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Selvam K, Ganapathy T, Najib MA, Khalid MF, Abdullah NA, Harun A, Wan Mohammad WMZ, Aziah I. Burden and Risk Factors of Melioidosis in Southeast Asia: A Scoping Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:15475. [PMID: 36497549 PMCID: PMC9741171 DOI: 10.3390/ijerph192315475] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 11/13/2022] [Accepted: 11/15/2022] [Indexed: 06/17/2023]
Abstract
This scoping review aims to provide a comprehensive overview of human melioidosis in Southeast Asia as well as to highlight knowledge gaps in the prevalence and risk factors of this life-threatening disease using available evidence-based data for better diagnosis and treatment. Preferred Reporting Items for Systematic Review and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) was used as the guideline for this review. The literature search was conducted on 23 March 2022 through two electronic databases (PubMed and Scopus) using lists of keywords referring to the Medical Subject Headings (MeSH) thesaurus. A total of 38 articles related to human melioidosis were included from 645 screened articles. These studies were carried out between 1986 and 2019 in six Southeast Asian countries: Thailand, Cambodia, Malaysia, Myanmar, Singapore, and Vietnam. Melioidosis has been reported with a high disease prevalence among high-risk populations. Studies in Thailand (48.0%) and Cambodia (74.4%) revealed disease prevalence in patients with septic arthritis and children with suppurative parotitis, respectively. Other studies in Thailand (63.5%) and Malaysia (54.4% and 65.7%) showed a high seroprevalence of melioidosis among Tsunami survivors and military personnel, respectively. Additionally, this review documented soil and water exposure, diabetes mellitus, chronic renal failure, thalassemia, and children under the age of 15 as the main risk factors for melioidosis. Human melioidosis is currently under-reported in Southeast Asia and its true prevalence is unknown.
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Affiliation(s)
- Kasturi Selvam
- Institute for Research in Molecular Medicine (INFORMM), Health Campus, Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia
| | - Thanasree Ganapathy
- School of Health Sciences, Health Campus, Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia
| | - Mohamad Ahmad Najib
- Institute for Research in Molecular Medicine (INFORMM), Health Campus, Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia
| | - Muhammad Fazli Khalid
- Institute for Research in Molecular Medicine (INFORMM), Health Campus, Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia
| | - Nor Azlina Abdullah
- Department of Community Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia
| | - Azian Harun
- Department of Medical Microbiology and Parasitology, School of Medical Sciences, Health Campus, Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia
- Hospital Universiti Sains Malaysia, Jalan Raja Perempuan Zainab 2, Kubang Kerian 16150, Kelantan, Malaysia
| | - Wan Mohd Zahiruddin Wan Mohammad
- Department of Community Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia
| | - Ismail Aziah
- Institute for Research in Molecular Medicine (INFORMM), Health Campus, Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia
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Tancharoen L, Pairattanakorn P, Thamlikitkul V, Angkasekwinai N. Epidemiology and Burden of Sepsis at Thailand's Largest University-Based National Tertiary Referral Center during 2019. Antibiotics (Basel) 2022; 11:antibiotics11070899. [PMID: 35884153 PMCID: PMC9312064 DOI: 10.3390/antibiotics11070899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 07/02/2022] [Accepted: 07/04/2022] [Indexed: 11/16/2022] Open
Abstract
Data specific to the epidemiology and burden of sepsis in low- and middle-income countries are limited. This study aimed to determine the epidemiology and burden of adult patients with sepsis at Siriraj Hospital during 2019. Randomly selected adult patients who had blood cultures performed at our center during January−December 2019 were enrolled. A Quick Sepsis-related Organ Failure Assessment (qSOFA) score was used to determine the presence of sepsis. Demographic data and clinical outcome data were collected, and the annual incidence of sepsis or septic shock and death was estimated. Of the 987 subjects who had blood cultures performed, 798 had infections, 341 had sepsis, and 104 had septic shock. The prevalence of sepsis or septic shock was 34.9% among blood cultured patients, and 42.7% among those with infections. The prevalence of septic shock was 30.5% among subjects with sepsis. Approximately 63% of sepsis subjects were hospital-acquired infections. The factors independently associated with 28-day mortality in sepsis were receiving an immunosuppressive agent (adjusted odds ratio [aOR]: 2.37, 95% confidence interval [CI]: 1.27−4.45; p = 0.007), septic shock (aOR: 2.88, 95% CI: 1.71−4.87; p < 0.001), and proven infection (aOR: 2.88, 95% CI: 1.55−5.36; p = 0.001). Receiving appropriate, definitive antibiotic therapy (ABT) was independently associated with lower mortality in sepsis (aOR: 0.50, 95% CI: 0.27−0.93; p = 0.028) and septic shock subjects (aOR: 0.21, 95% CI: 0.06−0.72; p = 0.013). Achievement of mean arterial pressure (MAP) ≥ 65 mmHg (aOR: 0.09, 95% CI: 0.01−0.77; p = 0.028) and urine output ≥ 0.5 mL/kg/h (aOR: 0.15, 95% CI: 0.04−0.51; p = 0.006) were independently associated with lower mortality in septic shock patients. The incidence and mortality of sepsis remains high. Appropriate choice of definitive ABT and achievement of MAP and urine output goals may lower mortality in patients with sepsis or septic shock.
