Simple guidelines target antibiotic treatment in Kenyan children

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 Kenya’s 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.

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 Full document.

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'