A randomized trial on effectiveness of artemether-lumefantrine versus artesunate plus amodiaquine for unsupervised treatment of uncomplicated Plasmodium falciparum malaria in Ghanaian children

<p>Abstract</p> <p>Background</p> <p>Numerous trials have demonstrated high efficacy and safety of artemisinin-based combination therapy (ACT) under supervised treatment. In contrast, effectiveness studies comparing different types of ACT applied unsupervised are scarce. The aim of this study was to compare effectiveness, tolerability and acceptance of artesunate plus amodiaquine (ASAQ) against that of artemether-lumefantrine (AL) in Ghanaian children with uncomplicated <it>Plasmodium falciparum </it>malaria.</p> <p>Methods</p> <p>A randomized open-label trial was conducted at two district hospitals in the Ashanti region, Ghana, an area of intense malaria transmission. A total of 246 children under five years of age were randomly assigned to either ASAQ (Arsucam^®) or AL (Coartem^®). Study participants received their first weight-adjusted dose under supervision. After the parent/guardian was advised of times and mode of administration the respective three-day treatment course was completed unobserved at home. Follow-up visits were performed on days 3, 7, 14 and 28 to evaluate clinical and parasitological outcomes, adverse events, and haematological recovery. Length polymorphisms of variable regions of <it>msp1 </it>and <it>msp2 </it>were determined to differentiate recrudescences from reinfections. Acceptance levels of both treatment regimens were assessed by means of standardized interviews.</p> <p>Results</p> <p>Adequate clinical and parasitological responses after AL and ASAQ treatment were similar (88.3% and 91.7%, respectively). Interestingly, more late clinical failures until day 28 occurred in AL-treated children than in those who received ASAQ (17.5% and 7.3%, respectively; Hazard Ratio 2.41, 95% CI 1.00–5.79, p < 0.05).</p> <p>Haematological recovery and drug tolerability were not found to be significantly different in both study arms. The acceptance of treatment with ASAQ was higher than that with AL (rank-scores 10.6 and 10.3, respectively; p < 0.05).</p> <p>Conclusion</p> <p>Unobserved AL and ASAQ treatment showed high adequate clinical and parasitological responses, though AL was inferior in preventing late clinical failures.</p

Clinical indicators for bacterial co-infection in Ghanaian children with P. falciparum infection.

Differentiation of infectious causes in severely ill children is essential but challenging in sub- Saharan Africa. The aim of the study was to determine clinical indicators that are able to identify bacterial co-infections in P. falciparum infected children in rural Ghana. In total, 1,915 severely ill children below the age of 15 years were recruited at Agogo Presbyterian Hospital in Ghana between May 2007 and February 2011. In 771 (40%) of the children malaria parasites were detected. This group was analyzed for indicators of bacterial co-infections using bivariate and multivariate regression analyses with 24 socio-economic variables, 16 terms describing medical history and anthropometrical information and 68 variables describing clinical symptoms. The variables were tested for sensitivity, specificity, positive predictive value and negative predictive value. In 46 (6.0%) of the children with malaria infection, bacterial co-infection was detected. The most frequent pathogens were non-typhoid salmonellae (45.7%), followed by Streptococcus spp. (13.0%). Coughing, dehydration, splenomegaly, severe anemia and leukocytosis were positively associated with bacteremia. Domestic hygiene and exclusive breastfeeding is negatively associated with bacteremia. In cases of high parasitemia (>10,000/μl), a significant association with bacteremia was found for splenomegaly (OR 8.8; CI 1.6-48.9), dehydration (OR 18.2; CI 2.0-166.0) and coughing (OR 9.0; CI 0.7-118.6). In children with low parasitemia, associations with bacteremia were found for vomiting (OR 4.7; CI 1.4-15.8), severe anemia (OR 3.3; CI 1.0-11.1) and leukocytosis (OR 6.8 CI 1.9-24.2). Clinical signs of impaired microcirculation were negatively associated with bacteremia. Ceftriaxone achieved best coverage of isolated pathogens. The results demonstrate the limitation of clinical symptoms to determine bacterial co-infections in P. falciparum infected children. Best clinical indicators are dependent on the parasitemia level. Even with a moderate sensitivity of >60%, only low positive predictive values can be obtained due to low prevalence of bacteremia. Rapid testing for distinguishing parasitemia and bacteremia is essential

Incidence and characteristics of bacteremia among children in rural Ghana.

