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Cui K, Feng S, Mao Y, Luo H, Yang J, Xu R, Bai L. The association between blood urea nitrogen to albumin ratio and the 28 day mortality in tuberculosis patients complicated by sepsis. Sci Rep 2024; 14:16430. [PMID: 39013924 PMCID: PMC11252304 DOI: 10.1038/s41598-024-65622-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Accepted: 06/21/2024] [Indexed: 07/18/2024] Open
Abstract
The relationship between blood urea nitrogen to albumin ratio (BAR) and the prognosis of patients with tuberculosis (TB) complicated by sepsis remains unclear. This study aimed to explore the association between BAR and overall patient prognosis. This was a retrospective cohort study of patients with TB complicated by sepsis who were admitted to the intensive care unit (ICU) of the Public Health Clinical Center of Chengdu between January 2019 and February 2023. The relationship between BAR values and prognosis in these patients was investigated using multivariate Cox regression, stratified analysis with interaction, restricted cubic spline (RCS), and threshold effect analysis. Sensitivity analyses were conducted to assess the robustness of the results. Our study included 537 TB patients complicated by sepsis admitted in the ICU, with a median age of 63.0 (48.0, 72.0) years; 76.7% of whom were men. The multivariate-restricted cubic spline analysis showed a non-linear association between BAR and patient prognosis. In the threshold analysis, we found that TB patients complicated by sepsis and a BAR < 7.916 mg/g had an adjusted hazard ratio (HR) for prognosis of 1.163 (95% CI 1.038-1.303; P = 0.009). However, when the BAR was ≥ 7.916 mg/g, there was no significant increase in the risk of death. The results of the sensitivity analysis were stable.
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Affiliation(s)
- Kunping Cui
- Center of Infectious Diseases, West China Hospital of Sichuan University, Chengdu, 610041, Sichuan, China
| | - Shuang Feng
- Ultrasonic Medicine, Public Health Clinical Center of Chengdu, Chengdu, 610000, Sichuan, China
| | - Yi Mao
- Intensive Care Unit, Public Health Clinical Center of Chengdu, Chengdu, 610000, Sichuan, China
| | - Haixia Luo
- Intensive Care Unit, Public Health Clinical Center of Chengdu, Chengdu, 610000, Sichuan, China
| | - Jiao Yang
- Intensive Care Unit, Public Health Clinical Center of Chengdu, Chengdu, 610000, Sichuan, China
| | - Ruyi Xu
- Center of Infectious Diseases, West China Hospital of Sichuan University, Chengdu, 610041, Sichuan, China
| | - Lang Bai
- Center of Infectious Diseases, West China Hospital of Sichuan University, Chengdu, 610041, Sichuan, China.
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2
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Spencer SA, Malowa F, McCarty D, Joekes E, Phulusa J, Chinoko B, Kaimba S, Keyala L, Mandala P, Mkandawire M, Mlongoti M, Mnesa B, Mukatipa A, Mijumbi R, Nyirenda M, Sawe HR, Henrion M, Augustine DX, Oxborough D, Worrall E, Limbani F, Dark P, Gordon SB, Rylance J, Morton B. Causes, outcomes and diagnosis of acute breathlessness hospital admissions in Malawi: protocol for a multicentre prospective cohort study. Wellcome Open Res 2024; 9:205. [PMID: 39157428 PMCID: PMC11327656 DOI: 10.12688/wellcomeopenres.21041.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/28/2024] [Indexed: 08/20/2024] Open
Abstract
Background Hospital admission due to breathlessness carries a significant burden to patients and healthcare systems, particularly impacting people in low-income countries. Prompt appropriate treatment is vital to improve outcomes, but this relies on accurate diagnostic tests which are of limited availability in resource-constrained settings. We will provide an accurate description of acute breathlessness presentations in a multicentre prospective cohort study in Malawi, a low resource setting in Southern Africa, and explore approaches to strengthen diagnostic capacity. Objectives Primary objective: Delineate between causes of breathlessness among adults admitted to hospital in Malawi and report disease prevalence. Secondary objectives : Determine patient outcomes, including mortality and hospital readmission 90 days after admission; determine the diagnostic accuracy of biomarkers to differentiate between heart failure and respiratory infections (such as pneumonia) including brain natriuretic peptides, procalcitonin and C-reactive protein. Methods This is a prospective longitudinal cohort study of adults (≥18 years) admitted to hospital with breathlessness across two hospitals: 1) Queen Elizabeth Central Hospital, Blantyre, Malawi; 2) Chiradzulu District Hospital, Chiradzulu, Malawi. Patients will be consecutively recruited within 24 hours of emergency presentation and followed-up until 90 days from hospital admission. We will conduct enhanced diagnostic tests with robust quality assurance and quality control to determine estimates of disease pathology. Diagnostic case definitions were selected following a systematic literature search. Discussion This study will provide detailed epidemiological description of adult hospital admissions due to breathlessness in low-income settings, which is currently poorly understood. We will delineate between causes using established case definitions and conduct nested diagnostic evaluation. The results have the potential to facilitate development of interventions targeted to strengthen diagnostic capacity, enable prompt and appropriate treatment, and ultimately improve both patient care and outcomes.
