Syndromic Management of Prolonged fever a Cost effective approach
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Syndromic Management of Prolonged fever : a Cost-effective approach Subhashchandra DagaEx-Professor of PediatricsB.J.Medical College and Sassoon General Hospital,Pune (India)Email – firstname.lastname@example.orgReference: Tropical Doctor, 2005, 35: 31 – 34.
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Some Facts One of the commonest reasons for attending out-patient department. High Fever/ prolonged fever, a common indication for hospitalization. Management relies heavily on investigations, involves frequent hospital visits and high cost.
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Methods We evaluated protocol- based management covering, occult bacteremia, malaria, and urinary tract infection on 113 consecutive children above 2 months of age admitted for fever lasting more than one week. Subjects were categorized as sick and stable, with or without pneumonia.
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Methods (contd.) A combination of antibiotic and anti-malarial was chosen based on effectiveness, ease of administration and affordability. Drugs from essential drugs’ list were preferred.
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Methods (contd.)Stable Patients First line of treatment for stable patients: Oral Co-trimoxazole + Chloroquine Blood counts and urine examination performed Chest X-ray in case of rapid breathing
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Methods (contd.)Stable Patients In case of non-response by 2 by 3 days, stable patients received chloramphenicol + mefloquine. Mantoux test, chest X-ray and Widal test
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Methods (Contd.) Sick patients with or without pneumonia Inj. Chloramphenicol / cefotaxime (for young infants) + Chloroquine Chest X-ray, if pneumonia suspected.
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Diagnostic Criteria Bacteremia = Abnormal blood counts UTI = Pyuria / organism on Gram stain Malaria = Splenomegaly + anaemia Conventional “Gold Standards” not used
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Important Findings -92 out of 113 (81.4%) responded to first line of treatment. -89 (79.5%) were afebrile by 48 hours and 102 (91.1%) by 72 hours. Average expenditure incurred on drugs (hospital supply). Stable Child : US$ 0.2 Sick Child : US$ 0.5
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Causes of Fever Malaria – 36 (31.8%) Occult bacteremia – 29 (25.7%) UTI – 17 (15%) Pneumonia – 8 (7.5%) Tuberculosis – 3 (2.7%) Cause not known – 23 (20.3%)
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Some Comments Typhoid and tuberculosis were uncommon causes of fever. Why Co-trimoxazole? Effective, available for oral use, cheap, and has convenient b.i.d dosaging. Why Chloramphenicol? Effective, economical and step down from parenteral to oral is easy.
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Table-1 : Comparison of Pre and Post –Protocol Period : Patient Profile
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Table –2 : Comparison of Pre and Post –Protocol Period : Outcome Variables
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Table –3 : Comparison of Pre and Post –Protocol Period : Expenditure on drugs
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Fig.1 Distribution of113 cases and response to treatment. ATT=anti-tubercular treatment.
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CBC=complete blood count; MT=Mantoux test; CXR=chest X-ray; ATT=anti-tubercular treatment Fig. 2 Suggested flowchart formanagement of prolonged fever with poor laboratory support.
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Lessons learnt later on This protocol works in acute fevers also, since fever is prolonged due to delayed / inappropriate / inadequate treatment. Investigations are not mandatory but only “if possible”. Protocol is useful even when laboratory services are not available. For fever management, distinction between pneumonia and no-pneumonia is not necessary. Chloroquine-resistance is rare. Mefloquine is expensive, quinine is equally effective. Urinary infection commoner than believed. Hence, threshold for gentamicin use is lower.
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