis media (95%), urinary tract infection (83%), bacteremia (50%), dysentery (48%), and skin infections (30%). It was also noted that the fever module identified only one additional case of meningitis. Children with bacteraemia were more likely to be febrile, feel hot and have history of fever than those with dysentery and skin infections. Fever combined with parental perception of fast breathing provided a more sensitive fever module for the detection of bacteraemia than the current ICMI module. In an area of low malaria prevalence, the IMCI guidelines provide antibiotics to the majority of children with bacterial infections, but improvements in the fever module are possible.
SYNOPSIS. 1998 Jan; (2):1-8.The World Health Organization (WHO)/UN Children's Fund (UNICEF) Integrated Management of Childhood Illness (IMCI) guidelines were designed to maximize detection and appropriate treatment of illnesses due to the most common causes of child mortality and morbidity in developing countries: pneumonia, diarrhea, malaria, measles, bacterial infections in young infants, malnutrition, anemia, and ear problems. The health worker first examines the child and checks immunization status, then classifies the child's illness and identifies the appropriate treatment based on a color-coded triage system. By May 1997, 17 countries had introduced IMCI and 16 others were in the process of introduction. This issue reports on field tests of the guidelines conducted in Kenya, the Gambia, Uganda, Bangladesh, and Tanzania. Health workers who used the guidelines performed well when compared to physicians who had access to laboratory and radiographic findings as well as health workers trained in full case management. Of concern, however, are research findings suggesting the potential for overdiagnosis in some disease classifications. Current IMCI research priorities include the following: 1) determining health workers' ability to learn to detect lower chest wall indrawing; 2) identifying clinical signs to increase the specificity of referral for severe pneumonia; 3) identifying other clinical signs to increase the specificity of hospital referrals, thereby reducing unnecessary referrals; 4) investigating how clinical care for severely ill children could be expanded in areas where referral is not feasible; 5) finding ways to increase the specificity of the diagnosis of malaria; and 6) recognizing clinical signs to increase the specificity of the diagnosis of severe anemia and the specificity of the diagnosis of moderate or mild anemia, with the possible goal of regional adaptation of the anemia guidelines.
Effectiveness of clinical guidelines for the presumptive treatment of streptococcal pharyngitis in Egyptian children.
Lancet. 1997 Sep 27; 350(9082):918-21.In developing country settings without access to bacterial culture and rapid diagnostic tests, the prevention of acute rheumatic fever depends on clinicians' presumptive treatment of streptococcal pharyngitis. This study evaluated the effectiveness of World Health Organization (WHO) acute respiratory infection guidelines in a large pediatric clinic (Abu Reesh Children's Hospital) in Cairo, Egypt. 451 children 2-13 years of age with sore throat and pharyngeal erythema were enrolled, 107 (24%) of whom had group A beta-hemolytic streptococci on throat culture. Purulent exudate, present in 99 (22%) of these children, was 31% sensitive and 81% specific for a positive culture. The WHO guidelines, which recommend treatment for pharyngeal exudate plus enlarged and tender cervical node, were 12% sensitive and 94% specific. Based on these guidelines, 13 of 107 children with a positive throat culture would correctly receive antibiotics and 323 of 344 with a negative culture would not receive antibiotics. A modified guideline in which exudate or large cervical nodes would indicate antibiotic treatment would be 84% sensitive and 40% specific. With this modification, 90 of 107 children with a positive throat culture would correctly receive antibiotics and 138 out of 344 with a negative culture would not receive treatment. However, additional prospective studies from other regions of Egypt are necessary before modified guidelines are implemented.