THE MANAGEMENT OF FEVER AT THE MILDMAY CENTRE

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THE MANAGEMENT OF FEVER AT THE MILDMAY CENTRE

• S Baingana, D Kyazze
• H Seruyange, B Mukasa
• A.Opio, M. Etima, E. Luyirika

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Outline

• A Retrospective Review of the management and
  outcome of HIV infected patients presenting with
  fever at the Mildmay Centre.
• Implications to an optimal approach
• Recommendations for further evaluation

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Background

• Fever is the most frequent reason for HIV
  infected individuals seeking medical care in
  Africa( Corbett et al,2002 ) and was the most
  frequent symptom after oral candidosis in a Rakai
  cohort (Malamba et al)
• Malaria is the cause of 30- 50 of fever, 30 of
  OP attendance and 10-15 of hospital admissions
  (Africa Health 1999)
• HIV infection has been associated with increased
  malaria parasitaemia and clinical episodes
  (Whitworth et al 2000 )
• Other causes of fever in HIV infected individuals
  include acute and opportunistic infections.

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The Problem

• Diagnosis is complicated by inadequate
  investigatory capacity, multiple conditions and
  prior treatment.
• Treatment is often empirical and limited by cost
• Resistance to antimalarials previously first
  line has developed in the region.(EANMAT 2003) ,
• There is increasing and multiple antibiotic
  resistance reported among bacterial pathogens.
  (Kelly P, Shapiro RL, Mugerwa )

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The Mildmay Centre.

• MILDMAY offers comprehensive HIV/AIDS care and
  treatment.
• Of the 800 1200 patients every month about ¼
  have fever at nursing assessment.

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Objectives of Study

• To describe the demographic characteristics of
  Mildmay patients presenting with fever
• To describe the investigations performed and the
  treatment initiated .
• To describe the outcome up to a year of follow-up.

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Methodology

• Study Design - Retrospective
• Study Setting The Mildmay centre
• Study population- patients with a recorded
  complaint of fever at nursing assessment from
  January to June 2002
• Inclusion criteria - Recorded HIV ve at the time
  of presentation
• Exclusion criteria- less than 6 months recorded
  follow-up.

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• After approval of the Research and Ethics
  committee, all subjects who had fever recorded at
  Nursing Assessment from January to June 2002
  consecutively listed had their files retrieved
  and the data compiled up to 1 year of follow-up.
• Analysis was by the EpiInfo Version 6 statistical
  package

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Variables

• Age, Home location, Category
• Prophylaxis/on-going treatment,Prior treatment
  for presenting episode.
• Other symptoms, temperature, anaemia,
  splenomegaly
• Investigations done.
• Treatment- tablets/injection, type
• Number of doses of anti-malarials and antibiotics
  prescribed up to 1 year follow-up.

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RESULTS

• Adults Children Total
• Number with fever 471 823
  1294
• Consecutively enlisted 116 166 282
• 1Episode per patient
• 2 episodes 11 15
• 3 episodes 1 8
• 4 episodes 4
• 7 episodes 1
• Recurrences were not re-evaluated.
• Number evaluated 217

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• Total Number- 217
• Age
• 5-18 71(35.9) Male 88(39.7)
• 18 43(21.7)
• Home location - 199(81.1)
• - 18 (8.3) 20km
• 19 paying patients 24 unemployed

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Previous and Continuing Treatment
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• SIGNS
• Children Adults
• Anaemia 15/111(13.51) 11/106(10.3)
• Spleen 8/111(7.2) 1/106(0.9)
• Thrush 6/111(5.4) 9/106(8.4)
• Laboratory Tests
• B/S done 67/217 (30.98)
• B/S ve 23/67 (39.3)
• Others
• CBC 18 Widal 1
• ESR 1 ISS 2
• TPHA 1 Stool 2
• Febrile Ag 1 CXRay 2

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Fever Treatment

• Including Antimalarial 67 (30.9)
• Including Antibiotic 145 (57.1)
• Including Antipyretic 101 (46.5)
• Antibiotic only 51 (23.5)
• Antimalarial only 12 (5.5)
• Antipyretic only 21 (9.7)
• Antimalarialantibiotic 14 (6.5)
• Antimalbioticpyretic 21 (9.7)
• Antimalarialpyretic 20 (9.2)
• Antibioticpyretic 39 (18)
• None 39 (18)

