Overdiagnosis and mistreatment of malaria among febrile patients at primary healthcare level in Afghanistan: observational study.
Overdiagnosis and mistreatment of malaria among febrile patients at primary healthcare level in Afghanistan: observational study.
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DOI：
10.1136/bmj.e4389
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发表时间：
2012-07-24
期刊：
影响因子：
--
通讯作者：
Rowland M
中科院分区：
文献类型：
--
作者：
Leslie T;Mikhail A;Mayan I;Anwar M;Bakhtash S;Nader M;Chandler C;Whitty CJ;Rowland M
目的评价阿富汗基层诊所疟疾诊疗的准确性。设计前瞻性观察性研究。在阿富汗的两个省设立了22个诊所，一个在北部(与塔吉克斯坦接壤)，一个在东部(与巴基斯坦接壤)；间日疟和恶性疟季节性传播的地区。研究对象2357名临床医生怀疑为疟疾的患者入选。干预措施建立了(5年)显微镜检查(阿富汗东部的12家诊所)，新建了显微镜检查(阿富汗北部的5家诊所)，没有实验室(阿富汗北部的5家诊所)。所有诊所都使用了国家疟疾治疗指南。主要结果衡量接受疟疾药物治疗的疟疾阳性和阴性患者的比例；基于临床的诊断的敏感性和特异性；处方者对临床幻灯片结果的反应；以及疟疾阳性和阴性患者服用抗生素的比例。结果是根据双读参考血液玻片来衡量的。结果在使用临床诊断的卫生中心，尽管414名患者中有413名患者的参考幻灯片为阴性，但412名(99%)接受了疟疾药物治疗，47名(11%)接受了抗生素治疗。在使用新显微镜的诊所中，37%(75/202)的参考玻片阴性患者接受了疟疾药物治疗，60%(103/202)接受了抗生素治疗。在使用现有显微镜的诊所中，50.8%(645/1269)的参考玻片阴性的患者接受了疟疾药物治疗，27.0%(342/1269)的患者接受了抗生素治疗。在疟疾检测阳性的患者中，94%(443/472)的患者正确地接受了疟疾药物治疗，但6例恶性疟疾患者中只有1例被发现并得到了适当的治疗。建立镜检和新镜检的特异度分别为72.9%和79.9%。针对镜检结果为阴性的病例，已建立镜检组和新设镜检组分别给270/905(28.8%)和32/154(21%)患者开了抗疟药，347/930(37.3%)和99/154(%)开了抗生素。护士比医生更不可能开错药。结论尽管阿富汗的疟疾发病率比非洲低得多，但在这个南亚地区，发热被误诊为疟疾。不准确的原因是实验室对疟疾的诊断为假阳性，以及临床医生对阴性结果置之不理。没有发现罕见但可能致命的恶性疟疾病例，这突显了快速诊断测试的潜在作用。显微镜检查增加了接受抗生素治疗的患者的比例，在过度使用疟疾药物和可能过度使用抗生素之间进行了权衡。
Objective To assess the accuracy of malaria diagnosis and treatment at primary level clinics in Afghanistan. Design Prospective observational study. Setting 22 clinics in two Afghan provinces, one in the north (adjoining Tajikistan) and one in the east (adjoining Pakistan); areas with seasonal transmission of Plasmodium vivax and Plasmodium falciparum. Participants 2357 patients of all ages enrolled if clinicians suspected malaria. Interventions Established (>5 years) microscopy (12 clinics in east Afghanistan), newly established microscopy (five clinics in north Afghanistan), and no laboratory (five clinics in north Afghanistan). All clinics used the national malaria treatment guidelines. Main outcome measures Proportion of patients positive and negative for malaria who received a malaria drug; sensitivity and specificity of clinic based diagnosis; prescriber’s response to the result of the clinic slide; and proportion of patients positive and negative for malaria who were prescribed antibiotics. Outcomes were measured against a double read reference blood slide. Results In health centres using clinical diagnosis, although 413 of 414 patients were negative by the reference slide, 412 (99%) received a malaria drug and 47 (11%) received an antibiotic. In clinics using new microscopy, 37% (75/202) of patients who were negative by the reference slide received a malaria drug and 60% (103/202) received an antibiotic. In clinics using established microscopy, 50.8% (645/1269) of patients who were negative by the reference slide received a malaria drug and 27.0% (342/1269) received an antibiotic. Among the patients who tested positive for malaria, 94% (443/472) correctly received a malaria drug but only 1 of 6 cases of falciparum malaria was detected and appropriately treated. The specificity of established and new microscopy was 72.9% and 79.9%, respectively. In response to negative clinic slide results, malaria drugs were prescribed to 270/905 (28.8%) and 32/154 (21%) and antibiotics to 347/930 (37.3%) and 99/154 (64%) patients in established and new microscopy arms, respectively. Nurses were less likely to misprescribe than doctors. Conclusions Despite a much lower incidence of malaria in Afghanistan than in Africa, fever was substantially misdiagnosed as malaria in this south Asian setting. Inaccuracy was attributable to false positive laboratory diagnoses of malaria and the clinicians’ disregard of negative slide results. Rare but potentially fatal cases of falciparum malaria were not detected, emphasising the potential role of rapid diagnostic tests. Microscopy increased the proportion of patients treated with antibiotics producing a trade-off between overtreatment with malaria drugs and probable overtreatment with antibiotics.
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DOI：
10.1136/bmj.c930
发表时间：
2010-03-05
期刊：
BMJ (Clinical research ed.)
影响因子：
--
作者：
Ansah EK;Narh-Bana S;Epokor M;Akanpigbiam S;Quartey AA;Gyapong J;Whitty CJ
通讯作者：
Whitty CJ
影响因子：
168.9
作者：
Kolaczinski, J;Graham, K;Rowland, M
通讯作者：
Rowland, M
影响因子：
11.8
作者：
Brooker S;Leslie T;Kolaczinski K;Mohsen E;Mehboob N;Saleheen S;Khudonazarov J;Freeman T;Clements A;Rowland M;Kolaczinski J
通讯作者：
Kolaczinski J
影响因子：
3
作者：
Chandler, Clare I. R.;Jones, Caroline;Whitty, Christopher J. M.
通讯作者：
Whitty, Christopher J. M.
影响因子：
--
作者：
Bailey, M. S.;Trinick, T. R.;Green, A. D.
通讯作者：
Green, A. D.