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Zhang K, Zhang X, Ding W, Xuan N, Tian B, Huang T, Zhang Z, Cui W, Huang H, Zhang G. National Early Warning Score Does Not Accurately Predict Mortality for Patients With Infection Outside the Intensive Care Unit: A Systematic Review and Meta-Analysis. Front Med (Lausanne) 2021; 8:704358. [PMID: 34336903 PMCID: PMC8319382 DOI: 10.3389/fmed.2021.704358] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 06/21/2021] [Indexed: 12/29/2022] Open
Abstract
Background: The prognostic value of the national early warning score (NEWS) in patients with infections remains controversial. We aimed to evaluate the prognostic accuracy of NEWS for prediction of in-hospital mortality in patients with infections outside the intensive care unit (ICU). Methods: We searched PubMed, Embase, and Scopus for related articles from January 2012 to April 2021. Sensitivity, specificity, and likelihood ratios were pooled by using the bivariate random-effects model. Overall prognostic performance was summarized by using the area under the curve (AUC). We performed subgroup analyses to assess the prognostic accuracy of NEWS in selected populations. Results: A total of 21 studies with 107,008 participants were included. The pooled sensitivity and specificity of NEWS were 0.71 and 0.60. The pooled AUC of NEWS was 0.70, which was similar to quick sequential organ failure assessment (qSOFA, AUC: 0.70) and better than systemic inflammatory response syndrome (SIRS, AUC: 0.60). However, the sensitivity (0.55) and AUC (0.63) of NEWS were poor in elder patients. The NEWS of 5 was more sensitive, which was a better threshold for activating urgent assessment and treatment. Conclusions: The NEWS had good diagnostic accuracy for early prediction of mortality in patients with infections outside the ICU, and the sensitivity and specificity were more moderate when compared with qSOFA and SIRS. Insufficient sensitivity and poor performance in the elder population may have limitations as an early warning score for adverse outcomes. NEWS should be used for continuous monitoring rather than a single time point predictive tool.