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Affiliation(s)
- Stephen A. Spencer
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Southern Region, Malawi
- Queen Elizabeth Central Hospital, Blantyre, Southern Region, Malawi
| | - Florence Malowa
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Southern Region, Malawi
| | - David McCarty
- Queen Elizabeth Central Hospital, Blantyre, Southern Region, Malawi
- The Kamuzu University of Health Sciences, Blantyre, Southern Region, Malawi
| | - Elizabeth Joekes
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Jacob Phulusa
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Southern Region, Malawi
| | - Beatrice Chinoko
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Southern Region, Malawi
| | - Sylvester Kaimba
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Southern Region, Malawi
| | - Lucy Keyala
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Southern Region, Malawi
| | - Peter Mandala
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Southern Region, Malawi
| | - Mercy Mkandawire
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Southern Region, Malawi
| | - Matthew Mlongoti
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Southern Region, Malawi
| | - Bright Mnesa
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Southern Region, Malawi
| | - Albert Mukatipa
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Southern Region, Malawi
| | - Rhona Mijumbi
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Southern Region, Malawi
| | - Mulinda Nyirenda
- Queen Elizabeth Central Hospital, Blantyre, Southern Region, Malawi
- The Kamuzu University of Health Sciences, Blantyre, Southern Region, Malawi
| | - Hendry R. Sawe
- Emergency Medicine Department, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Marc Henrion
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Southern Region, Malawi
| | | | - David Oxborough
- Liverpool Centre for Cardiovascular Sciences, Liverpool John Moores University, Liverpool, England, UK
| | - Eve Worrall
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Felix Limbani
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Southern Region, Malawi
| | - Paul Dark
- Humanitarian and Conflict Response Institute, The University of Manchester, Manchester, England, UK
| | - Stephen B. Gordon
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Southern Region, Malawi
- Queen Elizabeth Central Hospital, Blantyre, Southern Region, Malawi
| | - Jamie Rylance
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Ben Morton
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Collaborators
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Southern Region, Malawi
- Queen Elizabeth Central Hospital, Blantyre, Southern Region, Malawi
- The Kamuzu University of Health Sciences, Blantyre, Southern Region, Malawi
- Emergency Medicine Department, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
- Royal United Hospitals Bath NHS Foundation Trust, Bath, England, UK
- Liverpool Centre for Cardiovascular Sciences, Liverpool John Moores University, Liverpool, England, UK
- Humanitarian and Conflict Response Institute, The University of Manchester, Manchester, England, UK
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3
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Chansamouth V, Inlorkham P, Keohavong B, Bellingham K, van Doorn HR, Mayxay M, Newton PN, Turner P, Day NPJ, Ashley EA. Implementing the WHO AWaRe antibiotic book guidance in lower-resource settings: the case of the Lao PDR. JAC Antimicrob Resist 2024; 6:dlae004. [PMID: 38259905 PMCID: PMC10801825 DOI: 10.1093/jacamr/dlae004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2024] Open
Abstract
In 2022, WHO released the WHO AWaRe (Access, Watch, Reserve) antibiotic book to promote the rational use of antibiotics. Here, we review the AWaRe antibiotic book from the perspective of implementation in low-resource settings, using the Lao PDR (Laos) as a case study. Not all recommendations in the AWaRe antibiotic book match the epidemiology of infectious diseases and antimicrobial susceptibility patterns in Laos and other low- and middle-income countries (LMICs), e.g. melioidosis, rickettsial disease and leptospirosis are common causes of sepsis and febrile illness in Laos but do not feature in the AWaRe book. Conversely, some infectious diseases like Clostridioides difficile-associated diarrhoea are in the AWaRe antibiotic book but rarely considered in Laos with no diagnostic tests available. Only 29/39 antibiotics in the AWaRe book are available in Laos, with no Reserve group antimicrobials available. The AWaRe book stimulates countries such as Laos to consider alternative diagnoses and include additional antimicrobials in the national essential medicines list (NEML). However, it should be updated to include regional important pathogens that are not included. Comprehensive antibiotic use guidelines alone might not assure appropriate use or control overuse of antibiotics. Access to antibiotics is challenging in low-resource settings in terms of unavailability in the country (low demand or small market size), patchy access, especially for those living in remote areas, and unaffordability. All these systemic factors can contribute to inappropriate use of antibiotics. Improved access to antibiotics, strengthening diagnostic capacity and promoting antibiotic stewardship should be combined.
