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Williams RJ, Brintz BJ, Ribeiro Dos Santos G, Huang AT, Buddhari D, Kaewhiran S, Iamsirithaworn S, Rothman AL, Thomas S, Farmer A, Fernandez S, Cummings DAT, Anderson KB, Salje H, Leung DT. Integration of population-level data sources into an individual-level clinical prediction model for dengue virus test positivity. SCIENCE ADVANCES 2024; 10:eadj9786. [PMID: 38363842 PMCID: PMC10871531 DOI: 10.1126/sciadv.adj9786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 01/17/2024] [Indexed: 02/18/2024]
Abstract
The differentiation of dengue virus (DENV) infection, a major cause of acute febrile illness in tropical regions, from other etiologies, may help prioritize laboratory testing and limit the inappropriate use of antibiotics. While traditional clinical prediction models focus on individual patient-level parameters, we hypothesize that for infectious diseases, population-level data sources may improve predictive ability. To create a clinical prediction model that integrates patient-extrinsic data for identifying DENV among febrile patients presenting to a hospital in Thailand, we fit random forest classifiers combining clinical data with climate and population-level epidemiologic data. In cross-validation, compared to a parsimonious model with the top clinical predictors, a model with the addition of climate data, reconstructed susceptibility estimates, force of infection estimates, and a recent case clustering metric significantly improved model performance.
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Affiliation(s)
- Robert J. Williams
- Division of Infectious Diseases, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - Ben J. Brintz
- Division of Infectious Diseases, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | | | - Angkana T. Huang
- Department of Genetics, University of Cambridge, Cambridge, UK
- Department of Virology, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | - Darunee Buddhari
- Department of Virology, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | | | | | - Alan L. Rothman
- Institute for Immunology and Informatics and Department of Cell and Molecular Biology, University of Rhode Island, Providence, RI, USA
| | - Stephen Thomas
- Department of Microbiology and Immunology, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Aaron Farmer
- Department of Virology, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | - Stefan Fernandez
- Department of Virology, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | - Derek A. T. Cummings
- Department of Biology, University of Florida, Gainesville, FL, USA
- Emerging Pathogens Institute, University of Florida, Gainesville, FL, USA
| | - Kathryn B. Anderson
- Department of Virology, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
- Department of Microbiology and Immunology, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Henrik Salje
- Department of Genetics, University of Cambridge, Cambridge, UK
| | - Daniel T. Leung
- Division of Infectious Diseases, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
- Division of Microbiology and Immunology, Department of Pathology, University of Utah, Salt Lake City, UT, USA
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Williams RJ, Brintz BJ, Santos GRD, Huang A, Buddhari D, Kaewhiran S, Iamsirithaworn S, Rothman AL, Thomas S, Farmer A, Fernandez S, Cummings DAT, Anderson KB, Salje H, Leung DT. Integration of population-level data sources into an individual-level clinical prediction model for dengue virus test positivity. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.08.08.23293840. [PMID: 37609267 PMCID: PMC10441499 DOI: 10.1101/2023.08.08.23293840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
Abstract
The differentiation of dengue virus (DENV) infection, a major cause of acute febrile illness in tropical regions, from other etiologies, may help prioritize laboratory testing and limit the inappropriate use of antibiotics. While traditional clinical prediction models focus on individual patient-level parameters, we hypothesize that for infectious diseases, population-level data sources may improve predictive ability. To create a clinical prediction model that integrates patient-extrinsic data for identifying DENV among febrile patients presenting to a hospital in Thailand, we fit random forest classifiers combining clinical data with climate and population-level epidemiologic data. In cross validation, compared to a parsimonious model with the top clinical predictors, a model with the addition of climate data, reconstructed susceptibility estimates, force of infection estimates, and a recent case clustering metric, significantly improved model performance.
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Affiliation(s)
- RJ Williams
- Division of Infectious Diseases, Department of Internal Medicine, University of Utah, Salt Lake City, USA
| | - Ben J. Brintz
- Division of Infectious Diseases, Department of Internal Medicine, University of Utah, Salt Lake City, USA
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, USA
| | | | - Angkana Huang
- Department of Genetics, University of Cambridge, United Kingdom
- Department of Virology, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | - Darunee Buddhari
- Department of Virology, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | | | | | - Alan L. Rothman
- Institute for Immunology and Informatics and Department of Cell and Molecular Biology, University of Rhode Island, Providence, USA
| | - Stephen Thomas
- Department of Microbiology and Immunology, SUNY Upstate Medical University, Syracuse, USA
| | - Aaron Farmer
- Department of Virology, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | - Stefan Fernandez
- Department of Virology, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | - Derek A T Cummings
- Department of Biology, University of Florida, Gainesville, USA
- Emerging Pathogens Institute, University of Florida, Gainesville, USA
| | - Kathryn B Anderson
- Department of Virology, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
- Department of Microbiology and Immunology, SUNY Upstate Medical University, Syracuse, USA
| | - Henrik Salje
- Department of Genetics, University of Cambridge, United Kingdom
| | - Daniel T. Leung
- Division of Infectious Diseases, Department of Internal Medicine, University of Utah, Salt Lake City, USA
- Division of Microbiology and Immunology, Department of Pathology, University of Utah, Salt Lake City, USA
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Nooh F, Chernet A, Reither K, Okuma J, Brattig NW, Utzinger J, Probst-Hensch N, Paris DH, Dreyfus A. Prevalence of fever of unidentified aetiology in East African adolescents and adults: a systematic review and meta-analysis. Infect Dis Poverty 2023; 12:55. [PMID: 37231500 DOI: 10.1186/s40249-023-01105-z] [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: 01/17/2023] [Accepted: 05/16/2023] [Indexed: 05/27/2023] Open
Abstract
BACKGROUND Primary health care settings and hospitals of low- and middle-income countries have few accessible diagnostic tools and limited laboratory and human resources capacity to identify multiple pathogens with high accuracy. In addition, there is a paucity of information on fever and its underlying aetiology in the adolescent and adult population in East Africa. The purpose of this study was to estimate the pooled prevalence of fever of unidentified aetiology among adolescent and adult febrile patients seeking health care in East Africa. METHODS We pursued a systematic review using readily available electronic databases (i.e. PubMed, Cumulative Index to Nursing & Allied Health Literature, Scopus, Cochrane Library and Web of Science) without language restriction from inception date of the respective databases to October 31, 2022. We adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Identified studies were screened for relevance. Further analyses based on pre-set eligibility criteria were carried out for final inclusion. Two reviewers independently screened and extracted data. Risk of study bias was assessed. Meta-analysis of the prevalence of fever of unidentified aetiology was performed. RESULTS We identified 14,029 articles of which 25 were eligible for inclusion, reporting data from 8538 participants. The pooled prevalence of febrile cases with unidentified aetiology was 64% [95% confidence interval (CI): 51-77%, I2 = 99.6%] among febrile adolescents and adults in East Africa. For the proportion of patients with identified aetiology, the studies documented bacterial pathogens (human bloodstream infections), bacterial zoonotic pathogens and arboviruses as the main non-malarial causative agents in East Africa. CONCLUSIONS Our study provides evidence that almost two-thirds of adolescent and adult febrile patients attending health care facilities in East Africa might receive inappropriate treatments due to unidentified potential life-threatening fever aetiology. Hence, we call for a comprehensive fever syndromic surveillance to broaden a consequential differential diagnosis of syndromic fever and to considerably improve the course of patients' disease and treatment outcomes.
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Affiliation(s)
- Faisal Nooh
- Swiss Tropical and Public Health Institute, Kreuzstrasse 2, 4123, Allschwil, Switzerland.
- University of Basel, Basel, Switzerland.
- College of Medicine and Health Sciences, Jigjiga University, Jigjiga, Ethiopia.