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Affiliation(s)
- Kai Zhang
- Department of Critical Care Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xing Zhang
- Department of Critical Care Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Medical Security Bureau of Yinzhou District, Ningbo, China
| | - Wenyun Ding
- Department of Respiration and Critical Care Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Department of Respiration Medicine, Community Health Service Center, Shanghai, China
| | - Nanxia Xuan
- Department of Critical Care Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Baoping Tian
- Department of Critical Care Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Tiancha Huang
- Department of Critical Care Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Zhaocai Zhang
- Department of Critical Care Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Wei Cui
- Department of Critical Care Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Huaqiong Huang
- Department of Respiration and Critical Care Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Gensheng Zhang
- Department of Critical Care Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
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Aung NM, Nyein PP, Kyi MM, Hanson J. Bacterial Coinfection in Adults With Severe Malaria. Clin Infect Dis 2021; 72:535-536. [PMID: 33527124 DOI: 10.1093/cid/ciaa732] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Ne Myo Aung
- Department of Medicine, Insein General Hospital, Insein Township, Yangon, Myanmar
| | - Phyo Pyae Nyein
- Department of Medicine, Specialist Hospital Mingaladon, Mingaladon Township, Yangon, Myanmar
| | - Mar Mar Kyi
- Department of Medicine, Insein General Hospital, Insein Township, Yangon, Myanmar
| | - Josh Hanson
- Director's Unit, Kirby Institute, University of New South Wales, Sydney, Australia
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Mar Minn M, Aung NM, Kyaw DZ, Zaw TT, Chann PN, Khine HE, McLoughlin S, Kelleher AD, Tun NL, Oo TZC, Myint NPST, Law M, Mar Kyi M, Hanson J. The comparative ability of commonly used disease severity scores to predict death or a requirement for ICU care in patients hospitalised with possible sepsis in Yangon, Myanmar. Int J Infect Dis 2021; 104:543-550. [PMID: 33493689 DOI: 10.1016/j.ijid.2021.01.047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 01/17/2021] [Accepted: 01/19/2021] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES To determine the comparative prognostic utility of commonly used disease prediction scores in adults with presumed community-acquired sepsis in a resource-limited tropical setting. METHODS This prospective, observational study was performed on the medical ward of a tertiary-referral hospital in Yangon, Myanmar. The ability of the National Early Warning Score 2 (NEWS2), quick NEWS (qNEWS), quick Sequential Organ Failure Assessment (qSOFA) score, Universal Vital Assessment (UVA) and Sequential Organ Failure Assessment (SOFA) scores to predict a complicated inpatient course (death or requirement for intensive care unit (ICU) support) in patients with two or more systemic inflammatory response syndrome criteria was determined. RESULTS Among the 509 patients, 30 (6%) were HIV-seropositive. The most commonly confirmed diagnoses were tuberculosis (30/509, 5.9%) and measles (26/509, 5.1%). Overall, 75/509 (14.7%) died or required ICU support. All the scores except the qSOFA score, which was inferior, had a similar ability to predict a complicated inpatient course. CONCLUSIONS In this resource-limited tropical setting, disease severity scores calculated at presentation using only vital signs-such as the NEWS2 score-identified high-risk sepsis patient as well as the SOFA score, which is calculated at 24 h and which also requires laboratory data. Use of these simple clinical scores can be used to facilitate recognition of the high-risk patient and to optimise the use of finite resources.
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Affiliation(s)
- Mar Mar Minn
- Insein General Hospital, Insein Township, Yangon, Myanmar
| | - Ne Myo Aung
- Insein General Hospital, Insein Township, Yangon, Myanmar; University of Medicine 2, North Okkalapa Township, Yangon, Myanmar; Myanmar Australia Research Collaboration for Health (MARCH), Yangon, Myanmar
| | - De Zin Kyaw
- Myanmar Australia Research Collaboration for Health (MARCH), Yangon, Myanmar
| | - Thet Tun Zaw
- Myanmar Australia Research Collaboration for Health (MARCH), Yangon, Myanmar
| | - Pyae Nyein Chann
- Myanmar Australia Research Collaboration for Health (MARCH), Yangon, Myanmar
| | - Hnin Ei Khine
- Myanmar Australia Research Collaboration for Health (MARCH), Yangon, Myanmar
| | | | | | - Ne Lin Tun
- Insein General Hospital, Insein Township, Yangon, Myanmar; University of Medicine 2, North Okkalapa Township, Yangon, Myanmar; Myanmar Australia Research Collaboration for Health (MARCH), Yangon, Myanmar
| | - Thin Zar Cho Oo
- Insein General Hospital, Insein Township, Yangon, Myanmar; University of Medicine 2, North Okkalapa Township, Yangon, Myanmar; Myanmar Australia Research Collaboration for Health (MARCH), Yangon, Myanmar
| | - Nan Phyu Sin Toe Myint
- Insein General Hospital, Insein Township, Yangon, Myanmar; University of Medicine 2, North Okkalapa Township, Yangon, Myanmar; Myanmar Australia Research Collaboration for Health (MARCH), Yangon, Myanmar
| | - Matthew Law
- The Kirby Institute, University of New South Wales, Sydney, Australia
| | - Mar Mar Kyi
- Insein General Hospital, Insein Township, Yangon, Myanmar; University of Medicine 2, North Okkalapa Township, Yangon, Myanmar; Myanmar Australia Research Collaboration for Health (MARCH), Yangon, Myanmar
| | - Josh Hanson
- University of Medicine 2, North Okkalapa Township, Yangon, Myanmar; Myanmar Australia Research Collaboration for Health (MARCH), Yangon, Myanmar; The Kirby Institute, University of New South Wales, Sydney, Australia.
