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Keywords:

  • malaria;
  • therapy;
  • presumptive diagnosis;
  • rational use;
  • antimalarials;
  • Africa;
  • WHO guidelines
  • malaria;
  • thérapie;
  • diagnostic présomptif;
  • utilisation rationnelle des antimalariques;
  • Afrique;
  • directives de l’OMS
  • malaria;
  • terapia;
  • diagnóstico presuntivo;
  • uso racional;
  • antimaláricos;
  • África;
  • guías de la OMS

Abstract

  1. Top of page
  2. Abstract
  3. References

Editorial: L’utilisation rationnelle des antibiotiques sera-t-elle compromise dans l’ère de la prise en charge de la malaria basée sur les tests?

L’OMS a publié des directives révisées sur le traitement de la malaria qui recommandent la confirmation parasitologique avant le début du traitement des patients fébriles, y compris les enfants de moins de cinq ans. Le respect des nouvelles directives conduirait à un grand nombre de maladies fébriles confirmées comme étant non-malariques. Sans les compétences et la capacité de distinguer les causes de fièvre non malarique dans les régions à pauvres ressources, la tendance serait pour les cliniciens à recourir à l’utilisation présomptueuse d’antibiotiques dans tous les cas à test négatif. Une augmentation significative de l’utilisation inappropriée des antibiotiques en Afrique subsaharienne va accroître le problème mondial de la résistance aux antibiotiques. Des interventions ciblées sont nécessaires pour améliorer l’utilisation rationnelle des antibiotiques dans l’ère de la prise en charge de la malaria basée sur les tests. Cela comprend des modifications appropriées dans les directives actuelles de la PCIME, l’équipement et la reformation du personnel dans les services de soins primaires, l’établissement de systèmes de surveillance sentinelle pour déterminer l’étiologie de la maladie fébrile non-malarique et les profils de sensibilité aux antibiotiques, ainsi qu’un mécanisme efficace pour la diffusion des données de surveillance afin d’améliorer le diagnostic et la prise en charge des maladies fébriles chez les enfants.

La OMS ha publicado una versión revisada de las guías para el manejo de la malaria, en las que se recomienda la confirmación parasitológica antes del inicio del tratamiento de pacientes febriles, incluyendo a los niños menores de cinco años. La adherencia a las nuevas guías llevaría a que un buen número de enfermedades febriles se confirmaran como “no malaria”. En emplazamientos con pocos recursos, sin tener las habilidades y la capacidad para diferenciar la causa de la fiebre no relacionada con la malaria, la tendencia de los clínicos sería de recurrir al uso presuntivo de antibióticos en todos los casos con pruebas negativas para malaria. El aumento significativo del uso inapropiado de antibióticos en África sub-Sahariana se añadiría al problema global de resistencia a los antibióticos. Se hacen necesarias intervenciones con el objetivo de mejorar el uso racional de antibióticos en la era del manejo de la malaria basándose en pruebas diagnósticas. Esto incluye revisiones apropiadas de las actuales guías MIEI, el equipar y re-entrenar el personal de los centros sanitarios de atención primaria, establecer una vigilancia continua para determinar la etiología de las enfermedades febriles que no son malaria y los patrones de susceptibilidad frente a antibióticos, y un mecanismo efectivo para la diseminación de los datos obtenidos con el fin de mejorar el diagnóstico y el manejo de las enfermedades febriles en niños.

WHO’s revised malaria treatment guidelines (WHO 2010) recommend parasitological confirmation by microscopy or by rapid diagnostic test (RDT) in all patients including children suspected of malaria before starting treatment. Presumptive treatment of fever in children <5 years of age with antimalarial drugs, unless an alternative cause for the fever is diagnosed, was for many years recommended in malaria-endemic countries of sub-Saharan Africa. This approach to diagnosis of febrile illness in children, incorporated within the Integrated Management of Childhood Illness (IMCI), is part of the reason why nearly 80% of all malaria cases reported are unconfirmed (WHO 2009).

Endorsement of the presumptive approach to diagnosis contributed to an overemphasis on malaria and the under-diagnosis of non-malaria fevers, leading to wastage of antimalarial drugs, with possible adverse medical and economic consequences (Amexo et al. 2004). The new WHO guidelines, if adhered to by health workers, would address this problem. However, this strategy could accentuate the challenge of how to appropriately manage the ‘confirmed’ non-malaria febrile illnesses.

A declining trend in malaria transmission has been observed in many countries particularly in east and southern Africa. Areas previously known to be high transmission malaria settings are now recording malaria slide positivity rates of 5–11% in febrile children (Ceesay et al. 2008; O’Meara et al. 2008). Adherence to the new WHO guidelines would lead to a large number of febrile illnesses to be confirmed as non-malaria cases. In health systems that have for many years focused attention heavily on malaria, the capacity to appropriately manage non-malaria cases cannot be assumed. A shift in the mix of diagnosis will pose a challenge to the abilities of clinicians in peripheral health facilities who will continue to rely on little or no resources to distinguish between the causes of non-malaria fevers.