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Treatment related to B/S Result
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Type of Antimalarial

• Chloroquin 30 Chloroquinfansidar 22
• Fansidar 40 QuinineFansidar 5
• Quinine 9 Fansidar only 8
• Artemether 21 Chloroquin only 14
• Metakelfin 3 Artemetherfansidar 5
• None 151
• Total patients with at least 1 antimalarial 61
• No patient was given 2 antimalarials

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ANTIBIOTICS

• Ciprofloxacin 29 26.4
• Amoxycillin 22 20
• Augmentin 8 7.3
• Cefuroxime 8 7.3
• Anti TB 6 5.5
• Ampicloxacillin 4 3.6
• Cephalexin 4 3.6
• Others- Azithromycin, Clarithromycin, Nalidixic
  Acid, Pyrimethamine 17
• 10 received 2 antibiotics the second being
  metronidazole

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FOLLOW -UP

• Completed 6 months 209 96.3
• Completed 12 months 189 87.1
• Time to-
• Next visit (weeks) 5.28(0.379)
• Next Antimalarial dose 13.81(1.123)
• Next Antibiotic dose 12.89(1.495)
• At 6 months 12months
• No of reviews(SE) 5.07(0.237) 4.72(0.209)
• No of B/S done 0.836(0.08) 0.539(0.08)
• Antimalarial doses 0.89(0.08) 0.72(0.078)
• Antibiotic doses 2.7(0.199) 2.45(0.207)
• Significantly more antibiotic doses than
  antimalarial at 6 months(p0.000015)
  

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Associations

• Adult Child Pvalue
• Last Antimal. Rx 14.0 8.0 0.0048
• B/S done or not 0.0419
• B/S positive or negative 0.813
• Had antimal Rx or not 0.1138
• Time to next review 6.4 4.27 0.0173
• Time to next Antimal 13.35 15.23 0.3755
• No reviews in 6mths 4.16 5.96 0.000075
• Antimalarial doses 0.45 1.26 0.000001
• Antibiotic doses 2.017 3.161 0.00102

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• Children had an antimalarial dose from the centre
  more recently, were more likely to have a B/S
  done were likely to be reviewed sooner and had
  more frequent reviews subsequently.
• Children had more antimalarial and antibiotic
  doses in the subsequent 6 months

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• On ART Not P value
• Reviews in 6mths 4.357 5.667 0.081
• Time to next antimal 19.94 13.35 0.258
• Antimalarial doses 0.276 0.99 0.00041
• To next antibiotic 31.00 10.31 0.00005
• Antibiotic doses 1.32 2.94 0.0002
• Time to next review was significantly associated
  with Category (p0.038)
• Time to next antimal. Rx not associated with
  category (p0.412)

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• B/S B/S-
  pvalue
• To next review 6.273 5.86 0.544
• To next antimal. 15.36 12.35 0.412
• To next antibiotic 9.73 17.21 0.232
• No revs in 6mths 5.33 4.97 0.713

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• A survey from Mulago hospital of sensitivity
  patterns of isolates from specimens of the IDC
  (Najjuka 2004)have demonstrated resistance to
  penicillin, tetracyclin and erythromycin and
  septrin
• Possible algorithm
• Fever B/S
  Antimalarials
• Cough Diarrhoea
• Ampicillin/ Blood No blood
• Chloramphenicol Ciprofloxacin/flagyl Amoxyl/fla
  gyl
• Culture/sensitivity
• Augmentin/Cefuroxime cefuroxime/flagyl
• 
  gentamycin

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Discussion(Compiled with Clinical Team)

• Sources of Error/Bias
• Fever may be reported other than at nursing
  assessment. Episodes identified after are
  missed.
• Incomplete data- symptoms, signs, CBCs.
• Some laboratory results are received after
  treatment has been prescribed.
• Frequency of antibiotic treatment in follow-up
  not described.

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Conclusions

• Febrile episodes are managed as bacterial
  infections
• Children are more likely to have signs of chronic
  malaria, have a malaria parasite smear and have
  more antibiotics and antimalarials subsequently.
• Patients on anti-retroviral therapy have a longer
  duration to next antibiotic and fewer
  antimalarial and antibiotic doses subsequently.

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• Studies to isolate the pathogens and establish
  the sensitivity patterns in patients with fever
  and cough/diarrhoea/ sepsis for the formulation
  of cost effective treatment algorithms for the
  optimal management of these patients.