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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.
In: The HIV challenge to education: a collection of essays, edited by Carol Coombe. Paris, France, UNESCO, International Institute for Educational Planning, 2004. 253-263. (Education in the Context of HIV / AIDS)Twenty years after the identification of AIDS, some 60 million people have been infected by HIV, a number corresponding to the entire population of France, the United Kingdom or Thailand. Those who have died equal the population of Norway, Sweden, Finland and Denmark combined. Those currently infected - more than 40 million - number more than the entire population of Canada. The number of children thought to be orphaned by HIV/AIDS - some 14 million - is already more than the total population of Ecuador. Over the coming decade their numbers may rise to a staggering 50 million worldwide. In other words, the extent of this pandemic is unprecedented in human history. And the worst is yet to come, for many millions more will be infected, many millions more will die, many millions more will be orphaned. On September 11 2001, more than 3,000 people died in the New York bombings. Every day, around the world, HIV infects at least five times that number. But it is not only individuals who are at risk. The social fabric of whole communities, societies and cultures is threatened. The disease is certain to be a scourge throughout our lifetime. (excerpt)