The many years of over-emphasis on malaria have been at the expense of attention to other causes of acute childhood febrile illnesses in malaria-endemic countries. This is evident in both research and national disease control programmes. Very little is known about the causes of non-malarial fevers in most malaria-endemic countries (Perkins & Bell 2008). Although viral and bacterial aetiologies are commonly implicated, empirical data on the distribution of non-malarial causes of fever in children are scarce. While there is substantial evidence of the over-diagnosis of malaria, very little is reported on the alternative diagnoses. Unless targeted interventions to manage non-malaria febrile illness are instituted, the coming era of test-based management of malaria would increase the inappropriate treatment of febrile children.

Of particular concern is the extent to which antibiotics will be used appropriately. Given that skilled human resources are scarce while being faced with increasing demand for health care and a continued lack of point-of-care laboratory support, the effortless approach of simply substituting the presumptive use of antimalarials with the presumptive use of antibiotics whenever a rapid test for malaria returns a negative result is likely to emerge. A dogma that would translate as ‘antimalarial for RDT positive, antibiotic for RDT negative’ is in the offing. This is likely to be applied with little or no attempt at establishing the aetiology of the non-malaria fevers.

A few non-malaria infections such as diarrhoea and skin infections are relatively easy to differentiate but many other infections such as pneumonia, typhoid, hepatitis and viral infections are not easily distinguished solely on the basis of clinical judgment. In the absence of point-of-care diagnostics, these infections are likely to be classified within the large group of non-malarial acute undifferentiated fever (NMAUF) (Joshi et al. 2008). Presently, an accurate estimate of the burden of NMAUF for developing countries and Africa in particular is difficult to ascertain because of inadequate diagnostic aides, poor disease surveillance systems and widespread presumptive management of malaria. Without the capacity to differentiate the causes of non-malarial febrile illnesses, the tendency would be to use broad-spectrum antibiotics in all RDT-negative cases. This has been shown in recent studies in Tanzania and Zanzibar where RDT was used alongside routine case management (Msellem et al. 2009; Mosha et al. 2010).

A significant increase in the indiscriminate use of antibiotics in sub-Saharan Africa is likely to add to the global problem of antibiotic resistance. Methicillin-resistant Staphylococcus aureus alone infects more than 94 000 people and kills nearly 19 000 in the United States every year. In the European Union, about 25 000 patients die every year from infection with multidrug-resistant bacteria (Anonymous 2009). Although empirical data on the impact of antibiotic resistance on mortality in sub-Saharan Africa are not available, there is clear evidence of the problem in many parts of the region. In a study in Tanzania, only 47% of the isolated organisms in children with invasive bacterial disease were susceptible to the first recommended antimicrobial agent (Nadjm et al. 2010). About 20% prevalence of methicillin-resistant S. aureus (MRSA) has been detected in Southwest Nigeria, with 48% of isolates fulfilling the definition of community-acquired MRSA. Eighty-eight per cent of MRSA isolates collected from Dakar and five other African cities belonged to the three major clones with potential for pandemic spread (Breurec et al. 2010). While the development of resistance to the artemisinins would pose a significant threat to global health, widespread resistance to antibiotics in resource-poor settings would have more devastating consequences. The development of multidrug-resistant bacterial strains crosses geographic and racial borders (Obaro 2000).

There is a critical need to improve the capacity in primary care facilities to appropriately use antibiotics in the management of non-malaria fevers. For health systems that have for many years practiced a policy of equating fever with malaria, the transition to test-based malaria treatment management would require re-orientation. The ideal would be a point of care test that distinguishes malaria, bacterial and viral illnesses. While awaiting the development of such a technology, clinical care in peripheral health facilities needs to be improved through (i) revising the IMCI guidelines to incorporate malaria RDT, (ii) refresher training and supportive supervision to strengthen adherence to the revised IMCI guidelines, (iii) encouraging clinicians to avoid merely diagnosing NMAUF by documenting comprehensive history and systematic physical examination, (iv) enforcing the use of antibiotics only when absolutely indicated for the appropriate length of time at the optimum dose (Vento & Cainelli 2010), (v) establishing disease surveillance systems to determine the aetiology of NMAUF in children and antibiotic sensitivity patterns and (vi) effective dissemination of the information on aetiology of NMAUF and antibiotic sensitivity patterns to all clinicians, particularly to those working in peripheral health facilities.

Revision to current IMCI case management guidelines should take into account evidence on updated antibiotic susceptibility patterns, including the impact of conjugate pneumococcal vaccines on the carriage of pneumococcal serotypes in sub-Saharan Africa. An IMCI quality management system that makes it possible to track and audit the findings of clinical examination relative to the management approach needs to be instituted.

The majority of primary care facilities in sub-Saharan Africa are manned by cadres other than doctors who are taught to manage childhood fevers using simple algorithms. As part of re-orienting these personnel to meet the demand of appropriate management of non-malaria cases, there is the need to ensure the availability and skilled use of simple, yet important clinical diagnostic aides such as child stethoscopes, tongue depressors, otoscopes and oroscopes.

This is the time to focus attention on how to appropriately manage non-malaria fevers in Sub-Saharan Africa. To this end, it is imperative for studies designed to make the case for the deployment of rapid tests for malaria to simultaneously address the question, ‘if it is not malaria, then what is it?’ Improving the management of febrile illness in children requires effort and resources beyond the availability of rapid tests for malaria.

References

  1. Top of page
  2. Abstract
  3. References
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