Intended for healthcare professionals

Clinical Review

Management of adolescents and adults with febrile illness in resource limited areas

BMJ 2011; 343 doi: (Published 08 August 2011) Cite this as: BMJ 2011;343:d4847
  1. John A Crump, associate professor of medicine and pathology1234,
  2. Sandy Gove, team leader5,
  3. Christopher M Parry, senior clinical consultant67
  1. 1Division of Infectious Diseases and International Health, Department of Medicine, and Department of Pathology, Duke University, Durham, NC 27710, USA
  2. 2Duke Global Health Institute, Duke University, Durham, NC, USA
  3. 3Kilimanjaro Christian Medical Centre, Moshi, Tanzania
  4. 4Kilimanjaro Christian Medical College, Tumaini University, Moshi, Tanzania
  5. 5Integrated Management of Adolescent and Adult Illness (IMAI), World Health Organization, Department of HIV/AIDS, Geneva, Switzerland
  6. 6Wellcome Trust Major Overseas Programme, Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
  7. 7Angkor Hospital for Children, Siem Reap, Cambodia
  1. Correspondence to: J A Crump john.crump{at}

Summary points

  • Overlap in the clinical features of febrile illnesses and limited laboratory services make the management of febrile patients in resource limited settings challenging

  • WHO guidelines for managing febrile adolescents and adults in resource limited settings are available for first level health facilities and are forthcoming for district hospitals

  • First level health facility guidelines recommend antimalarials for those with a positive malaria diagnostic test, antibacterials for those with signs of severe illness or specific bacterial infections, and hospital referral of those with severe illness or no apparent diagnosis

  • Management guidelines should be validated, locally adapted, and improved on the basis of local or national surveillance data and sentinel hospital studies

  • Malaria, tuberculosis, and HIV diagnostic tests can enhance management by ruling out a specific illness or by directing towards a particular diagnosis

  • Clinical trials of empirical treatment strategies and advocacy for better clinical laboratory services could help improve management guidelines and patient outcomes

Fever is common among adolescents and adults seeking healthcare in low income countries; in this setting, case fatality rates are often high and the range of potential infectious and non-infectious causes is broad (table 1).1 2 These differences, combined with limited resources, mean that management guidelines developed for high income countries cannot readily be adapted to resource limited areas. It is often difficult to establish a diagnosis from the clinical history and physical examination alone because a range of diseases share similar clinical features. The diagnostic problem may be compounded by limited laboratory capacity for diagnostic testing.3 There may be limited or no laboratory services available; laboratory services may be prohibitively expensive for users; concerns may exist regarding the quality of results; and practical reliable diagnostic tests may not have been developed for some infections of local importance. When clinical and laboratory evaluations do …

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