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Affiliation(s)
- Vilada Chansamouth
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), Mahosot Hospital, Vientiane, Lao PDR
- Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao PDR
- Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | | | - Khonsavath Bellingham
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), Mahosot Hospital, Vientiane, Lao PDR
| | - H Rogier van Doorn
- Nuffield Department of Medicine, Oxford University Clinical Research Unit, Hanoi, Viet Nam
| | - Mayfong Mayxay
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), Mahosot Hospital, Vientiane, Lao PDR
- Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Institute of Research and Education Development (IRED), University of Health Sciences, Ministry of Health, Vientiane, Lao PDR
| | - Paul N Newton
- Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Paul Turner
- Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Cambodia Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia
| | - Nicholas P J Day
- Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Elizabeth A Ashley
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), Mahosot Hospital, Vientiane, Lao PDR
- Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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4
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Cummings MJ, Bakamutumaho B, Price A, Owor N, Kayiwa J, Namulondo J, Byaruhanga T, Jain K, Postler TS, Muwanga M, Nsereko C, Nayiga I, Kyebambe S, Che X, Sameroff S, Tokarz R, Shah SS, Larsen MH, Lipkin WI, Lutwama JJ, O’Donnell MR. HIV infection drives pro-inflammatory immunothrombotic pathway activation and organ dysfunction among adults with sepsis in Uganda. AIDS 2023; 37:233-245. [PMID: 36355913 PMCID: PMC9780191 DOI: 10.1097/qad.0000000000003410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND The global burden of sepsis is concentrated in high HIV-burden settings in sub-Saharan Africa (SSA). Despite this, little is known about the immunopathology of sepsis in persons with HIV (PWH) in the region. We sought to determine the influence of HIV on host immune responses and organ dysfunction among adults hospitalized with suspected sepsis in Uganda. DESIGN Prospective cohort study. METHODS We compared organ dysfunction and 30-day outcome profiles of PWH and those without HIV. We quantified 14 soluble immune mediators, reflective of key domains of sepsis immunopathology, and performed whole-blood RNA-sequencing on samples from a subset of patients. We used propensity score methods to match PWH and those without HIV by demographics, illness duration, and clinical severity, and compared immune mediator concentrations and gene expression profiles across propensity score-matched groups. RESULTS Among 299 patients, 157 (52.5%) were PWH (clinical stage 3 or 4 in 80.3%, 67.7% with known HIV on antiretroviral therapy). PWH presented with more severe physiologic derangement and shock, and had higher 30-day mortality (34.5% vs. 10.2%; P < 0.001). Across propensity score-matched groups, PWH exhibited greater pro-inflammatory immune activation, including upregulation of interleukin (IL)-6, IL-8, IL-15, IL-17 and HMGB1 signaling, with concomitant T-cell exhaustion, prothrombotic pathway activation, and angiopoeitin-2-related endothelial dysfunction. CONCLUSIONS Sepsis-related organ dysfunction and mortality in Uganda disproportionately affect PWH, who demonstrate exaggerated activation of multiple immunothrombotic and metabolic pathways implicated in sepsis pathogenesis. Further investigations are needed to refine understanding of sepsis immunopathology in PWH, particularly mechanisms amenable to therapeutic manipulation.