- College of Medicine and Health Sciences, University of Hargeisa, Hargeisa, Somaliland.
| | - Afona Chernet
- Swiss Tropical and Public Health Institute, Kreuzstrasse 2, 4123, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
| | - Klaus Reither
- Swiss Tropical and Public Health Institute, Kreuzstrasse 2, 4123, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
| | - James Okuma
- Swiss Tropical and Public Health Institute, Kreuzstrasse 2, 4123, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
| | - Norbert W Brattig
- Department Infectious Disease Epidemiology, Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany
| | - Jürg Utzinger
- Swiss Tropical and Public Health Institute, Kreuzstrasse 2, 4123, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
| | - Nicole Probst-Hensch
- Swiss Tropical and Public Health Institute, Kreuzstrasse 2, 4123, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
| | - Daniel H Paris
- Swiss Tropical and Public Health Institute, Kreuzstrasse 2, 4123, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
| | - Anou Dreyfus
- Swiss Tropical and Public Health Institute, Kreuzstrasse 2, 4123, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
- Section of Epidemiology, University of Zürich, Zurich, Switzerland
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Wainaina M, Vey da Silva DA, Dohoo I, Mayer-Scholl A, Roesel K, Hofreuter D, Roesler U, Lindahl J, Bett B, Al Dahouk S. A systematic review and meta-analysis of the aetiological agents of non-malarial febrile illnesses in Africa. PLoS Negl Trop Dis 2022; 16:e0010144. [PMID: 35073309 PMCID: PMC8812962 DOI: 10.1371/journal.pntd.0010144] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 02/03/2022] [Accepted: 01/04/2022] [Indexed: 12/16/2022] Open
Abstract
Background The awareness of non-malarial febrile illnesses (NMFIs) has been on the rise over the last decades. Therefore, we undertook a systematic literature review and meta-analysis of causative agents of non-malarial fevers on the African continent. Methodology We searched for literature in African Journals Online, EMBASE, PubMed, Scopus, and Web of Science databases to identify aetiologic agents that had been reported and to determine summary estimates of the proportional morbidity rates (PMr) associated with these pathogens among fever patients. Findings A total of 133 studies comprising 391,835 patients from 25 of the 54 African countries were eligible. A wide array of aetiologic agents were described with considerable regional differences among the leading agents. Overall, bacterial pathogens tested from blood samples accounted for the largest proportion. The summary estimates from the meta-analysis were low for most of the agents. This may have resulted from a true low prevalence of the agents, the failure to test for many agents or the low sensitivity of the diagnostic methods applied. Our meta-regression analysis of study and population variables showed that diagnostic methods determined the PMr estimates of typhoidal Salmonella and Dengue virus. An increase in the PMr of Klebsiella spp. infections was observed over time. Furthermore, the status of patients as either inpatient or outpatient predicted the PMr of Haemophilus spp. infections. Conclusion The small number of epidemiological studies and the variety of NMFI agents on the African continent emphasizes the need for harmonized studies with larger sample sizes. In particular, diagnostic procedures for NMFIs should be standardized to facilitate comparability of study results and to improve future meta-analyses. Reliable NMFI burden estimates will inform regional public health strategies. Previous systematic reviews have highlighted the research priorities of causative agents for non-malarial febrile illnesses by counting the number of publications attributed to an agent. However, proportional morbidity rates are calculated by dividing the number of cases with a specific disease (numerator) by the total number of diagnosed fever cases (denominator) and are better indicators of the relative importance of aetiological agents in a population. Therefore, we present the leading causes of non-malarial febrile illnesses in African patients in both healthcare and community settings. Preference is given to HIV-negative patients when data could be found. We also determined summary estimates of Brucella spp., Chikungunya virus, Dengue virus, Haemophilus spp., Klebsiella spp., Leptospira spp., non-typhoidal Salmonella spp., typhoidal Salmonella spp., Staphylococcus spp., and Streptococcus spp. The wide array of aetiological agents causing febrile illnesses on the African continent does not only complicate malaria control programs but may also hamper response to epidemic and pandemic illnesses such as Ebola and COVID-19. The harmonisation of diagnostics and study designs will reduce between-study differences, which may result in better estimates of disease burden on the continent and in the different African regions. This information is important for Pan-African surveillance and control efforts.
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Affiliation(s)
- Martin Wainaina
- Department of Biological Safety, German Federal Institute for Risk Assessment, Berlin, Germany
- Department of Veterinary Medicine, Freie Universität Berlin, Berlin, Germany
- International Livestock Research Institute, Nairobi, Kenya
- * E-mail:
| | - David Attuy Vey da Silva
- Department of Biological Safety, German Federal Institute for Risk Assessment, Berlin, Germany
- Department of Veterinary Medicine, Freie Universität Berlin, Berlin, Germany
| | - Ian Dohoo
- University of Prince Edward Island, Charlottetown, Canada
| | - Anne Mayer-Scholl
- Department of Biological Safety, German Federal Institute for Risk Assessment, Berlin, Germany
| | - Kristina Roesel
- Department of Veterinary Medicine, Freie Universität Berlin, Berlin, Germany
- International Livestock Research Institute, Nairobi, Kenya
| | - Dirk Hofreuter
- Department of Biological Safety, German Federal Institute for Risk Assessment, Berlin, Germany
| | - Uwe Roesler
- Institute for Animal Hygiene and Environmental Health, Freie Universität Berlin, Berlin, Germany
| | - Johanna Lindahl
- International Livestock Research Institute, Nairobi, Kenya
- Department of Clinical Sciences, Swedish University of Agricultural Sciences, Uppsala, Sweden
- Department of Medical Biochemistry and Microbiology, Uppsala University, Uppsala, Sweden
| | - Bernard Bett
- International Livestock Research Institute, Nairobi, Kenya
| | - Sascha Al Dahouk
- Department of Biological Safety, German Federal Institute for Risk Assessment, Berlin, Germany
- Department of Internal Medicine, RWTH Aachen University Hospital, Aachen, Germany
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5
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Appiah GD, Mpimbaza A, Lamorde M, Freeman M, Kajumbula H, Salah Z, Kugeler K, Mikoleit M, White PB, Kapisi J, Borchert J, Sserwanga A, Van Dyne S, Mead P, Kim S, Lauer AC, Winstead A, Manabe YC, Flick RJ, Mintz E. Salmonella Bloodstream Infections in Hospitalized Children with Acute Febrile Illness-Uganda, 2016-2019. Am J Trop Med Hyg 2021; 105:37-46. [PMID: 33999850 DOI: 10.4269/ajtmh.20-1453] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 03/19/2021] [Indexed: 12/23/2022] Open
Abstract
Invasive Salmonella infection is a common cause of acute febrile illness (AFI) among children in sub-Saharan Africa; however, diagnosing Salmonella bacteremia is challenging in settings without blood culture. The Uganda AFI surveillance system includes blood culture-based surveillance for etiologies of bloodstream infection (BSIs) in hospitalized febrile children in Uganda. We analyzed demographic, clinical, blood culture, and antimicrobial resistance data from hospitalized children at six sentinel AFI sites from July 2016 to January 2019. A total of 47,261 children were hospitalized. Median age was 2 years (interquartile range, 1-4) and 26,695 (57%) were male. Of 7,203 blood cultures, 242 (3%) yielded bacterial pathogens including Salmonella (N = 67, 28%), Staphylococcus aureus (N = 40, 17%), Escherichia spp. (N = 25, 10%), Enterococcus spp. (N = 18, 7%), and Klebsiella pneumoniae (N = 17, 7%). Children with BSIs had longer median length of hospitalization (5 days versus 4 days), and a higher case-fatality ratio (13% versus 2%) than children without BSI (all P < 0.001). Children with Salmonella BSIs did not differ significantly in length of hospitalization or mortality from children with BSI resulting from other organisms. Serotype and antimicrobial susceptibility results were available for 49 Salmonella isolates, including 35 (71%) non-typhoidal serotypes and 14 Salmonella serotype Typhi (Typhi). Among Typhi isolates, 10 (71%) were multi-drug resistant and 13 (93%) had decreased ciprofloxacin susceptibility. Salmonella strains, particularly non-typhoidal serotypes and drug-resistant Typhi, were the most common cause of BSI. These data can inform regional Salmonella surveillance in East Africa and guide empiric therapy and prevention in Uganda.
