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WHO guidelines for antimicrobial treatment in children admitted to hospital in an area of intense Plasmodium falciparum transmission: prospective study

BMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c1350 (Published 30 March 2010) Cite this as: BMJ 2010;340:c1350

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Comments from a reader

Dear Editor:

I have read the article: “WHO guidelines for antimicrobial treatment
in children admitted to hospital in an area of intense Plasmodium
falciparum transmission: prospective study” and I can say how my reactions
fluctuated from uncertainty to sadness to hope. Sadly, malaria is endemic
to 106 nations (Finkel, 2007) and it has been overlooked for many, many
years. While preventable, these countries seem to be losing the battle
against the Anopheles mosquito. The paper highlights the need to consider
particular applications.

Nadjm paper’s contains a powerful conclusion that suggests that WHO
guidelines must be re-examined, specifically if they are to be implemented
in African countries. The drug resistant bacterial infection which can be
associated with other tropical infections e.g. non-typhoidal salmonellae
(Maitland, 2010) must be treated differently and Nagjm’s research strongly
recommends the use of third generation antibiotics instead of “routine”
medications commonly used to treat the disease. Nevertheless, I do have
few questions:

• Should a single research paper spark re-examinations of WHO
standards?

• Is it possible to replicate Nagjm’s research in other African countries,
e.g. Zambia, to validate its findings and suggestions?

• It is not clear which guidelines is Nadjm referring to: 2006 or 2010,
which can cause some confusion for the reader.

• Is Nadjm recommending re-examination of a specific aspect of the
guidelines, or is it the revision of the complete document?

Notwithstanding the foregoing questions, the paper represents the
type of research that can foster evidenced-based interventions and it
embodies the concern and passion of the health team for improving health
outcomes for patients. This paper is a useful example of the type of the
regionally focused research that should be undertaken with other WHO
guidelines.

Lourdes Parada-Webster

References

1- Finkel, M. (2007) Bedlam in the Blood Malaria. National Geographic
Magazine; 212:1

2- Maitland, K. (2010) Antimicrobials in children admitted to
hospital in malaria endemic areas. BMJ 2010;340:c1818

3- Management of the Child with a Serious Infection or Severe
Malnutrition - Guidelines for Care at the First-Referral Level in
Developing Countries. Retrieved may 29, 2010 from:

http://helid.desastres.net/en/d/Jwho89e/12.1.1.html#Jwho89e.12.1.1

4- Nadjm B, Amos B, Mtove G et al (2010) WHO guidelines for
antimicrobial treatment in children admitted to hospital in an area of
intense Plasmodium falciparum transmission: prospective study. BMJ
2010;340:c1350

5- Treatment of Malaria (Guidelines for Clinicians) Retrieved may 29,
2010 from:
http://www.rollbackmalaria.org/toolbox/tool_TreatmentGuidanceCDC.html

6- UNICEF Provides 1,000 ITNs to Help Combat Malaria Outbreak in
Jamaica. Retrieved may 29, 2010 from:
http://www.medindia.net/news/view_news_main.asp?x=17280

Competing interests:
None declared

Competing interests: No competing interests

04 June 2010
Lourdes M. Parada-Webster
Assistant Lecturer
University of the West Indies, Kingston, Jamaica

WHO guideline, antimicrobial treatment, drug resistance, malaria and future direction

Editor, I read the publication by Nadjm et al. with a great interest
[1]. Nadjm et al. give a very interesting conclusion that "In an area
exposed to high transmission of malaria, current WHO guidelines failed to
identify almost a third of children with invasive bacterial disease, and
more than half of the organisms isolated were not susceptible to currently
recommended antimicrobials. Improved diagnosis and treatment of invasive
bacterial disease are needed to reduce childhood mortality [1]." I agree
the problem of the drug resistant bacterial infection can be seen in the
area with high incidence of malaria. However, the question if whether the
high prevalence of drug resistant bacterial infection is due to the
improper usage or wide usage of antimalarial drug. Indeed, the area with
high prevalence of malaria usually has the problem of other tropical
infections including several bacterial diseases. The problem in bacterial
disease treatment might be independantly relateing to malaria treatment.
For sure, the application of basic rule "identification of pathogen then
give proper drug" should be applied as Nadjm et al.' note.

References
1. Nadjm B, Amos B, Mtove G et al . WHO guidelines for antimicrobial
treatment in children admitted to hospital in an area of intense
Plasmodium falciparum transmission: prospective study. BMJ 2010; 340:
c1350

Competing interests:
None declared

Competing interests: No competing interests

21 April 2010
professor viroj wiwanitkit
physician, director
wiwanitkit house, bangkhae, bangkok thailand 10160
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