Etiologies of illness among patients meeting integrated management of adolescent and adult illness district clinician manual criteria for severe infections in northern Tanzania
Implications for empiric antimicrobial therapy.
Abstract
In resource-limited settings that often lack laboratory capacity for the diagnostic evaluation of illnesses, algorithmic patient management by syndrome classification is an important tool for healthcare workers. Such syndromic management approaches were first widely promulgated for children in the Integrated Management of Childhood Illness (IMCI). In 2011, the World Health Organization (WHO) issued Integrated Management of Adolescent and Adult Illness District Clinician Manual (IMAI). Although multiple studies have assessed the performance and impact of IMCI at the district and referral hospital level, studies are needed to assess the performance and impact of IMAI recommendations.
The IMAI recommended antibacterial therapy for emergency situations is ceftriaxone, or ampicillin plus gentamicin if ceftriaxone is not available. For septic shock and severe respiratory distress (SRD) without shock, IMAI recommends empiric antibacterials. Although substantial guidance is given on the broad differential diagnosis of septic shock, one can assume most providers at district hospitals in resource-limited settings would generally have recourse to the endorsed emergency antibacterial agents, ceftriaxone or ampicillin plus gentamicin. In malaria-endemic areas or in patients who have traveled to malaria-endemic areas, empiric antimalarials are also advised while awaiting the results of a malaria diagnostic test. For severe pneumonia, IMAI recommends empiric ceftriaxone plus one of three recommended macrolides (i.e., azithromycin, clarithromycin, or erythromycin), with ampicillin plus gentamicin offered as an alternative to ceftriaxone and doxycycline or a respiratory fluoroquinolone offered as alternatives to a macrolide. For those suspected or confirmed to have human immunodeficiency virus (HIV) infection who present with severe pneumonia, IMAI also advises empiric treatment of Pneumocystis pneumonia and consideration of pulmonary tuberculosis.
Using patient-level data from an etiology of febrile illness cohort study undertaken among hospitalized adolescents and adults in the Kilimanjaro Region of northern Tanzania we sought to describe the laboratory-confirmed infectious etiologies among participants who met IMAI criteria for septic shock, SRD without shock, and severe pneumonia. We then assessed the potential utility of selected antimicrobial agents, including antimicrobials that feature prominently in IMAI guidance, for treatment of these syndromes. In addition, for those enrolled who died in-hospital, we similarly described the laboratory-confirmed etiologies and assessed the potential use of selected antimicrobial agents.
This is a publication arising from the Zoonoses and Emerging Livestock Systems (ZELS) programme.
Citation
Rubach M, Maro V, Bartlett J, Crump J (2015). Etiologies of illness among patients meeting integrated management of adolescent and adult illness district clinician manual criteria for severe infections in northern Tanzania: implications for empiric antimicrobial therapy. Am J Trop Med Hyg. 92(2):454-62.