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Affiliation(s)
- Grace D Appiah
- 1Division of Foodborne, Waterborne, and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Arthur Mpimbaza
- 2Infectious Disease Research Collaboration, Kampala, Uganda.,3Child Health and Development Center, Makerere University, Kampala, Uganda
| | | | - Molly Freeman
- 1Division of Foodborne, Waterborne, and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Henry Kajumbula
- 5Department of Microbiology, Makerere University, Kampala, Uganda
| | - Zainab Salah
- 1Division of Foodborne, Waterborne, and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Kiersten Kugeler
- 6Division of Vector-Borne Disease, Centers for Disease Control and Prevention, Fort Collins, Colorado
| | - Matthew Mikoleit
- 7Division of Global Health Protection, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Porscha Bumpus White
- 1Division of Foodborne, Waterborne, and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - James Kapisi
- 2Infectious Disease Research Collaboration, Kampala, Uganda
| | - Jeff Borchert
- 6Division of Vector-Borne Disease, Centers for Disease Control and Prevention, Fort Collins, Colorado
| | | | - Susan Van Dyne
- 1Division of Foodborne, Waterborne, and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Paul Mead
- 6Division of Vector-Borne Disease, Centers for Disease Control and Prevention, Fort Collins, Colorado
| | - Sunkyung Kim
- 1Division of Foodborne, Waterborne, and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Ana C Lauer
- 1Division of Foodborne, Waterborne, and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Alison Winstead
- 8Division of Parasitic Disease and Malaria, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Yukari C Manabe
- 9Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Robert J Flick
- 9Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Eric Mintz
- 1Division of Foodborne, Waterborne, and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
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6
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A Systematic Review and Meta-analysis of the Prevalence of Community-Onset Bloodstream Infections among Hospitalized Patients in Africa and Asia. Antimicrob Agents Chemother 2019; 64:AAC.01974-19. [PMID: 31636071 PMCID: PMC7187598 DOI: 10.1128/aac.01974-19] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 10/09/2019] [Indexed: 02/07/2023] Open
Abstract
Community-onset bloodstream infections (CO-BSI) are major causes of severe febrile illness and death worldwide. In light of new data and the growing problem of antimicrobial resistance (AMR) among pathogens causing BSI, we undertook a systematic review of hospital-based studies of CO-BSI among patients hospitalized with fever. Community-onset bloodstream infections (CO-BSI) are major causes of severe febrile illness and death worldwide. In light of new data and the growing problem of antimicrobial resistance (AMR) among pathogens causing BSI, we undertook a systematic review of hospital-based studies of CO-BSI among patients hospitalized with fever. Without restriction to language or country, we searched PubMed, Web of Science, and Scopus for prospective hospital-based studies of culture-confirmed CO-BSI among febrile inpatients. We determined by study the prevalence of BSI among participants, the pathogens responsible for BSI, and the antimicrobial susceptibility patterns of pathogens causing BSI, according to place and time. Thirty-four (77.3%) of 44 eligible studies recruited 29,022 participants in Africa and Asia combined. Among participants in these two regions, the median prevalence of BSI was 12.5% (range, 2.0 to 48.4%); of 3,220 pathogens isolated, 1,119 (34.8%) were Salmonella enterica, 425 (13.2%) Streptococcus pneumoniae, and 282 (8.8%) Escherichia coli. Antimicrobial susceptibility testing was reported in 16 (36.4%) studies. When isolates collected prior to 2008 were compared to those collected in the period of 2008 through 2018, the proportions of typhoidal Salmonella and Staphylococcus aureus isolates resistant to several clinically relevant antimicrobials increased over time, while S. pneumoniae susceptibility was stable. CO-BSI remain a major cause of severe febrile illness among hospitalized patients in Africa and Asia, with S. enterica, S. pneumoniae, and E. coli predominating. There is a concerning increase in AMR among serious infections caused by community-onset pathogens. Ongoing surveillance is needed to inform empirical management and strategies to control AMR.
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7
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Marchello CS, Dale AP, Pisharody S, Crump JA. Using hospital-based studies of community-onset bloodstream infections to make inferences about typhoid fever incidence. Trop Med Int Health 2019; 24:1369-1383. [PMID: 31633858 PMCID: PMC6916262 DOI: 10.1111/tmi.13319] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Objectives Hospital-based studies of community-onset bloodstream infections (CO-BSI) are less resource-intensive to carry out than population-based incidence studies. We examined several metrics capturing the potential role of Salmonella Typhi as a cause of CO-BSI for making inferences about incidence. Methods We systematically reviewed three databases for hospital-based studies of CO-BSI. We determined, by study, the prevalence and rank order of Salmonella among pathogenic bloodstream isolates, and the prevalence ratio of Salmonella Typhi to Escherichia coli (S:E ratio). We then describe these hospital-based study metrics in relation to population-based typhoid fever incidence data from a separate systematic review. Results Forty-four studies met the inclusion criteria, of which 23 (52.3%) isolated Salmonella Typhi at least once. Among studies isolating Salmonella Typhi, the median (interquartile range) prevalence and rank order of Salmonella Typhi compared to other pathogens isolated in BSI was 8.3% (3.2–37.9%) and 3 (1–6), respectively. The median (interquartile range) S:E ratio was 1.0 (0.4–3.0). With respect to incidence, in Pemba Island, Tanzania, prevalence, rank order, S:E ratio, and incidence was 64.8%, 1, 9.2 and 110 cases per 100 000, respectively, and in Boulkiemdé, Burkina Faso, was 13.3%, 3, 2.3 and 249 cases per 100 000. Conclusions We describe considerable variation in place and time for Salmonella Typhi prevalence, rank order, and S:E ratio among hospital-based studies of CO-BSI. Data from simultaneous typhoid prevalence and incidence studies are limited. We propose that hospital-based study metrics warrant evaluation for making inference about typhoid incidence and as covariates in typhoid incidence models.
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Affiliation(s)
| | - Ariella P Dale
- Colorado Department of Public Health and Environment, Denver, CO, USA
| | | | - John A Crump
- Centre for International Health, University of Otago, Dunedin, New Zealand
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8
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Wang Y, Wu Q, Zhang W, Zhang N. Tuberculosis and HIV Coinfection–the Challenge in the Prevention, Detection and Treatment of Tuberculosis. Curr Bioinform 2019. [DOI: 10.2174/1574893613666180621153734] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background:
Tuberculosis (TB) is still a major public health concern world-wide. The
increasing global burden of TB is linked to HIV infection. HIV-TB coinfection has also
conditioned clinical aspects of the TB. Since the HIV is beginning in the 1980s, the HIV infection
poses a significant challenge in global TB control.
Objective:
In this review we focused on the challenges of epidemiological and clinical feature of
tuberculosis presented by the HIV coinfection.
Method:
The article consists of a summary of the most important effects presented by the HIV
coinfection on epidemiological and clinical feature of tuberculosis. The article analyzes and
summary the causes for these challenges.
Results:
The major challenges to strategy of TB control and clinical feature of TB-HIV coinfection
are presented in this paper.
Conclusion:
HIV/TB co-infection is synergic, interactive and reciprocal with significant impact.
The infection of HIV and Mtb affect each other and the breakdown the immune function in
TB/HIV coinfected individual. HIV infection has changed the strategy of TB control, however
HIV increases global burden of TB, the reduction in the TB incidence rate is far from sufficient.
Atypically clinical manifestations in TB/HIV co-infected patients and increased MDR-TB and
XDR-TB contribute to the challenges in the diagnosis and treatment. Increased complexity of
managing patients requires expertise in the clinical m knowledge. The focused efforts to control
HIV-related TB are of great urgency. These findings will provide insight into the prevention,
detection and treatment of tuberculosis and will guide advances towards tuberculosis control.
