A prospective study on the management of suspected malaria using a protocol
on a general medical ward during the months of February and March, 1992 was done
and the results compared with those of a retrospective study covering the months
of November and December, 1991. The retrospective analysis showed that 78 (65%)
from a total of 120 patients received antimalarial drugs despite negative or
absent blood smears for malarial parasites. In 41 (34%) of the 120 patients, the
first line treatment given was quinine. In the prospective study the overall
quinine use dropped sharply to 19% from 54% in the retrospective study. 94 (49%)
from a total of 193 patients with suspected malaria had negative blood smears of
whom only 8 (4%) received quinine while 63 (33%) did not receive any
antimalarial therapy and 38 of these 63 patients ended up with different final
diagnoses; the remaining 25 were observed on no antimalarial treatment and
discharged home feeling well. These results emphasize the need for proper
diagnosis of malaria and suggest that chloroquine is still acceptable and
effective as a first line drug for proven cases of malaria in adult patients in
Eldoret. Unnecessary quinine use is discouraged as the drug is more expensive
with more toxic effects compared to chloroquine.
PIP:
In Kenya, health professionals compared prospective data on 193
suspected malaria patients at the Eldoret District Hospital during
February-March, 1992, with retrospective data on 120 suspected malaria cases at
the same hospital during November-December, 1991, to examine the protocol on the
management of suspected malaria cases. Between these 2 periods, physicians
introduced a simple algorithm to follow in suspected malaria cases. The use of
quinine as the 1st choice drug fell considerably between the 2 periods
(54.2-19%). There was an increase in the use of chloroquine as the 1st choice
drug for uncomplicated malaria (38.4-63.9%). The proportion of blood smear
positive patients increased (27.5-51.3%), probably because the department
technician was more careful conducting repeat blood smears than were technicians
at the busy hospital laboratory. Blood smear negative patients were less likely
to automatically receive any antimalarial treatment or quinine in 1992 than in
1991 (14.6% vs. 47.5% and 4.1% vs. 30.9%, respectively). The proportion of
patients whose final diagnosis was an illness other than malaria was higher in
1992 than in 1991 (19.7% vs. 15.8%). No clear diagnosis other than flu-like
illness was the case for 28 (14.5%) of the prospective patients. The tendency
for clinicians to accept a diagnosis of malaria without enough evidence to
confirm it can have the damaging effect of masking other serious diagnoses
(e.g., dysentery [8 cases], meningitis [6 cases], and HIV infection [2 case]).
These findings show that hospital physicians should develop simple protocols for
inpatient management of suspected malaria cases, a properly quantified blood
smear should be done of all suspected malaria cases to confirm or refute the
diagnosis, and chloroquine should be the 1st line of treatment in the Kenyan
highlands, until considerable parasite resistance is confirmed.