Kristina Keitel

• Swiss Tropical and Public Health Institute

Background In response to the challenges faced by emergency departments (ED), including overcrowding and high patient volumes, Fast Track (FT) systems are designed to optimize patient flow, yet their implementation and impact in Switzerland remain understudied. Our study provides a comprehensive description of Fast Track (FT) processes across both...

Digital clinical decision support tools have contributed to improved quality of care at primary care level health facilities. However, data from real-world randomized trials are lacking. We conducted a cluster randomized, open-label trial in Tanzania evaluating the use of a digital clinical decision support algorithm (CDSA), enhanced by point-of-ca...

Background Mycoplasma pneumoniae is a major cause of community-acquired pneumonia (CAP) in school-aged children. Macrolides are the first-line treatment for this infection. However, it is unclear whether macrolides are effective in treating M. pneumoniae CAP, mainly due to limitations in microbiological diagnosis of previous studies. The extensive...

Background Lower respiratory tract infections (LRTIs), particularly pneumonia, are a leading cause of morbidity and mortality among children worldwide, especially in low-resource settings. The World Health Organization (WHO) Integrated Management of Childhood Illness (IMCI) guidelines currently recommend antibiotic treatment for all case of with pn...

Introduction: Lower respiratory tract infections, including pneumonia, are one of the leading causes of child mortality, especially in low-resource settings. Current guidelines rely on clinical signs for diagnosis, leading to over-prescription of antibiotics, which in turn contribute to antimicrobial resistance. Lung point of care ultrasound (L-POC...

Effective and sustainable strategies are needed to address the burden of preventable deaths among children under-five in resource-constrained settings. The Tools for Integrated Management of Childhood Illness (TIMCI) project aims to support healthcare providers to identify and manage severe illness, whilst promoting resource stewardship, by introdu...

Digital clinical decision support tools have contributed to improved quality of care at primary care level health facilities. However, data from real-world randomized trials are lacking. We conducted a cluster randomized, open-label trial in Tanzania evaluating the use of a digital clinical decision support algorithm (CDSA), enhanced by point-of-ca...

Early recognition of children at risk of serious illness is essential in preventing morbidity and mortality, particularly in low- and middle-income countries (LMICs). This study aimed to validate the Emergency Department-Paediatric Early Warning Score (ED-PEWS) for use in acute care settings in LMICs. This observational study is based on previously...

Large language and multimodal models (LLMs and LMMs) will transform access to medical knowledge and clinical decision support. However, the current leading systems fall short of this promise, as they are either limited in scale, which restricts their capabilities, closed-source, which limits the extensions and scrutiny that can be applied to them,...

Excessive antibiotic use and antimicrobial resistance are major global public health threats. We developed ePOCT+, a digital clinical decision support algorithm in combination with C-reactive protein test, hemoglobin test, pulse oximeter and mentorship, to guide health-care providers in managing acutely sick children under 15 years old. To evaluate...

Background Improved tools are required to detect bacterial infection in children with fever without source (FWS), especially when younger than 3 years old. The aim of the present study was to investigate the diagnostic accuracy of a host signature combining for the first time two viral-induced biomarkers, tumor necrosis factor-related apoptosis-ind...

Clinical decision support systems (CDSSs) can strengthen the quality of integrated management of childhood illness (IMCI) in resource-constrained settings. Several IMCI-related CDSSs have been developed and implemented in recent years. Yet, despite having a shared starting point, the IMCI-related CDSSs are markedly varied due to the need for interp...

Clinical Decision Support Systems (CDSS) have the potential to improve and standardise care with probabilistic guidance. However, many CDSS deploy static, generic rule-based logic, resulting in inequitably distributed accuracy and inconsistent performance in evolving clinical environments. Data-driven models could resolve this issue by updating pre...

Excessive antibiotic use and antimicrobial resistance are major global public health threats. We developed ePOCT+, a digital Clinical Decision Support Algorithm in combination with C-reactive protein test, haemoglobin test, pulse oximeter and mentorship, to guide healthcare providers in managing acutely sick children under 15 years old. To evaluate...

Aims of the study: Globally, since the introduction of conjugate-vaccines against encapsulated bacteria, respiratory viruses have caused most hospitalisations for community-acquired pneumonia. The aim of this study was to describe pathogens detected and their association with clinical findings in Switzerland. Methods: Baseline data were analysed...

Electronic clinical decision support algorithms (CDSAs) have been developed to address high childhood mortality and inappropriate antibiotic prescription by helping clinicians adhere to guidelines. Previously identified challenges of CDSAs include their limited scope, usability, and outdated clinical content. To address these challenges we develope...

Electronic clinical decision support algorithms (CDSAs) have been developed to address high childhood mortality and inappropriate antibiotic prescription by helping clinicians adhere to guidelines. Previously identified challenges of CDSAs include its limited scope, usability, and outdated clinical algorithms. To address these challenges we develop...

Background Clinical Decision Support Systems (CDSS) have the potential to improve and standardise care with probabilistic guidance. However, many CDSS deploy static, generic rule-based logic, resulting in inequitably distributed accuracy and inconsistent performance in evolving clinical environments. Data-driven models could resolve this issue by u...

Aim: To provide insight in the primary health care (PHC) case management of febrile children under-five in Dar es Salaam, and to identify areas for improving quality of care. Methods: We used data from the routine care arm of the ePOCT trial, including children aged 2–59 months who presented with an acute febrile illness to two health centers in Da...

Viral infections are the leading cause of childhood acute febrile illnesses motivating consultation in sub-Saharan Africa. The majority of causal viruses are never identified in low-resource clinical settings as such testing is either not part of routine screening or available diagnostic tools have limited ability to detect new/unexpected viral var...