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Affiliation(s)
- Yiyi Wang
- TCM Key Research Laboratory for Infectious Disease Prevention for State Administration of Traditional Chinese Medicine, China
| | - Qi Wu
- TCM Key Research Laboratory for Infectious Disease Prevention for State Administration of Traditional Chinese Medicine, China
| | - Wei Zhang
- Clinical and Research Center of Infectious Diseases Beijing Ditan Hospital, Capital Medical University, 100015, Peiking, China
| | - Ning Zhang
- Department of Biomedical Engineering, Tianjin Key Lab of Biomedical Engineering Measurement, Tianjin University, Tianjin, China
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9
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Pavlinac PB, Lokken EM, Walson JL, Richardson BA, Crump JA, John-Stewart GC. Mycobacterium tuberculosis bacteremia in adults and children: a systematic review and meta-analysis. Int J Tuberc Lung Dis 2018; 20:895-902. [PMID: 27287641 DOI: 10.5588/ijtld.15.0773] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
UNLABELLED SETTINGp: Among human immunodeficiency virus (HIV) infected adults living in tuberculosis (TB) endemic settings, Mycobacterium tuberculosis is a common cause of bloodstream infections. Although young children have an increased propensity for M. tuberculosis dissemination, M. tuberculosis bacteremia is infrequently described in children. OBJECTIVE To determine the prevalence of M. tuberculosis bacteremia in adult and pediatric patients and to examine sources of heterogeneity between estimates. DESIGN Systematic review and meta-analysis. RESULTS Of 1077 reviewed abstracts, 27 publications met the inclusion criteria, yielding 29 independent M. tuberculosis bacteremia prevalence estimates: 22 in adults, 6 in children, and 1 not stratified by age group. The random effects pooled M. tuberculosis bacteremia prevalence in adults was 13.5% (95%CI 10.8-16.2) and 0.4% (95%CI 0-0.9) in children (P for difference = 0.004). Restricting analyses to HIV-infected participants, pooled M. tuberculosis bacteremia prevalence from 21 adult studies was 15.5% (95%CI 12.5-18.5) and 0.8% (95%CI 0-1.8) in three pediatric studies (P = 0.001). Inclusion of pre-determined study-level confounders did not account for observed differences in M. tuberculosis bacteremia prevalence between age groups. CONCLUSION While M. tuberculosis bacteremia appears relatively common in adults, particularly those with HIV infection, bloodstream M. tuberculosis appears to be rare in children.
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Affiliation(s)
- P B Pavlinac
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - E M Lokken
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - J L Walson
- Department of Global Health, University of Washington, Seattle, Washington, USA; Department of Epidemiology, University of Washington, Seattle, Washington, USA; Department of Pediatrics, University of Washington, Seattle, Washington, USA; Department of Medicine, University of Washington, Seattle, Washington, USA
| | - B A Richardson
- Department of Global Health, University of Washington, Seattle, Washington, USA; Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - J A Crump
- Centre for International Health, University of Otago, Dunedin, New Zealand
| | - G C John-Stewart
- Department of Global Health, University of Washington, Seattle, Washington, USA; Department ofEpidemiology, University of Washington, Seattle, Washington, USA; Department of Pediatrics, University of Washington, Seattle, Washington, USA; Department ofMedicine, University of Washington, Seattle, Washington, USA
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Uche IV, MacLennan CA, Saul A. A Systematic Review of the Incidence, Risk Factors and Case Fatality Rates of Invasive Nontyphoidal Salmonella (iNTS) Disease in Africa (1966 to 2014). PLoS Negl Trop Dis 2017; 11:e0005118. [PMID: 28056035 PMCID: PMC5215826 DOI: 10.1371/journal.pntd.0005118] [Citation(s) in RCA: 124] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2016] [Accepted: 10/19/2016] [Indexed: 11/19/2022] Open
Abstract
This study systematically reviews the literature on the occurrence, incidence and case fatality rate (CFR) of invasive nontyphoidal Salmonella (iNTS) disease in Africa from 1966 to 2014. Data on the burden of iNTS disease in Africa are sparse and generally have not been aggregated, making it difficult to describe the epidemiology that is needed to inform the development and implementation of effective prevention and control policies. This study involved a comprehensive search of PubMed and Embase databases. It documents the geographical spread of iNTS disease over time in Africa, and describes its reported incidence, risk factors and CFR. We found that Nontyphoidal Salmonella (NTS) have been reported as a cause of bacteraemia in 33 out of 54 African countries, spanning the five geographical regions of Africa, and especially in sub-Saharan Africa since 1966. Our review indicates that NTS have been responsible for up to 39% of community acquired blood stream infections in sub-Saharan Africa with an average CFR of 19%. Salmonella Typhimurium and Enteritidis are the major serovars implicated and together have been responsible for 91%% of the cases of iNTS disease, (where serotype was determined), reported in Africa. The study confirms that iNTS disease is more prevalent amongst Human Immunodeficiency Virus (HIV)-infected individuals, infants, and young children with malaria, anaemia and malnutrition. In conclusion, iNTS disease is a substantial cause of community-acquired bacteraemia in Africa. Given the high morbidity and mortality of iNTS disease in Africa, it is important to develop effective prevention and control strategies including vaccination.
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Affiliation(s)
| | | | - Allan Saul
- Novartis Vaccines Institute for Global Health, Siena, Italy
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11
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Cummings MJ, O'Donnell MR. Inverting the pyramid: increasing awareness of mycobacterial sepsis in sub-Saharan Africa. Int J Tuberc Lung Dis 2016; 19:1128-34. [PMID: 26459522 DOI: 10.5588/ijtld.14.0967] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Disseminated Mycobacterium tuberculosis is a leading cause of bloodstream infection and severe sepsis in sub-Saharan African settings with a high burden of tuberculosis (TB) and human immunodeficiency virus (HIV) infection. Despite the high prevalence of M. tuberculosis bacteremia in these settings it is under-recognized. This is in part because timely diagnosis of M. tuberculosis bacteremia is difficult using traditional TB diagnostics. Novel triage algorithms and rapid diagnostic tests are needed to expedite the identification and treatment of patients with severe sepsis due to M. tuberculosis bacteremia. In this article, we emphasize the importance of M. tuberculosis bacteremia as an under-recognized etiology of severe sepsis, and discuss the potential role of two emerging rapid diagnostic tests in the triage and prognostication of critically ill patients with advanced HIV infection and suspected disseminated M. tuberculosis. We conclude with the recommendation that clinicians in high TB-HIV burden settings strongly consider empiric anti-tuberculosis treatment in patients with advanced HIV infection and severe sepsis in the appropriate clinical context. Future studies are needed to assess diagnostic and prognostic algorithms for severe sepsis caused by disseminated M. tuberculosis in these settings, and the safety, efficacy, and duration of empiric anti-tuberculosis treatment.
