The prognostic utility of bedside assessment of adults hospitalized with malaria in Myanmar: a retrospective analysis

Abstract

BackgroundData collected in clinical trials have been used to develop scoring systems that identify adults with malaria at greatest risk of death. One of these, the RCAM score, can be simply determined by measuring a patient’s Glasgow Coma Score and respiratory rate on admission to hospital. However the safety of using the RCAM score to define high-risk patients has not been assessed outside of the clinical trial setting.MethodsA retrospective audit of medical records of all adults admitted with a diagnosis of malaria to two tertiary referral hospitals in Lower Myanmar in 2013 was undertaken. An RCAM score was calculated in all patients and related to their subsequent clinical course.ResultsThe recent decline in malaria hospitalizations at both sites continued in 2013. During the year 90 adults were hospitalized with malaria; 62 (69%) had Plasmodium falciparum mono-infection, 11 (12%) had Plasmodium vivax mono-infection, 17 (19%) had mixed infection. All seven (7.7%) deaths occurred in patients infected with P. falciparum. An admission RCAM score <2 identified all the patients that would survive to discharge (positive predictive value (95% confidence interval (CI)) 100% (94.9-100%) and also predicted a requirement for less supportive care: 9/70 (13%) patients with an admission RCAM score <2 required supportive care (blood transfusion, vasopressor support or oxygen supplementation) during their hospitalization compared with 12/20 (60%) patients with an admission RCAM score ≥2 (p < 0.0001). No patient with P. vivax mono-infection required supportive care during their hospitalization. Patients with an oxygen saturation ≤95% on room air on admission were more likely to die before discharge (odds ratio 17.3 (95% CI: 2.9-101.2) than patients with a higher oxygen saturation (p = 0.002).ConclusionsEven outside a clinical trial setting the RCAM score reliably identifies adults with malaria who are at greatest risk of death and can be safely used in the initial triage and management of these patients.

Antibiotic Therapy in Adults with Malaria (ANTHEM): High Rate of Clinically Significant Bacteremia in Hospitalized Adults Diagnosed with Falciparum Malaria

“…There were 26 malaria cases, 20 with P. falciparum and six with P. vivax. The 20 patients with falciparum malaria were enrolled in the study, their median (interquartile range [IQR]) age was 28 (19)(20)(21)(22)(23)(24)(25)(26)(27)(28)(29)(30)(31)(32)(33)(34)(35) years; 19 (95%) were male. Their clinical characteristics are presented in Table 1.…”

“…The fundamental pathological process underlying falciparum malaria in adults and children is microvascular obstruction from parasitized red blood cells [26][27][28] with associated endothelial dysfunction. 19,29 This leads to impaired blood flow and tissue ischemia, which in the gastrointestinal tract is believed to impair mucosal barrier function, increasing bacterial translocation. [30][31][32] Indeed, intestinal ulceration has been demonstrated at autopsy in adults with falciparum malaria dying from Gram-negative bacteremia.…”

“…17,18 When able to tolerate oral medications, the patient was switched from intravenous artesunate to oral artemether-lumefantrine. Disease severity was classified using the RCAM score which has been validated previously in patients in Myanmar, 19 with a score of ³ 2 used to define severe disease. 20 The likelihood of a concurrent bacterial infection was assessed at the time of hospitalization by a local consultant physician (Ne Myo Aung), with more than 10 years' postgraduate experience.…”

The clinical implications of thrombocytopenia in adults with severe falciparum malaria: a retrospective analysis

“…Disease severity was defined by the number of these criteria that a patient satisfied. The independent prognostic utility of the admission platelet count was compared with the widely validated RCAM score [ 20 - 22 ] calculated from the patients’ respiratory rate and GCS on admission (Table 1 ). Major bleeding was defined as bleeding which resulted in death or necessitated blood transfusion.…”

The Safety of a Conservative Fluid Replacement Strategy in Adults Hospitalised with Malaria

“…Prior to the study’s commencement, there had been no protocol for fluid management of malaria at either hospital; instead medical staff used their clinical judgement to determine the rate of fluid delivery. Therefore to further assess the safety of the conservative fluid strategy, the study’s case-fatality rate was compared with the case-fatality rate in a clinical audit of patients admitted with malaria at the two hospitals in the year before the study began [ 22 ].…”