Clinical profiles and predictors of intensive care unit transfer among children hospitalized with severe Plasmodium falciparum malaria in a tertiary care hospital in Libreville, Gabon: a retrospective study

BACKGROUND: Severe Plasmodium falciparum malaria remains a major cause of paediatric morbidity in sub-Saharan Africa. While mortality has declined in many settings, severe disease requiring escalation of care persists. Data on predictors of intensive care unit (ICU) transfer among children with severe malaria remain limited in Central Africa. This study aimed to describe the clinical and biological profiles of paediatric severe malaria in an urban Gabonese setting and to identify factors associated with ICU transfer as an early marker of clinical deterioration. METHODS: A retrospective analytical study was conducted at the Centre Hospitalier Universitaire Mère-Enfant Fondation Jeanne Ebori (CHUMEFJE) in Libreville, Gabon. Medical records of children below 17 years and hospitalised between January 2021 and July 2022 with microscopically confirmed P. falciparum malaria were reviewed. Severe malaria was defined according to WHO 2014 criteria. ICU transfer among survivors was the primary adverse outcome. Clinical, laboratory, and demographic variables were analysed using univariate and multivariable logistic regression. A cumulative count of WHO severe malaria criteria was used as an indicator of disease severity. RESULTS: Among 3.009 hospitalised children, 480 (15.9%) met WHO criteria for severe malaria and were included. The median age was 6 [1-10] years. Overall mortality was low (0.7%), while 8.5% (n = 41) required ICU transfer. Neurological manifestations (64.2%) predominated, particularly prostration (49.2%), impaired consciousness (10.8), and coma (4.2%). ICU transfer was significantly associated with delayed consultation (p = 0.01) and neurological signs (p < 0.01). In multivariable analysis, impaired consciousness (aOR: 14.86; 95%IC [5.58-42.40], p < 0.01) and coma (aOR: 53.3; 95%IC [10.9-178.1], p < 0.01) remained the strongest independent predictors of ICU transfer, whereas isolated biological abnormalities such as severe anaemia or hyperparasitaemia were not. The risk of ICU transfer increased markedly with the number of concurrent severe malaria criteria, especially beyond three criteria (aOR: 10.59; 95%IC [2.38-42.87], p < 0.01). CONCLUSION: ICU transfer was frequent and primarily driven by neurological and accumulated severity features. Assessing the number of concurrent WHO criteria offers a pragmatic tool for risk stratification. Although conducted in a referral centre capturing the city's transmission heterogeneity, multicentre studies are needed to validate these predictors across diverse healthcare systems. CLINICAL TRIAL NUMBER: Not applicable.