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Affiliation(s)
- M J Cummings
- Department of Medicine, Columbia University Medical Center, New York, USA
| | - M R O'Donnell
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Medical Center, New York, USA; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
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12
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Fleischmann C, Scherag A, Adhikari NKJ, Hartog CS, Tsaganos T, Schlattmann P, Angus DC, Reinhart K. Assessment of Global Incidence and Mortality of Hospital-treated Sepsis. Current Estimates and Limitations. Am J Respir Crit Care Med 2016; 193:259-72. [PMID: 26414292 DOI: 10.1164/rccm.201504-0781oc] [Citation(s) in RCA: 2065] [Impact Index Per Article: 258.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
RATIONALE Reducing the global burden of sepsis, a recognized global health challenge, requires comprehensive data on the incidence and mortality on a global scale. OBJECTIVES To estimate the worldwide incidence and mortality of sepsis and identify knowledge gaps based on available evidence from observational studies. METHODS We systematically searched 15 international citation databases for population-level estimates of sepsis incidence rates and fatality in adult populations using consensus criteria and published in the last 36 years. MEASUREMENTS AND MAIN RESULTS The search yielded 1,553 reports from 1979 to 2015, of which 45 met our criteria. A total of 27 studies from seven high-income countries provided data for metaanalysis. For these countries, the population incidence rate was 288 (95% confidence interval [CI], 215-386; τ = 0.55) for hospital-treated sepsis cases and 148 (95% CI, 98-226; τ = 0.99) for hospital-treated severe sepsis cases per 100,000 person-years. Restricted to the last decade, the incidence rate was 437 (95% CI, 334-571; τ = 0.38) for sepsis and 270 (95% CI, 176-412; τ = 0.60) for severe sepsis cases per 100,000 person-years. Hospital mortality was 17% for sepsis and 26% for severe sepsis during this period. There were no population-level sepsis incidence estimates from lower-income countries, which limits the prediction of global cases and deaths. However, a tentative extrapolation from high-income country data suggests global estimates of 31.5 million sepsis and 19.4 million severe sepsis cases, with potentially 5.3 million deaths annually. CONCLUSIONS Population-level epidemiologic data for sepsis are scarce and nonexistent for low- and middle-income countries. Our analyses underline the urgent need to implement global strategies to measure sepsis morbidity and mortality, particularly in low- and middle-income countries.
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Affiliation(s)
- Carolin Fleischmann
- 1 Department for Anesthesiology and Intensive Care Medicine.,2 Integrated Research and Treatment Center, Center for Sepsis Control and Care
| | - André Scherag
- 3 Clinical Epidemiology, Integrated Research and Treatment Center, Center for Sepsis Control and Care, and
| | - Neill K J Adhikari
- 4 Department of Critical Care Medicine, Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Ontario, Canada
| | - Christiane S Hartog
- 1 Department for Anesthesiology and Intensive Care Medicine.,2 Integrated Research and Treatment Center, Center for Sepsis Control and Care
| | - Thomas Tsaganos
- 5 4th Department of Internal Medicine, University of Athens, Medical School, Athens, Greece; and
| | - Peter Schlattmann
- 6 Institute of Medical Statistics, Computer Sciences and Documentation, Jena University Hospital, Jena, Germany
| | - Derek C Angus
- 7 Critical Care Medicine Division, Department of Anesthesiology and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Konrad Reinhart
- 1 Department for Anesthesiology and Intensive Care Medicine.,2 Integrated Research and Treatment Center, Center for Sepsis Control and Care
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13
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Pavlinac PB, Naulikha JM, John-Stewart GC, Onchiri FM, Okumu AO, Sitati RR, Cranmer LM, Lokken EM, Singa BO, Walson JL. Mycobacterium tuberculosis Bacteremia Among Acutely Febrile Children in Western Kenya. Am J Trop Med Hyg 2015; 93:1087-91. [PMID: 26324730 DOI: 10.4269/ajtmh.15-0365] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Accepted: 07/13/2015] [Indexed: 12/28/2022] Open
Abstract
In children, Mycobacterium tuberculosis (M. tuberculosis) frequently disseminates systemically, presenting with nonspecific signs including fever. We determined prevalence of M. tuberculosis bacteremia among febrile children presenting to hospitals in Nyanza, Kenya (a region with high human immunodeficiency virus (HIV) and M. tuberculosis prevalence). Between March 2013 and February 2014, we enrolled children aged 6 months to 5 years presenting with fever (axillary temperature ≥ 37.5°C) and no recent antibiotic use. Blood samples were collected for bacterial and mycobacterial culture using standard methods. Among 148 children enrolled, median age was 3.1 years (interquartile range: 1.8-4.1 years); 10.3% of children were living with a household member diagnosed with M. tuberculosis in the last year. Seventeen percent of children were stunted (height-for-age z-score < -2), 18.6% wasted (weight-for-height z-score < -2), 2.7% were HIV-infected, and 14.2% were HIV-exposed uninfected. Seventeen children (11.5%) had one or more signs of tuberculosis (TB). All children had a Bacille Calmette-Guerin vaccination scar. Among 134 viable blood cultures, none (95% confidence interval: 0-2.7%) had Mycobacterium isolated. Despite exposure to household TB contacts, HIV exposure, and malnutrition, M. tuberculosis bacteremia was not detected in this pediatric febrile cohort, a finding consistent with other pediatric studies.
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Affiliation(s)
- Patricia B Pavlinac
- Department of Global Health, University of Washington, Seattle, Washington; Department of Pediatrics, University of Washington, Seattle, Washington; Department of Epidemiology, University of Washington, Seattle, Washington; Department of Medicine, University of Washington, Seattle, Washington; Kenya Medical Research Institute, Centre for Clinical Research, Nairobi, Kenya; Kenya Medical Research Institute (KEMRI)/CGHR Centre for Global Health Research, Kisumu, Kenya; Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Jaqueline M Naulikha
- Department of Global Health, University of Washington, Seattle, Washington; Department of Pediatrics, University of Washington, Seattle, Washington; Department of Epidemiology, University of Washington, Seattle, Washington; Department of Medicine, University of Washington, Seattle, Washington; Kenya Medical Research Institute, Centre for Clinical Research, Nairobi, Kenya; Kenya Medical Research Institute (KEMRI)/CGHR Centre for Global Health Research, Kisumu, Kenya; Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Grace C John-Stewart
- Department of Global Health, University of Washington, Seattle, Washington; Department of Pediatrics, University of Washington, Seattle, Washington; Department of Epidemiology, University of Washington, Seattle, Washington; Department of Medicine, University of Washington, Seattle, Washington; Kenya Medical Research Institute, Centre for Clinical Research, Nairobi, Kenya; Kenya Medical Research Institute (KEMRI)/CGHR Centre for Global Health Research, Kisumu, Kenya; Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Frankline M Onchiri
- Department of Global Health, University of Washington, Seattle, Washington; Department of Pediatrics, University of Washington, Seattle, Washington; Department of Epidemiology, University of Washington, Seattle, Washington; Department of Medicine, University of Washington, Seattle, Washington; Kenya Medical Research Institute, Centre for Clinical Research, Nairobi, Kenya; Kenya Medical Research Institute (KEMRI)/CGHR Centre for Global Health Research, Kisumu, Kenya; Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Albert O Okumu
- Department of Global Health, University of Washington, Seattle, Washington; Department of Pediatrics, University of Washington, Seattle, Washington; Department of Epidemiology, University of Washington, Seattle, Washington; Department of Medicine, University of Washington, Seattle, Washington; Kenya Medical Research Institute, Centre for Clinical Research, Nairobi, Kenya; Kenya Medical Research Institute (KEMRI)/CGHR Centre for Global Health Research, Kisumu, Kenya; Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Ruth R Sitati
- Department of Global Health, University of Washington, Seattle, Washington; Department of Pediatrics, University of Washington, Seattle, Washington; Department of Epidemiology, University of Washington, Seattle, Washington; Department of Medicine, University of Washington, Seattle, Washington; Kenya Medical Research Institute, Centre for Clinical Research, Nairobi, Kenya; Kenya Medical Research Institute (KEMRI)/CGHR Centre for Global Health Research, Kisumu, Kenya; Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Lisa M Cranmer