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Stewart AGA, Smith S, Hanson J. Prompt defervescence after initiation of treatment for rickettsial infections - time to dispense with the dogma? Int J Infect Dis 2020; 102:132-135. [PMID: 33075531 DOI: 10.1016/j.ijid.2020.10.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 10/05/2020] [Accepted: 10/08/2020] [Indexed: 01/21/2023] Open
Abstract
INTRODUCTION Clinicians are commonly taught that if patients with suspected rickettsial disease have continuing fever after 48 hours of anti-rickettsial therapy, an alternative diagnosis is likely. METHODS This retrospective study of patients hospitalised with scrub typhus and Queensland tick typhus (QTT) in tropical Australia, examined the time to defervescence after initiation of the patients' anti-rickettsial therapy. It also identified factors associated with delayed defervescence (time to defervescence >48 hours after antibiotic commencement). RESULTS Of the 58 patients, 32 (56%) had delayed defervescence. The median (interquartile range (IQR)) age of patients with delayed defervescence was 52 (37-62) versus 40 (28-53) years in those who defervesced within 48 hours (p = 0.05). Patients with delayed defervescence were more likely to require Intensive Care Unit (ICU) admission than those who defervesced within 48 hours (12/32 (38%) versus 3/26 (12%), p = 0.02). Even among patients not requiring ICU care, patients with delayed defervescence required a longer hospitalisation than that those who defervesced within 48 hours (median (IQR): 6 (3-8) versus 3 (2-5) days, p = 0.006). CONCLUSIONS A significant proportion of patients with confirmed scrub typhus and QTT will remain febrile for >48 hours after appropriate anti-rickettsial therapy. Delayed defervescence is more common in patients with severe disease.
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Affiliation(s)
| | - Simon Smith
- Department of Medicine, Cairns Hospital, Cairns, Queensland, Australia
| | - Josh Hanson
- Department of Medicine, Cairns Hospital, Cairns, Queensland, Australia; The Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia.
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Hanson J, Nyein PP, Aung NM, Kyi MM. Time for pragmatic, prospective clinical trials to determine the role of empirical antibacterial therapy in critically ill adults hospitalized with malaria. Int J Infect Dis 2020; 102:28-31. [PMID: 33017698 DOI: 10.1016/j.ijid.2020.09.1472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 09/25/2020] [Accepted: 09/25/2020] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Children with severe falciparum malaria in malaria-endemic regions are predisposed to developing life-threatening bacterial co-infection. International guidelines therefore recommend empirical broad-spectrum antibacterial therapy in these children. Few studies have examined co-infection in adults, although it has been believed to be relatively rare; antibacterial therapy is therefore not routinely recommended in adults with falciparum malaria. DISCUSSION However, the fundamental pathophysiology of falciparum malaria in adults and children is the same; it is therefore unclear why adults would not also be predisposed to bacterial infection. Indeed, recent studies have identified bacteraemia in >10% of adults hospitalized with malaria. Some have suggested that these adults probably had bacterial sepsis, with the parasitaemia an incidental finding. However, it is usually impossible in resource-limited settings to determine-at presentation-whether critically ill, parasitaemic adults have severe malaria, bacterial sepsis, or both. Given the significant case-fatality rates of severe malaria and bacterial sepsis, the pragmatic initial approach would be to cover both possibilities. CONCLUSIONS Life-threatening bacterial co-infection may be more common in critically ill adults with malaria than previously believed. While further prospective data are awaited to confirm these findings, it might be more appropriate to provide empirical aantibacterial cover in these patients than current guidelines suggest.
