Objectives: To determine how well antibiotic treatment is targeted by simple c linical syndromes and to what extent drug resistance threatens affordable antibi otics. Design: Observational study involving a priori definition of a hierarchy of syndromic indications for antibiotic therapy derived from World Health Organi zation integrated management of childhood illness and inpatient guidelines and a pplication of these rules to a prospectively collected dataset. Setting: Kilifi District Hospital, Kenya. Participants: 11 847 acute paediatric admissions. Main outcome measures: Presence of invasive bacterial infection (bacteraemia or meni ngitis) or Plasmodium falciparum parasitaemia; antimicrobial sensitivities of is olated bacteria. Results: 6254 (53%) admissions met criteria for syndromes requ iring antibiotics (sick young infants; meningitis/ encephalopathy; severe malnut rition; very severe, severe, or mild pneumonia; skin or soft tissue infection): 672 (11%) had an invasive bacterial infection (80%of all invasive bacterial in fections identified), and 753 (12%)-died (93%of all inpatient deaths). Among P falciparum infected children with a syndromic indication for parenteral antibi otics, an invasive bacterial infection was detected in 4.0-8.8%. For the syndr ome of meningitis/encephalopathy, 96/123 (76%) isolates were fully sensitive in vitro to penicillin or chloramphenicol. Conclusions: Simple clinical syndromes effectively target children admitted with invasive bacterial infection and those at risk of death. Malaria parasitaemia does not justify withholding empirical p arenteral antibiotics. Lumbar puncture is critical to the rational use of antibi otics.
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