Introduction Early identification of children at risk of severe febrile illness can optimise referral, admission and treatment decisions, particularly in resource-limited settings. We aimed to identify prognostic clinical and laboratory factors that predict progression to severe disease in febrile children presenting from the community. Methods We...

Background: Viral infections are the leading cause of childhood acute febrile illnesses motivating consultation in sub-Saharan Africa. The majority of causal viruses are never identified in low-resource clinical settings as such testing is either not part of routine screening or available diagnostic tools have limited ability to detect new/unexpect...

Background Low-density (LD) Plasmodium infections are missed by standard malaria rapid diagnostic tests (standard mRDT) when the blood antigen concentration is below the detection threshold. The clinical impact of these LD infections is unknown. This study investigates the clinical presentation and outcome of untreated febrile children with LD infe...

Children with malnutrition compared with those without are at higher risk of infection, with more severe outcomes. How clinicians assess nutritional risk factors in febrile children in primary care varies. We conducted a post hoc subgroup analysis of febrile children with severe malnutrition enrolled in a randomized, controlled trial in primary car...

Background: The safety and efficacy of using C-reactive protein (CRP) to decide on antibiotic prescription among febrile children at risk of pneumonia has not been tested. Methods: This was a randomized (1:1) controlled noninferiority trial in 9 primary care centers in Tanzania (substudy of the ePOCT trial evaluating a novel electronic decision...

Background: Health-workers in developing countries rely on clinical algorithms, such as the Integrated Management of Childhood Illnesses (IMCI), for the management of patients, including diagnosis of serious bacterial infections (SBI). The diagnostic accuracy of IMCI in detecting children with SBI is unknown. Prediction rules and guidelines for SB...

Metagenomic approaches enable an open exploration of microbial communities without requiring a priori knowledge of a sample's composition by shotgun sequencing the total RNA or DNA of the sample. Such an approach is valuable for exploratory diagnostics of novel pathogens in clinical practice. Yet, one may also identify surprising off-target finding...

Fever is the leading cause of paediatric outpatient consultations in Sub-Saharan Africa. Although most are suspected to be of viral origin, a putative causative pathogen is not identified in over a quarter of these febrile episodes. Using a de novo assembly sequencing approach, we report the detection (15.4%) of dicistroviruses (DicV) RNA in sera c...

Introduction: Global health research is hampered by the lack of inexpensive and reliable assays to annotate clinical study cohorts for geographically localized endemic genetic disorders. The most prevalent modifier in Africa is sickle cell disease (SCD, HbSS). In SCD, sickling of erythrocytes by polymerization of hemoglobin S (HbS) causes vaso-occl...

Background: A novel ultra-sensitive malaria RDT (us-RDT) has been developed for improved active P.falciparum case detection. The utility of this us-RDT in clinical diagnosis and fever management has not been evaluated to date. Methods: Diagnostic performance of us-RDT was compared retrospectively to conventional RDT (co-RDT) in 3000 children and...

Background: The lack of effective, integrated diagnostic tools pose a major challenge to the primary care management of febrile childhood illnesses. These limitations are especially evident in low-resource settings and are often inappropriately compensated by antimicrobial over-prescription. Interactive electronic decision trees (IEDTs) have the p...

Background The management of childhood infections remains inadequate in resource-limited countries, resulting in high mortality and irrational use of antimicrobials. Current disease management tools, such as the Integrated Management of Childhood Illness (IMCI) algorithm, rely solely on clinical signs and have not made use of available point-of-car...

Statistical analysis plan. (PDF)

Flowchart of literature search results and included publications. (PDF)

Literature search terms. (DOCX)

Mantel–Haenszel estimates of the effect of clinician and health center on primary and secondary outcome measures (randomized study). (DOCX)

Detailed description and discussion of the methods and evidence used for the development of the e-POCT algorithm. (DOCX)

Schematic representation of ALMANACH algorithm. (PDF)

Days to resolution of fever (e-POCT arm and routine care cohort). (TIF)

Primary and secondary study outcomes for randomized study (intention-to-treat population). (DOCX)

Mixed effects logistic regression (randomized study). (DOCX)

Primary and secondary study outcome comparisons between the e-POCT arm and the routine care cohort (intention-to-treat population). (DOCX)

Recommendations for the management of community-acquired pneumonia (CAP) advocate that, in the absence of the clinical and laboratory findings typical of bacterial CAP, antibiotics are not required. However, the true value of the clinical and laboratory predictors of pediatric CAP still needs to be assessed. This prospective cohort study in three e...

Our study is the first to compare the nasopharyngeal microbiota of pediatric pneumonia patients and control children by 454 pyrosequencing. A distinct microbiota was associated with different pneumonia etiologies. Viral pneumonia was associated with a high abundance of the operational taxonomic unit (OTU) corresponding to Moraxella lacunata. Patien...

Despite various efforts to estimate cost-effectiveness of pneumococcal conjugate vaccines, only scarce information on the cost burden of paediatric community acquired pneumonia (CAP) exists. The objective of this study was to prospectively calculate direct and indirect costs associated with treatment of CAP from a society perspective in children be...

Community-acquired pneumonia (CAP) is a serious cause of morbidity among children in developed countries. The real impact of 7-valent pneumococcal conjugate vaccine (PCV7) on pneumococcal pneumonia is difficult to assess accurately. Children aged <=16years with clinical and radiological pneumonia were enrolled in a multicenter prospective study. Ch...

Unlabelled: Rapid tests for diagnosis of influenza are valuable assets in the management of influenza in pediatric patients. However, test performance fluctuates with virus subtypes. We assessed the test characteristics of Influenzatop®, a rapid immunochromatographic influenza A and B test, in detecting pandemic 2009 influenza A (H1N1) in children...