- Department of Global Health, University of Washington, Seattle, Washington; Department of Pediatrics, University of Washington, Seattle, Washington; Department of Epidemiology, University of Washington, Seattle, Washington; Department of Medicine, University of Washington, Seattle, Washington; Kenya Medical Research Institute, Centre for Clinical Research, Nairobi, Kenya; Kenya Medical Research Institute (KEMRI)/CGHR Centre for Global Health Research, Kisumu, Kenya; Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Erica M Lokken
- Department of Global Health, University of Washington, Seattle, Washington; Department of Pediatrics, University of Washington, Seattle, Washington; Department of Epidemiology, University of Washington, Seattle, Washington; Department of Medicine, University of Washington, Seattle, Washington; Kenya Medical Research Institute, Centre for Clinical Research, Nairobi, Kenya; Kenya Medical Research Institute (KEMRI)/CGHR Centre for Global Health Research, Kisumu, Kenya; Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Benson O Singa
- Department of Global Health, University of Washington, Seattle, Washington; Department of Pediatrics, University of Washington, Seattle, Washington; Department of Epidemiology, University of Washington, Seattle, Washington; Department of Medicine, University of Washington, Seattle, Washington; Kenya Medical Research Institute, Centre for Clinical Research, Nairobi, Kenya; Kenya Medical Research Institute (KEMRI)/CGHR Centre for Global Health Research, Kisumu, Kenya; Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Judd L Walson
- Department of Global Health, University of Washington, Seattle, Washington; Department of Pediatrics, University of Washington, Seattle, Washington; Department of Epidemiology, University of Washington, Seattle, Washington; Department of Medicine, University of Washington, Seattle, Washington; Kenya Medical Research Institute, Centre for Clinical Research, Nairobi, Kenya; Kenya Medical Research Institute (KEMRI)/CGHR Centre for Global Health Research, Kisumu, Kenya; Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia
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14
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Prasad N, Murdoch DR, Reyburn H, Crump JA. Etiology of Severe Febrile Illness in Low- and Middle-Income Countries: A Systematic Review. PLoS One 2015; 10:e0127962. [PMID: 26126200 PMCID: PMC4488327 DOI: 10.1371/journal.pone.0127962] [Citation(s) in RCA: 121] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2014] [Accepted: 04/22/2015] [Indexed: 02/04/2023] Open
Abstract
Background With apparent declines in malaria worldwide during the last decade and more widespread use of malaria rapid diagnostic tests, healthcare workers in low-resource areas face a growing proportion of febrile patients without malaria. We sought to describe current knowledge and identify information gaps of the etiology severe febrile illness in low-and middle-income countries. Methods and Findings We conducted a systematic review of studies conducted in low-and-middle income countries 1980–2013 that prospectively assessed consecutive febrile patients admitted to hospital using rigorous laboratory-based case definitions. We found 45 eligible studies describing 54,578 patients; 9,771 (17.9%) had a positive result for ≥1 pathogen meeting diagnostic criteria. There were no eligible studies identified from Southern and Middle Africa, Eastern Asia, Oceania, Latin American and Caribbean regions, and the European region. The median (range) number of diagnostic tests meeting our confirmed laboratory case definitions was 2 (1 to 11) per study. Of diagnostic tests, 5,052 (10.3%) of 49,143 had confirmed bacterial or fungal bloodstream infection; 709 (3.8%) of 18,142 had bacterial zoonosis; 3,488 (28.5%) of 12,245 had malaria; and 1,804 (17.4%) of 10,389 had a viral infection. Conclusions We demonstrate a wide range of pathogens associated with severe febrile illness and highlight the substantial information gaps regarding the geographic distribution and role of common pathogens. High quality severe febrile illness etiology research that is comprehensive with respect to pathogens and geographically representative is needed.
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Affiliation(s)
- Namrata Prasad
- Centre for International Health, Dunedin School of Medicine, University of Otago, PO Box 56, Dunedin, 9054, New Zealand
| | - David R. Murdoch
- Department of Pathology, University of Otago Christchurch, 2 Riccarton Avenue, PO Box 4345, Christchurch, 8011, New Zealand
| | - Hugh Reyburn
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, United Kingdom
| | - John A. Crump
- Centre for International Health, Dunedin School of Medicine, University of Otago, PO Box 56, Dunedin, 9054, New Zealand
- * E-mail:
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15
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Nakiyingi L, Ssengooba W, Nakanjako D, Armstrong D, Holshouser M, Kirenga BJ, Shah M, Mayanja-Kizza H, Joloba ML, Ellner JJ, Dorman SE, Manabe YC. Predictors and outcomes of mycobacteremia among HIV-infected smear- negative presumptive tuberculosis patients in Uganda. BMC Infect Dis 2015; 15:62. [PMID: 25888317 PMCID: PMC4332438 DOI: 10.1186/s12879-015-0812-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Accepted: 02/09/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Sputum smear microscopy for tuberculosis (TB) diagnosis lacks sensitivity in HIV-infected symptomatic patients and increases the likelihood that mycobacterial infections particularly disseminated TB will be missed; delays in diagnosis can be fatal. Given the duration for MTB growth in blood culture, clinical predictors of MTB bacteremia may improve early diagnosis of mycobacteremia. We describe the predictors and mortality outcome of mycobacteremia among HIV-infected sputum smear-negative presumptive TB patients in a high prevalence HIV/TB setting. METHODS Between January and November 2011, all consenting HIV-infected adults suspected to have TB (presumptive TB) were consecutively enrolled. Diagnostic assessment included sputum smear microscopy, urine Determine TB lipoarabinomannan (LAM) antigen test, mycobacterial sputum and blood cultures, chest X-ray, and CD4 cell counts in addition to clinical and socio-demographic data. Patients were followed for 12 months post-enrolment. RESULTS Of 394 sputum smear-negative participants [female, 63.7%; median age (IQR) 32 (28-39) years], 41/394 (10.4%) had positive mycobacterial blood cultures (mycobacteremia); all isolates were M. tuberculosis (MTB). The median CD4 cell count was significantly lower among patients with mycobacteremia when compared with those without (CD4 31 versus 122 cells/μL, p < 0.001). In a multivariate analysis, male gender [OR 3.4, 95%CI (1.4-7.6), p = 0.005], CD4 count <100 cells/μL [OR 3.1, 95% CI (1.1-8.6), p = 0.030] and a positive lateral flow urine TB LAM antigen test [OR 15.3, 95%CI (5.7-41.1), p < 0.001] were significantly associated with mycobacteremia. At 12 months of follow-up, a trend towards increased mortality was observed in patients that were MTB blood culture positive (35.3%) compared with those that were MTB blood culture negative (23.3%) (p = 0.065). CONCLUSIONS Mycobacteremia occurred in 10% of smear-negative patients and was associated with higher mortality compared with smear-negative patients without mycobacteremia. Advanced HIV disease (CD4 < 100 cells/mm(3)), male gender and positive lateral flow urine TB LAM test predicted mycobacteremia in HIV-infected smear-negative presumptive TB patients in this high prevalence TB/HIV setting.
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Affiliation(s)
- Lydia Nakiyingi
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda. .,Makerere University College of Heath Sciences, Kampala, Uganda.
| | - Willy Ssengooba
- Makerere University College of Heath Sciences, Kampala, Uganda. .,Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
| | - Damalie Nakanjako
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda. .,Makerere University College of Heath Sciences, Kampala, Uganda.
| | - Derek Armstrong
- Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Molly Holshouser
- Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Bruce J Kirenga
- Makerere University College of Heath Sciences, Kampala, Uganda.
| | - Maunank Shah
- Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | | | - Moses L Joloba
- Makerere University College of Heath Sciences, Kampala, Uganda.
| | - Jerrold J Ellner
- Boston Medical Center, Boston University School of Medicine, Boston, MA, USA.