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Affiliation(s)
- Matthew J. Cummings
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
- Center for Infection and Immunity, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Barnabas Bakamutumaho
- Department of Arbovirology, Emerging and Re-emerging Infectious Diseases, Uganda Virus Research Institute, Entebbe, Uganda
- Immunizable Diseases Unit, Uganda Virus Research Institute, Entebbe, Uganda
| | - Adam Price
- Center for Infection and Immunity, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Nicholas Owor
- Department of Arbovirology, Emerging and Re-emerging Infectious Diseases, Uganda Virus Research Institute, Entebbe, Uganda
| | - John Kayiwa
- Department of Arbovirology, Emerging and Re-emerging Infectious Diseases, Uganda Virus Research Institute, Entebbe, Uganda
| | - Joyce Namulondo
- Department of Arbovirology, Emerging and Re-emerging Infectious Diseases, Uganda Virus Research Institute, Entebbe, Uganda
| | - Timothy Byaruhanga
- Department of Arbovirology, Emerging and Re-emerging Infectious Diseases, Uganda Virus Research Institute, Entebbe, Uganda
| | - Komal Jain
- Center for Infection and Immunity, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Thomas S. Postler
- Department of Microbiology and Immunology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Moses Muwanga
- Entebbe General Referral Hospital, Ministry of Health, Entebbe, Uganda
| | | | - Irene Nayiga
- Entebbe General Referral Hospital, Ministry of Health, Entebbe, Uganda
| | - Stephen Kyebambe
- Entebbe General Referral Hospital, Ministry of Health, Entebbe, Uganda
| | - Xiaoyu Che
- Center for Infection and Immunity, Mailman School of Public Health, Columbia University, New York, NY, USA
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Stephen Sameroff
- Center for Infection and Immunity, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Rafal Tokarz
- Center for Infection and Immunity, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Shivang S. Shah
- Division of Infectious Diseases, Department of Pediatrics, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Michelle H. Larsen
- Department of Microbiology and Immunology, Albert Einstein College of Medicine, Bronx, NY, USA
| | - W. Ian Lipkin
- Center for Infection and Immunity, Mailman School of Public Health, Columbia University, New York, NY, USA
- Department of Pathology and Cell Biology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Julius J. Lutwama
- Department of Arbovirology, Emerging and Re-emerging Infectious Diseases, Uganda Virus Research Institute, Entebbe, Uganda
| | - Max R. O’Donnell
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
- Center for Infection and Immunity, Mailman School of Public Health, Columbia University, New York, NY, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
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5
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Lester R, Musicha P, Kawaza K, Langton J, Mango J, Mangochi H, Bakali W, Pearse O, Mallewa J, Denis B, Bilima S, Gordon SB, Lalloo DG, Jewell CP, Feasey NA. Effect of resistance to third-generation cephalosporins on morbidity and mortality from bloodstream infections in Blantyre, Malawi: a prospective cohort study. THE LANCET. MICROBE 2022; 3:e922-e930. [PMID: 36335953 PMCID: PMC9712123 DOI: 10.1016/s2666-5247(22)00282-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 09/13/2022] [Accepted: 09/13/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND The burden of antimicrobial resistance is a major threat to global health; however, prospective clinical outcome data from Africa are scarce. In Malawi, third-generation cephalosporins are the antibiotics of choice in patients admitted to hospital despite a rapid proliferation of resistance to these drugs. We aimed to quantify the effect of resistance to third-generation cephalosporins on mortality and length of hospital stay among patients with bloodstream infections. METHODS We did a prospective cohort study of patients admitted to Queen Elizabeth Central Hospital in Blantyre, Malawi. Patients of all ages who had positive blood cultures for Enterobacterales were included, with the exception of those from the genus Salmonella, and were followed up for 180 days. We characterised blood culture isolates using whole-genome sequencing and used Cox regression models to estimate the effect of resistance to third-generation cephalosporins on length of hospital stay, in-hospital mortality, and survival. FINDINGS Between Jan 31, 2018, and Jan 13, 2020, we recruited 326 patients, from whom 220 (68%) of 326 isolates were resistant to third-generation cephalosporins. The case fatality proportion was 45% (99 of 220) in patients with bloodstream infections that were resistant to third-generation cephalosporins, and 34% (36 of 106) in patients with bloodstream infections that were sensitive to third-generation cephalosporins. Resistance to third-generation cephalosporins was associated with an increased probability of in-hospital mortality (hazard ratio [HR] 1·44, 95% CI 1·02-2·04), longer hospital stays (1·5 days, 1·0-2·0) and decreased probability of discharge alive (HR 0·31, 0·22-0·45). Whole-genome sequencing showed a high diversity of sequence types of both Escherichia coli and Klebsiella pneumoniae. Although isolates associated with death were distributed across clades, we identified three E coli clades (ST410, ST617, and ST648) that were isolated from 14 patients who all died. INTERPRETATION Resistance to third-generation cephalosporins is associated with increased mortality and longer hospital stays in patients with bloodstream infections in Malawi. These data show the urgent need for allocation of resources towards antimicrobial resistance mitigation strategies in Africa. FUNDING Wellcome Trust and Wellcome Asia and Africa Programme.