The objective of the study was to describe systemic bacterial infections occurring in acutely ill and hospitalized children in a rural region in Ghana, regarding frequency, incidence, antimicrobial susceptibility patterns and associations with anthropometrical data.Blood cultures were performed in all children below the age of five years, who were admitted to Agogo Presbyterian Hospital (APH), Asante Region, Ghana, between September 2007 and July 2009. Medical history and anthropometrical data were assessed using a standardized questionnaire at admission. Incidences were calculated after considering the coverage population adjusted for village-dependent health-seeking behavior.Among 1,196 hospitalized children, 19.9% (n = 238) were blood culture positive. The four most frequent isolated pathogens were nontyphoidal salmonellae (NTS) (53.3%; n = 129), Staphylococcus aureus (13.2%; n = 32), Streptococcus pneumoniae (9.1%; n = 22) and Salmonella ser. Typhi (7.0%; n = 17). Yearly cumulative incidence of bacteremia was 46.6 cases/1,000 (CI 40.9-52.2). Yearly cumulative incidences per 1,000 of the four most frequent isolates were 25.2 (CI 21.1-29.4) for NTS, 6.3 (CI 4.1-8.4) for S. aureus, 4.3 (CI 2.5-6.1) for S. pneumoniae and 3.3 (CI 1.8-4.9) for Salmonella ser. Typhi. Wasting was positively associated with bacteremia and systemic NTS bloodstream infection. Children older than three months had more often NTS bacteremia than younger children. Ninety-eight percent of NTS and 100% of Salmonella ser. Typhi isolates were susceptible to ciprofloxacin, whereas both tested 100% susceptible to ceftriaxone. Seventy-seven percent of NTS and 65% of Salmonella ser. Typhi isolates were multi-drug resistant (MDR). Systemic bacterial infections in nearly 20% of hospitalized children underline the need for microbiological diagnostics, to guide targeted antimicrobial treatment and prevention of bacteremia. If microbiological diagnostics are lacking, calculated antimicrobial treatment of severely ill children in malaria-endemic areas should be considered

Unstratified bivariate and multivariate analysis of characteristics associated with bacteremia in parasitemic children <15 years (with p < 0.1).

<p>¹ OR (CI), odds ratio (95% confidence interval)</p><p>² Children who cannot hold their head at the age of three months, roll over at the age of 6 months, sit unsupported at the age of 9 months, stand unsupported at the age of 12 months or walk single steps at the age of 18 months</p><p>³ Circulation impaired = cold extremities and/or capillary refill time >2 sec. and/or tachycardia</p><p>⁴ Dehydration ≥dehydration grade 1 (3–5%)</p><p>⁵ Variables <i>developmental delay</i>, <i>exclusive breastfeeding</i> and <i>watery stool</i> were removed from multivariate analysis due to small case number (<300 cases)</p><p>* Predicts failure perfectly</p><p>** No calculation possible due to small case numbers</p><p>Unstratified bivariate and multivariate analysis of characteristics associated with bacteremia in parasitemic children <15 years (with p < 0.1).</p

Bivariate analysis of characteristics associated with bacteremia in parasitemic children <15 years stratified for parasite count (with p < 0.1).

<p>¹ Circulation impaired = cold extremities and/or capillary refill time ≤2 sec. and/or tachycardia</p><p>² Diarrhea >7 days</p><p>³ Dehydration ≥dehydration grade 1 (3–5%)</p><p>⁴ Leukocytosis = white blood cell count ≥10,000/μl; Leukopenia = white blood cell count <4,000/μl</p><p>Bivariate analysis of characteristics associated with bacteremia in parasitemic children <15 years stratified for parasite count (with p < 0.1).</p

Parsimonious multivariate regressions model of characteristics positively associated with bacteremia in parasitemic children, stratified for parasite count.

<p>¹ OR (CI), odds ratio (95% confidence interval)</p><p>² Dehydration ≥ grade 1 (3–5%)</p><p>Parsimonious multivariate regressions model of characteristics positively associated with bacteremia in parasitemic children, stratified for parasite count.</p

Admissions, enrollment, frequencies and percentages of parasitemia/bacteremia.

<p>Admissions, enrollment, frequencies and percentages of parasitemia/bacteremia.</p

Test accuracy.

<p>¹ PPV, positive predictive value for bacteremia (for prevalence 12.7%)</p><p>² NPV, negative predictive value for bacteremia (for prevalence 12.7%)</p><p>³ Dehydration ≥ grade 1 (3–5%)</p><p>Test accuracy.</p