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Affiliation(s)
- Josh Hanson
- The Kirby Institute, University of New South Wales, Sydney, Australia; University of Medicine 2, North Okkalapa Township, Yangon, Myanmar; Myanmar Australia Research Collaboration for Health (MARCH), Yangon, Myanmar.
| | - Phyo Pyae Nyein
- Myanmar Australia Research Collaboration for Health (MARCH), Yangon, Myanmar; Mingaladon Specialist Hospital, Mingaladon Township, Yangon, Myanmar
| | - Ne Myo Aung
- University of Medicine 2, North Okkalapa Township, Yangon, Myanmar; Myanmar Australia Research Collaboration for Health (MARCH), Yangon, Myanmar; Insein General Hospital, Insein Township, Yangon, Myanmar
| | - Mar Mar Kyi
- University of Medicine 2, North Okkalapa Township, Yangon, Myanmar; Myanmar Australia Research Collaboration for Health (MARCH), Yangon, Myanmar; Insein General Hospital, Insein Township, Yangon, Myanmar
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Myint NPST, Zaw TT, Sain K, Waiyan S, Danta M, Cooper D, Aung NM, Kyi MM, Hanson J. Sequential Helicobacter pylori eradication therapy in Myanmar; a randomized clinical trial of efficacy and tolerability. J Gastroenterol Hepatol 2020; 35:617-623. [PMID: 31758571 DOI: 10.1111/jgh.14942] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 11/12/2019] [Accepted: 11/19/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND AIM There is little published research to examine the best approach to the management of Helicobacter pylori in Myanmar. This study aimed to determine the relative efficacy and tolerability of sequential eradication therapy compared to Myanmar's current recommendation of a concomitant four drug regimen. METHODS Patients were screened for H. pylori using monoclonal Stool Antigen Testing (SAT). Those testing positive were randomized 1:1 to receive receive Myanmar's first-line regimen of 14 days of concomitant rabeprazole, clarithromycin, amoxycillin and tinidazole (140 pills, cost US$23) or 10 days of sequential rabeprazole, clarithromycin, amoxycillin and tinidazole (60 pills, cost US$10). Adherence and adverse effects were recorded, and the efficacy of the regimens assessed with repeat SAT. RESULTS Of the 1011 patients screened for H. pylori infection, 313 (31%) tested positive. There was no statistical difference in the cure rates of the two regimens in either intention-to-treat: 128/157 (82%; 95% confidence interval (CI): 75-87%) receiving sequential therapy versus 123/156 (79%; 95% CI: 72-85%) receiving concomitant therapy (P = 0.55) or per-protocol analysis: 125/131 (95%; 95% CI: 90-98) receiving sequential therapy versus 121/130 (93%; 95% CI: 87-96) receiving concomitant therapy (P = 0.42). Side effects of therapy were reported in 54/157 (47%) patients taking sequential therapy compared with 62/156 (53%) taking concomitant therapy, but this difference did not reach statistical significance (P = 0.33). CONCLUSIONS In this high-burden, resource-poor setting, less expensive sequential therapy was as effective and as well tolerated as the currently recommended concomitant four drug regimen for eradication of H. pylori.
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Affiliation(s)
- Nan Phyu Sin Toe Myint
- Insein General Hospital, Insein Township, Yangon, Myanmar.,University of Medicine 2, North Okkalapa Township, Yangon, Myanmar.,Myanmar Australia Research Collaboration for Health (MARCH), Yangon, Myanmar
| | - Thet Tun Zaw
- Insein General Hospital, Insein Township, Yangon, Myanmar
| | - Kyauk Sain
- Insein General Hospital, Insein Township, Yangon, Myanmar
| | - Soe Waiyan
- Insein General Hospital, Insein Township, Yangon, Myanmar
| | - Mark Danta
- St Vincent's Clinical School, Faculty of Medicine, University of New South Wales, Kensington, Sydney, Australia.,Department of Gastroenterology, St Vincent's Hospital, Darlinghurst, Sydney, Australia
| | - David Cooper
- Myanmar Australia Research Collaboration for Health (MARCH), Yangon, Myanmar.,Kirby Institute, University of New South Wales, Kensington, Sydney, Australia
| | - Ne Myo Aung
- Insein General Hospital, Insein Township, Yangon, Myanmar.,University of Medicine 2, North Okkalapa Township, Yangon, Myanmar.,Myanmar Australia Research Collaboration for Health (MARCH), Yangon, Myanmar
| | - Mar Mar Kyi
- Insein General Hospital, Insein Township, Yangon, Myanmar.,University of Medicine 2, North Okkalapa Township, Yangon, Myanmar.,Myanmar Australia Research Collaboration for Health (MARCH), Yangon, Myanmar
| | - Josh Hanson