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Affiliation(s)
- Rebecca Lester
- Malawi-Liverpool Wellcome Research Programme, Kamuzu University of Health Sciences, Blantyre, Malawi; Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK.
| | - Patrick Musicha
- Malawi-Liverpool Wellcome Research Programme, Kamuzu University of Health Sciences, Blantyre, Malawi; Parasites and Microbes Programme, Wellcome Sanger Institute, Hinxton, UK
| | - Kondwani Kawaza
- Department of Paediatrics and Child Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Josephine Langton
- Department of Paediatrics and Child Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - James Mango
- Malawi-Liverpool Wellcome Research Programme, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Helen Mangochi
- Malawi-Liverpool Wellcome Research Programme, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Winnie Bakali
- Malawi-Liverpool Wellcome Research Programme, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Oliver Pearse
- Malawi-Liverpool Wellcome Research Programme, Kamuzu University of Health Sciences, Blantyre, Malawi; Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Jane Mallewa
- Department of Medicine, Kamuzu University of Health Sciences, Blantyre, Malawi; Department of Medicine, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Brigitte Denis
- Malawi-Liverpool Wellcome Research Programme, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Sithembile Bilima
- Malawi-Liverpool Wellcome Research Programme, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Stephen B Gordon
- Malawi-Liverpool Wellcome Research Programme, Kamuzu University of Health Sciences, Blantyre, Malawi; Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - David G Lalloo
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Christopher P Jewell
- Centre for Health Informatics, Computing and Statistics, Lancaster University, Lancaster, UK
| | - Nicholas A Feasey
- Malawi-Liverpool Wellcome Research Programme, Kamuzu University of Health Sciences, Blantyre, Malawi; Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
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6
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Blair PW, Kobba K, Kakooza F, Robinson ML, Candia E, Mayito J, Ndawula EC, Kandathil AJ, Matovu A, Aniku G, Manabe YC, Lamorde M. Aetiology of hospitalized fever and risk of death at Arua and Mubende tertiary care hospitals in Uganda from August 2019 to August 2020. BMC Infect Dis 2022; 22:869. [PMID: 36411415 PMCID: PMC9680122 DOI: 10.1186/s12879-022-07877-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 10/17/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Epidemiology of febrile illness in Uganda is shifting due to increased HIV treatment access, emerging viruses, and increased surveillance. We investigated the aetiology and outcomes of acute febrile illness in adults presenting to hospital using a standardized testing algorithm of available assays in at Arua and Mubende tertiary care hospitals in Uganda. METHODS We recruited adults with a ≥ 38.0 °C temperature or history of fever within 48 h of presentation from August 2019 to August 2020. Medical history, demographics, and vital signs were recorded. Testing performed included a complete blood count, renal and liver function, malaria smears, blood culture, and human immunodeficiency virus (HIV). When HIV positive, testing included cryptococcal antigen, CD4 count, and urine lateral flow lipoarabinomannan assay for tuberculosis. Participants were followed during hospitalization and at a 1-month visit. A Cox proportional hazard regression was performed to evaluate for baseline clinical features and risk of death. RESULTS Of 132 participants, the median age was 33.5 years (IQR 24 to 46) and 58.3% (n = 77) were female. Overall, 73 (55.3%) of 132 had a positive microbiologic result. Among those living with HIV, 31 (68.9%) of 45 had at least one positive assay; 16 (35.6%) had malaria, 14 (31.1%) tuberculosis, and 4 (8.9%) cryptococcal antigenemia. The majority (65.9%) were HIV-negative; 42 (48.3%) of 87 had at least one diagnostic assay positive; 24 (27.6%) had positive malaria smears and 1 was Xpert MTB/RIF Ultra positive. Overall, 16 (12.1%) of 132 died; 9 (56.3%) of 16 were HIV-negative, 6 died after discharge. High respiratory rate (≥ 22 breaths per minute) (hazard ratio [HR] 8.05; 95% CI 1.81 to 35.69) and low (i.e., < 92%) oxygen saturation (HR 4.33; 95% CI 1.38 to 13.61) were identified to be associated with increased risk of death. CONCLUSION In those with hospitalized fever, malaria and tuberculosis were common causes of febrile illness, but most deaths were non-malarial, and most HIV-negative participants did not have a positive diagnostic result. Those with respiratory failure had a high risk of death.