| | - Susan E Dorman
- Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Yukari C Manabe
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda. .,Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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16
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Bwanga F, Disqué C, Lorenz MG, Allerheiligen V, Worodria W, Luyombya A, Najjingo I, Weizenegger M. Higher blood volumes improve the sensitivity of direct PCR diagnosis of blood stream tuberculosis among HIV-positive patients: an observation study. BMC Infect Dis 2015; 15:48. [PMID: 25656799 PMCID: PMC4326319 DOI: 10.1186/s12879-015-0785-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2014] [Accepted: 01/27/2015] [Indexed: 12/14/2022] Open
Abstract
Background Blood stream tuberculosis (TB), caused by Mycobacterium tuberculosis (MTB) is common among HIV-positive patients, turning rapidly fatal unless detected and treated promptly. Blood culture is currently the standard test for the detection of MTB in whole blood but results take weeks; patients deteriorate markedly and often die before a diagnosis of blood stream TB is made. Rapid molecular tests on whole blood, with potential for same day diagnosis of blood stream TB usually show low sensitivity due to the problem of insufficient MTB DNA template when extraction is performed directly on low blood volumes. This study assessed the influence of blood volume on the sensitivity of a HyBeacon PCR assay-the FluoroType® MTB (Hain Lifescience, Nehren, Germany) on direct detection of MTB in whole blood. Methods Prospective recruitment of HIV-positive patients with clinical suspicion of blood stream TB but not on anti-TB or HIV drug treatment was done. Venous blood samples were collected and DNA extracted using the MolYsis (Molzym, Bremen, Germany) methods; for study A, from duplicate 1 ml (42 patients) and for study B (31 patients) from 9 ml EDTA blood samples. The FluoroType® MTB PCR assay targeting an IS6110 sequence was performed and results compared with blood culture. Results The diagnostic sensitivity and specificity of the FluoroType® MTB PCR in study A was 33% and 97%, respectively. Corresponding values in study B were 71% and 96%, respectively. In both studies, one case each of blood culture-negative blood stream TB was detected with the FluoroType® MTB PCR assay. The median time to positivity of blood culture was 20.1 (range 12–32) for study A and 19.9 days (range 15–30) for study B. Conclusion Larger blood volumes (9 ml) improved and gave acceptable sensitivity of direct PCR diagnosis of blood stream TB.
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Affiliation(s)
- Freddie Bwanga
- Makerere University College of Health Sciences, Kampala, Uganda. .,MBN Clinical Laboratories, Kampala, Uganda.
| | | | | | | | - William Worodria
- Makerere University College of Health Sciences, Kampala, Uganda.
| | | | | | - Michael Weizenegger
- Medizinisches Versorgungszentrum Labor Dr. Limbach und Kollegen, Heidelberg, Germany.
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17
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Simplified severe sepsis protocol: a randomized controlled trial of modified early goal-directed therapy in Zambia. Crit Care Med 2014; 42:2315-24. [PMID: 25072757 DOI: 10.1097/ccm.0000000000000541] [Citation(s) in RCA: 131] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To assess the efficacy of a simple, goal-directed sepsis treatment protocol for reducing mortality in patients with severe sepsis in Zambia. DESIGN Single-center nonblinded randomized controlled trial. SETTING Emergency department, ICU, and medical wards of the national referral hospital in Lusaka, Zambia. PATIENTS One hundred twelve patients enrolled within 24 hours of admission with severe sepsis, defined as systemic inflammatory response syndrome with suspected infection and organ dysfunction INTERVENTIONS : Simplified Severe Sepsis Protocol consisting of up to 4 L of IV fluids within 6 hours, guided by jugular venous pressure assessment, and dopamine and/or blood transfusion in selected patients. Control group was managed as usual care. Blood cultures were collected and early antibiotics administered for both arms. MEASUREMENTS AND MAIN RESULTS Primary outcome was in-hospital all-cause mortality. One hundred nine patients were included in the final analysis and 88 patients (80.7%) were HIV positive. Pulmonary infections were the most common source of sepsis. In-hospital mortality rate was 64.2% in the intervention group and 60.7% in the control group (relative risk, 1.05; 95% CI, 0.79-1.41). Mycobacterium tuberculosis complex was isolated from 31 of 82 HIV-positive patients (37.8%) with available mycobacterial blood culture results. Patients in Simplified Severe Sepsis Protocol received significantly more IV fluids in the first 6 hours (2.7 L vs 1.7 L, p = 0.002). The study was stopped early because of high mortality rate among patients with hypoxemic respiratory failure in the intervention arm (8/8, 100%) compared with the control arm (7/10, 70%; relative risk, 1.43; 95% CI, 0.95-2.14). CONCLUSION Factors other than tissue hypoperfusion probably account for much of the end-organ dysfunction in African patients with severe sepsis. Studies of fluid-based interventions should utilize inclusion criteria to accurately capture patients with hypovolemia and tissue hypoperfusion who are most likely to benefit from fluids. Exclusion of patients with severe respiratory distress should be considered when ventilatory support is not readily available.
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18
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Huson MAM, Grobusch MP, van der Poll T. The effect of HIV infection on the host response to bacterial sepsis. THE LANCET. INFECTIOUS DISEASES 2014; 15:95-108. [PMID: 25459220 DOI: 10.1016/s1473-3099(14)70917-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Bacterial sepsis is an important cause of morbidity and mortality in patients with HIV. HIV causes increased susceptibility to invasive infections and affects sepsis pathogenesis caused by pre-existing activation and exhaustion of the immune system. We review the effect of HIV on different components of immune responses implicated in bacterial sepsis, and possible mechanisms underlying the increased risk of invasive bacterial infections. We focus on pattern recognition receptors and innate cellular responses, cytokines, lymphocytes, coagulation, and the complement system. A combination of factors causes increased susceptibility to infection and can contribute to a disturbed immune response during a septic event in patients with HIV. HIV-induced perturbations of the immune system depend on stage of infection and are only in part restored by combination antiretroviral therapy. Immunomodulatory treatments currently under development for sepsis might be particularly beneficial to patients with HIV co-infection because many pathogenic mechanisms in HIV and sepsis overlap.
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Affiliation(s)
- Michaëla A M Huson
- Division of Infectious Diseases, Centre of Experimental and Molecular Medicine, University of Amsterdam, Amsterdam, Netherlands.
| | - Martin P Grobusch
- Division of Infectious Diseases, Centre of Tropical Medicine and Travel Medicine, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Tom van der Poll
- Division of Infectious Diseases, Centre of Experimental and Molecular Medicine, University of Amsterdam, Amsterdam, Netherlands
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19
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Manabe YC, Nonyane BAS, Nakiyingi L, Mbabazi O, Lubega G, Shah M, Moulton LH, Joloba M, Ellner J, Dorman SE. Point-of-care lateral flow assays for tuberculosis and cryptococcal antigenuria predict death in HIV infected adults in Uganda. PLoS One 2014; 9:e101459. [PMID: 25000489 PMCID: PMC4084886 DOI: 10.1371/journal.pone.0101459] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2013] [Accepted: 06/06/2014] [Indexed: 11/29/2022] Open
Abstract
Background Mortality in hospitalized, febrile patients in Sub-Saharan Africa is high due to HIV-infected, severely immunosuppressed patients with opportunistic co-infection, particularly disseminated tuberculosis (TB) and cryptococcal disease. We sought to determine if a positive lateral flow assay (LFA) result for urine lipoarabinomannan (LAM) and cryptococcal antigenuria was associated with mortality. Methods 351 hospitalized, HIV-positive adults with symptoms consistent with TB and who were able to provide both urine and sputum specimens were prospectively enrolled at Mulago National Referral Hospital in Uganda as part of a prospective accuracy evaluation of the lateral flow Determine TB LAM test. Stored frozen urine was retrospectively tested for cryptococcal antigen (CRAG) using the LFA. We fitted a multinomial logistic regression model to analyze factors associated with death within 2 months after initial presentation. Results The median CD4 of the participants was 57 (IQR: 14–179) cells/µl and 41% (145) were microbiologically confirmed TB cases. LAM LFA was positive in 38% (134), 7% (25) were CRAG positive, and 43% (151) were positive for either test in urine. Overall, 21% (75) died within the first 2 months, and a total of 32% (114) were confirmed dead by 6 months. At 2 months, 30% of LAM or CRAG positive patients were confirmed dead compared to 15.0% of those who were negative. In an adjusted model, LAM or CRAG positive results were associated with an increased risk of death (RRR 2.29, 95% CI: 1.29, 4.05; P = 0.005). Conclusions In hospitalized HIV-infected patients, LAM or CRAG LFA positivity was associated with subsequent death within 2 months. Further studies are warranted to examine the impact of POC diagnostic ‘test and treat’ approach on patient-centered outcomes.