- University of Medicine 2, North Okkalapa Township, Yangon, Myanmar.,Myanmar Australia Research Collaboration for Health (MARCH), Yangon, Myanmar.,Kirby Institute, University of New South Wales, Kensington, Sydney, Australia
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Stewart AGA, Smith S, Binotto E, McBride WJH, Hanson J. The epidemiology and clinical features of rickettsial diseases in North Queensland, Australia: Implications for patient identification and management. PLoS Negl Trop Dis 2019; 13:e0007583. [PMID: 31318873 PMCID: PMC6667154 DOI: 10.1371/journal.pntd.0007583] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 07/30/2019] [Accepted: 06/27/2019] [Indexed: 12/12/2022] Open
Abstract
Background Rickettsial infections are a common cause of hospitalization in tropical settings, although early diagnosis is challenging in the rural locations where these infections are usually seen. Methods This retrospective, clinical audit of microbiologically-confirmed cases of scrub typhus or spotted fever group (SFG) rickettsial infection between 1997 and 2016 was performed a tertiary referral hospital in tropical Australia. Clinical, laboratory and radiological findings at presentation were correlated with the patients’ subsequent clinical course. Results There were 135 locally-acquired cases (95 scrub typhus, 37 SFG, 3 undifferentiated). There were nine hospitalizations during the first 5 years of the study period and 81 in the last 5 years (p for trend = 0.003). Eighteen (13%) of the 135 cases required ICU admission, all of whom were adults. A greater proportion of patients with SFG infection required ICU support (8/37 (22%) compared with 10/95 (11%) scrub typhus cases), although this difference did not reach statistical significance (p = 0.10). Three (8%) of the 37 patients with SFG infection had severe disease (1 died, 2 developed permanent disability) versus 0/95 scrub typhus patients (p = 0.02). Adults with a high admission qSOFA score (≥2) had an odds ratio (OR) of 19 (95% CI:4.8–74.5) for subsequent ICU admission (p<0.001); adults with a high NEWS2 score (≥7) had an OR of 14.3 (95% CI:4.5–45.32) for ICU admission (p<0.001). A patient’s respiratory rate at presentation had strong prognostic utility: if an adult had an admission respiratory rate <22 breaths/minute, the negative predictive value for subsequent ICU admission was 95% (95% CI 88–99). Conclusions In the well-resourced Australian health system outcomes are excellent, but the local burden of rickettsial disease appears to be increasing and the clinical phenotype of SFG infections may be more severe than previously believed. Simple, clinical assessment on admission has prognostic utility and may be used to guide management. Rickettsial infections are a common cause of hospitalization in tropical settings, although early, definitive diagnosis is challenging in the rural and remote locations where they are usually seen. It is important to recognise rickettsial infections early in their disease course as they can lead to life-threatening multi-organ failure if specific anti-rickettsial antimicrobial therapy is not prescribed promptly. In tropical Australia, scrub typhus and spotted fever group (SFG) rickettsiae are the dominant rickettsial pathogens and this twenty-year retrospective series examines the clinical and laboratory findings which might facilitate their recognition. The study highlights the infections’ increasing local clinical burden and reports that over 20% of the SFG cases in the series required Intensive Care Unit (ICU) admission, suggesting that severe SFG disease may be more common than previously believed. Simple, clinical prediction scores—calculated at presentation—identified patients who would subsequently require ICU admission. Importantly, they were also able to identify patients at low risk of disease progression. These entirely clinical scores—which can be calculated rapidly at the bedside—have the potential to facilitate the management of patients with scrub typhus and SFG infection, particularly in resource-limited settings which have the greatest burden of disease.
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Affiliation(s)
| | - Simon Smith
- Department of Medicine, Cairns Hospital, Cairns, Australia
| | - Enzo Binotto
- Department of Medicine, Cairns Hospital, Cairns, Australia
| | | | - Josh Hanson
- Department of Medicine, Cairns Hospital, Cairns, Australia
- Kirby Institute, University of New South Wales, Sydney, Australia
- * E-mail:
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