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Affiliation(s)
- Paul W Blair
- John Hopkins University School of Medicine Division of Infectious Diseases, Baltimore, MD, USA.
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., 6720A Rockledge Dr., Bethesda, MD, USA.
| | - Kenneth Kobba
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Francis Kakooza
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Matthew L Robinson
- John Hopkins University School of Medicine Division of Infectious Diseases, Baltimore, MD, USA
| | - Emmanuel Candia
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Jonathan Mayito
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Edgar C Ndawula
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Abraham J Kandathil
- John Hopkins University School of Medicine Division of Infectious Diseases, Baltimore, MD, USA
| | | | | | - Yukari C Manabe
- John Hopkins University School of Medicine Division of Infectious Diseases, Baltimore, MD, USA
| | - Mohammed Lamorde
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
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7
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Lewis JM, Mphasa M, Banda R, Beale MA, Heinz E, Mallewa J, Jewell C, Faragher B, Thomson NR, Feasey NA. Colonization dynamics of extended-spectrum beta-lactamase-producing Enterobacterales in the gut of Malawian adults. Nat Microbiol 2022; 7:1593-1604. [PMID: 36065064 PMCID: PMC9519460 DOI: 10.1038/s41564-022-01216-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 07/25/2022] [Indexed: 01/09/2023]
Abstract
Drug-resistant bacteria of the order Enterobacterales which produce extended-spectrum beta-lactamase enzymes (ESBL-Enterobacterales, ESBL-E) are global priority pathogens. Antimicrobial stewardship interventions proposed to curb their spread include shorter courses of antimicrobials to reduce selection pressure but individual-level acquisition and selection dynamics are poorly understood. We sampled stool of 425 adults (aged 16-76 years) in Blantyre, Malawi, over 6 months and used multistate modelling and whole-genome sequencing to understand colonization dynamics of ESBL-E. Models suggest a prolonged effect of antimicrobials such that truncating an antimicrobial course at 2 days has a limited effect in reducing colonization. Genomic analysis shows largely indistinguishable diversity of healthcare-associated and community-acquired isolates, hence some apparent acquisition of ESBL-E during hospitalization may instead represent selection from a patient's microbiota by antimicrobial exposure. Our approach could help guide stewardship protocols; interventions that aim to review and truncate courses of unneeded antimicrobials may be of limited use in preventing ESBL-E colonization.
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Affiliation(s)
- Joseph M Lewis
- Malawi-Liverpool Wellcome Clinical Research Programme, Blantyre, Malawi.
- Liverpool School of Tropical Medicine, Liverpool, UK.
- University of Liverpool, Liverpool, UK.
- Wellcome Sanger Institute, Hinxton, UK.
| | - Madalitso Mphasa
- Malawi-Liverpool Wellcome Clinical Research Programme, Blantyre, Malawi
| | - Rachel Banda
- Malawi-Liverpool Wellcome Clinical Research Programme, Blantyre, Malawi
| | | | - Eva Heinz
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - Jane Mallewa
- Kamuzu University of Health Sciences, Blantyre, Malawi
| | | | | | - Nicholas R Thomson
- Wellcome Sanger Institute, Hinxton, UK
- London School of Hygiene and Tropical Medicine, London, UK
| | - Nicholas A Feasey
- Malawi-Liverpool Wellcome Clinical Research Programme, Blantyre, Malawi
- Liverpool School of Tropical Medicine, Liverpool, UK
- London School of Hygiene and Tropical Medicine, London, UK
| |
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