Clinical presentation, diagnostic evaluation, treatment and diagnoses of febrile children presenting to the emergency department at Muhimbili national hospital in Dar es Salaam, Tanzania

While there are many guidelines for the ED evaluation of febrile children, these are largely derived and validated in high-resource settings. There is limited literature documenting recommended or actual management in resource-limited settings. We describe the presentation, diagnostic evaluation, treatment, and ED diagnoses of febrile children under 5 years old presenting to an urban emergency department in Dar es Salaam. Methods: This was a prospective observational study of children under 5 with fever or reported fever at Muhimbili National Hospital (MNH) ED. Treating physicians prospectively completed a standardized data form. Results: We enrolled 105 children, median age 14 months, with 80% >6 months, and 64% male. Presenting symptoms included poor feeding (47.6%) vomiting (42.9%), cough (34.3), difficulty breathing (28.6%), and diarrhoea (22.9%). 78% had vital sign abnormalities and 82% had abnormal physical examination. Among those undergoing point-of care testing, 11/105 tested (10.5%) had hypoglycaemia, 9/103 (8.7 %) were malaria positive, 17/30 (56.7%) had positive urine dipstick testing, and 5/26 tested (19.2%) were HIV positive. Laboratory-based tests included CBC and chemistry (each performed in 95.2%), VBG (56.2%), CSF (5.7%), blood culture (5.7%), urine culture (10.5%), CSF culture (1.9%), and CXR of chest (25.7%) and abdomen (3.8%). Interventions included antibiotics (70%), antimalarial (12%), IV fluids (54%), and antipyretics (41%). Top ED diagnoses included malaria (24.3%), pneumonia (15.2%), septicaemia (9.5%), urinary tract infections (7.6%), acute watery diarrhoea with dehydration (6.7%), meningitis (4.8%), anaemia (4.8%), skin and soft tissue infections (4.8%), bowel obstructions (3.8%), and pulmonary tuberculosis, sickle cell disease, and hepatitis (2.9% each). Laboratory-based tests were often abnormal; culture results were often unavailable; Conclusion: A wide range of presentations and management were documented. There was a high rate of positive diagnostic test results. Malaria and pneumonia were top diagnoses, but a wide range of infections were diagnosed

The systemic inflammatory response syndrome as a predictor of mortality among febrile children in the emergency department

Sepsis is defined as a known or suspected infection in a patient with elements of the systemic inflammatory response syndrome (SIRS). Septic patients present with a variety of clinical manifestations, but temperature dysregulation, tachycardia, tachypnoea, and an abnormal white blood cell (WBC) count are considered cardinal components of SIRS. We investigated the predictive value of SIRS criteria for in-hospital mortality among febrile children under 5 years old presenting to the Emergency Department (ED) at Muhimbili National Hospital in Dar es Salam, Tanzania. Methods: This was a descriptive cohort study of febrile children under 5 years, presenting to our ED. Providers prospectively completed a standardized data sheet. Outcome data was obtained from hospital records and telephone follow-up. Study data were entered into Excel (Microsoft, Redmond, WA, USA) and analysed in SAS 9.3 (Cary, North Carolina, USA). Results: We enrolled 105 patients between August and November 2012. The median age was 14 months, with 80% over 6 months old, and 63.8% were male. 57 (54.3%) children were referred from outside facilities. The overall mortality rate was 19%, and 90% of children who died had  ⩾ 2 SIRS criteria. Mortality in children with ⩾2 SIRS criteria (in addition to fever) was significantly higher (27.7% versus 5%) than in those with 0–1 SIRS criteria, and children with fever and  > 2 SIRS criteria were seven times more likely to die (OR 7.05, p = 0.01). 85 children were discharged from the hospital, and of the 64 (75.3%) children we were able to reach after discharge, all were alive at 14 day telephone follow-up. 19/85 children who survived to hospital discharge were lost to follow up. Conclusion: SIRS criteria may be helpful to predict febrile children at high risk of mortality. Further studies are needed to validate these findings in larger cohorts