Malaria treatment practice and clinical presentation of adult patients with antimalarial prescriptions in Mulago hospital assessment centre.

Abstract

Back ground: Malaria is a major cause of morbidity and mortality worldwide. It is endemic in over 95% of Uganda and accounts for 25-40% of all outpatient attendances. The World Health Organisation recommends parasitological confirmation of malaria in all age groups before treatment with antimalarial drugs. In spite of this policy, most malaria diagnosis is still based on clinical symptoms. Improper diagnosis based on symptoms alone often results in fevers being presumptively treated for malaria, resulting in the wastage of antimalarial drugs and increased morbidity and mortality due to non malarial causes of illness. This study describes the malaria treatment practices in Mulago National Referral and Teaching Hospital and contributes information for policy reviews on malaria diagnosis and management. Objective: We sought to determine the prevalence of presumptive malaria treatment and the prevalence of negative malaria smears among adult patients with antimalarial prescriptions in Mulago hospital assessment centre. We also described the clinical presentation of adult patients with confirmed malaria diagnosed on expert microscopy. Methods: This was a cross-sectional descriptive study carried out in Mulago hospital assessment centre. Hospital exit interviews were done for adult patients with antimalarial prescriptions. Data was collected on the absence or presence of a hospital malaria smear test done before antimalarial prescription. Data on clinical presentation of study participants was obtained. Additional evaluations included HIV status, complete blood count (CBC) and expert malaria microscopy. Results: A total of 400 adult patients with antimalarial prescriptions were recruited into the study. The prevalence of presumptive malaria treatment was 97% (386/400) and the prevalence of negative hospital smears among malaria treated adult patients with smear results was 89% (110/124). Thirty three of the 400 (8%) participants were confirmed to have malaria on expert microscopy. At expert microscopy participants with confirmed malaria were more likely to have rigors (13/33 vs. 78/367; odds ratio [OR], 2.62; 95% confidence interval [CI], 1.06 - 6.49), abdominal tenderness (11/33 vs. 60/367; OR, 4.18; CI, 1.51- 11.54) and low haemoglobin (9/33 vs. 30/367; OR, 4.16; CI, 1.32 – 13.11) compared with those without malaria. Participants with confirmed malaria were less likely to have cough (8/33 vs. 137/367; OR, 0.33; CI 0.11- 0.95) compared to participants without malaria. Conclusion: In this low-endemic setting, the majority of patients treated for malaria do not have the disease and the majority of adult patients treated for malaria do not get malaria smear tests done prior to antimalarial prescription. Recommendation: Further studies to elucidate on why malaria smear tests are not done and why the test results are not used to make appropriate clinical decisions for antimalarial prescription are required. Prescribers should be given refresher courses for alternative causes of illness in patients without malaria.