Factors Associated with Prolonged Hospital Length of Stay in Adults with Imported Falciparum Malaria-An Observational Study from a Tertiary Care University Hospital in Berlin, Germany

Outcome of falciparum malaria is largely influenced by the standard of care provided, which in turn depends on the available medical resources. Worldwide, the COVID-19 pandemic has had a major impact on the availability of these resources, even in resource-rich healthcare systems such as Germany's. The present study aimed to determine the under-explored factors associated with hospital length of stay (LOS) in imported falciparum malaria to identify potential targets for improving management. This retrospective observational study used multivariate Cox proportional hazard regression with time to discharge as an endpoint for adults hospitalized between 2001 and 2015 with imported falciparum malaria in the Charite University Hospital, Berlin. The median LOS of the 535 cases enrolled was 3 days (inter-quartile range, IQR, 3-4 days). The likelihood of being discharged by day 3 strongly decreased with severe malaria (hazard ratio, HR, 0.274; 95% Confidence interval, 95%CI: 0.190-0.396) and by 40% with each additional presenting complication (HR, 0.595; 95%CI: 0.510-0.694). The 55 (10.3%) severe cases required a median LOS of 7 days (IQR, 5-12 days). In multivariate analysis, occurrence of shock (adjusted HR, aHR, 0.438; 95%CI 0.220-0.873), acute pulmonary oedema or acute respiratory distress syndrome (aHR, 0.450; 95%CI: 0.223-0.874), and the need for renal replacement therapy (aHR, 0.170; 95%CI: 0.063-0.461) were independently associated with LOS. All patients survived to discharge. This study illustrates that favourable outcomes can be achieved with high-standard care in imported falciparum malaria. Early recognition of disease severity together with targeted supportive care can lead to avoidance of manifest organ failure, thereby potentially decreasing LOS and alleviating pressure on bed capacities.