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Affiliation(s)
- Yukari C. Manabe
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- * E-mail:
| | - Bareng A. S. Nonyane
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Lydia Nakiyingi
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Olive Mbabazi
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Gloria Lubega
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Maunank Shah
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Lawrence H. Moulton
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Moses Joloba
- Department of Microbiology, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Jerrold Ellner
- Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts, United States of America
| | - Susan E. Dorman
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
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Feasey NA, Houston A, Mukaka M, Komrower D, Mwalukomo T, Tenthani L, Jahn A, Moore M, Peters RPH, Gordon MA, Everett DB, French N, van Oosterhout JJ, Allain TJ, Heyderman RS. A reduction in adult blood stream infection and case fatality at a large African hospital following antiretroviral therapy roll-out. PLoS One 2014; 9:e92226. [PMID: 24643091 PMCID: PMC3958486 DOI: 10.1371/journal.pone.0092226] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2013] [Accepted: 02/20/2014] [Indexed: 11/26/2022] Open
Abstract
Introduction Blood-stream infection (BSI) is one of the principle determinants of the morbidity and mortality associated with advanced HIV infection, especially in sub-Saharan Africa. Over the last 10 years, there has been rapid roll-out of anti-retroviral therapy (ART) and cotrimoxazole prophylactic therapy (CPT) in many high HIV prevalence African countries. Methods A prospective cohort of adults with suspected BSI presenting to Queen's Hospital, Malawi was recruited between 2009 and 2010 to describe causes of and outcomes from BSI. Comparison was made with a cohort pre-dating ART roll-out to investigate whether and how ART and CPT have affected BSI. Malawian census and Ministry of Health ART data were used to estimate minimum incidence of BSI in Blantyre district. Results 2,007 patients were recruited, 90% were HIV infected. Since 1997/8, culture-confirmed BSI has fallen from 16% of suspected cases to 10% (p<0.001) and case fatality rate from confirmed BSI has fallen from 40% to 14% (p<0.001). Minimum incidence of BSI was estimated at 0.03/1000 years in HIV uninfected vs. 2.16/1000 years in HIV infected adults. Compared to HIV seronegative patients, the estimated incidence rate-ratio for BSI was 80 (95% CI:46–139) in HIV-infected/untreated adults, 568 (95% CI:302–1069) during the first 3 months of ART and 30 (95% CI:16–59) after 3 months of ART. Conclusions Following ART roll-out, the incidence of BSI has fallen and clinical outcomes have improved markedly. Nonetheless, BSI incidence remains high in the first 3 months of ART despite CPT. Further interventions to reduce BSI-associated mortality in the first 3 months of ART require urgent evaluation.
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Affiliation(s)
- Nicholas A. Feasey
- Malawi Liverpool Wellcome Trust Clinical Research Programme (MLW), University of Malawi College of Medicine, Blantyre, Malawi
- Department of Medicine, University of Malawi College of Medicine, Blantyre, Malawi
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
- * E-mail:
| | - Angela Houston
- Department of Medicine, University of Malawi College of Medicine, Blantyre, Malawi
| | - Mavuto Mukaka
- Malawi Liverpool Wellcome Trust Clinical Research Programme (MLW), University of Malawi College of Medicine, Blantyre, Malawi
| | - Dan Komrower
- Department of Medicine, University of Malawi College of Medicine, Blantyre, Malawi
| | - Thandie Mwalukomo
- Malawi Liverpool Wellcome Trust Clinical Research Programme (MLW), University of Malawi College of Medicine, Blantyre, Malawi
- Department of Medicine, University of Malawi College of Medicine, Blantyre, Malawi
| | - Lyson Tenthani
- Department of HIV and AIDS, Ministry of Health, Lilongwe, Malawi
- I-TECH Lilongwe, Malawi
| | - Andreas Jahn
- Department of HIV and AIDS, Ministry of Health, Lilongwe, Malawi
- I-TECH, Department for Global Health, University of Washington, Seattle, Washington, United States of America
| | - Mike Moore
- Malawi Liverpool Wellcome Trust Clinical Research Programme (MLW), University of Malawi College of Medicine, Blantyre, Malawi
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | | | - Melita A. Gordon
- Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
| | - Dean B. Everett
- Malawi Liverpool Wellcome Trust Clinical Research Programme (MLW), University of Malawi College of Medicine, Blantyre, Malawi
- Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
| | - Neil French
- Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
| | - Joep J. van Oosterhout
- Malawi Liverpool Wellcome Trust Clinical Research Programme (MLW), University of Malawi College of Medicine, Blantyre, Malawi
- Dignitas International, Zomba, Blantyre, Malawi
| | - Theresa J. Allain
- Department of Medicine, University of Malawi College of Medicine, Blantyre, Malawi
| | - Robert S. Heyderman
- Malawi Liverpool Wellcome Trust Clinical Research Programme (MLW), University of Malawi College of Medicine, Blantyre, Malawi
- Department of Medicine, University of Malawi College of Medicine, Blantyre, Malawi
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
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Huson MAM, Stolp SM, van der Poll T, Grobusch MP. Community-acquired bacterial bloodstream infections in HIV-infected patients: a systematic review. Clin Infect Dis 2013; 58:79-92. [PMID: 24046307 DOI: 10.1093/cid/cit596] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Information on community-acquired bacterial bloodstream infections (BSIs) in individuals infected with human immunodeficiency virus (HIV) is limited. We conducted a systematic literature review. The case fraction of community-acquired bacterial BSIs in hospitalized patients is 20% and 30% in adults and children, respectively, compared to 9% in HIV-negative adults and children. Worldwide, the main pathogens of community-acquired BSI are nontyphoid salmonellae (NTS), Streptococcus pneumoniae, Escherichia coli, and Staphylococcus aureus, but regional differences are apparent, especially for S. pneumoniae. Compared to HIV-negative populations, HIV patients are particularly at risk to develop NTS bacteremia. Bacteremia incidence is related to immunosuppression, and antiretroviral therapy reduces the incidence of BSI in HIV patients (rate ratios, 0.63-0.02). Mortality rates varied between 7% and 46%. These results suggest that bacterial BSI is more likely to be found in HIV-positive than in HIV-negative patients upon hospitalization, and that causative pathogens vary by region.
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Affiliation(s)
- Michaëla A M Huson
- Division of Infectious Diseases, Center of Experimental and Molecular Medicine, Center of Infection and Immunity and Center of Tropical Medicine and Travel Medicine, Academic Medical Center, University of Amsterdam, The Netherlands
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Lorenzi OD, Gregory CJ, Santiago LM, Acosta H, Galarza IE, Hunsperger E, Muñoz J, Bui DM, Oberste MS, Peñaranda S, García-Gubern C, Tomashek KM. Acute febrile illness surveillance in a tertiary hospital emergency department: comparison of influenza and dengue virus infections. Am J Trop Med Hyg 2013; 88:472-80. [PMID: 23382160 DOI: 10.4269/ajtmh.12-0373] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
In 2009, an increased proportion of suspected dengue cases reported to the surveillance system in Puerto Rico were laboratory negative. As a result, enhanced acute febrile illness (AFI) surveillance was initiated in a tertiary care hospital. Patients with fever of unknown origin for 2-7 days duration were tested for Leptospira, enteroviruses, influenza, and dengue virus. Among the 284 enrolled patients, 31 dengue, 136 influenza, and 3 enterovirus cases were confirmed. Nearly half (48%) of the confirmed dengue cases met clinical criteria for influenza. Dengue patients were more likely than influenza patients to have hemorrhage (81% versus 26%), rash (39% versus 9%), and a positive tourniquet test (52% versus 18%). Mean platelet and white blood cell count were lower among dengue patients. Clinical diagnosis can be particularly difficult when outbreaks of other AFI occur during dengue season. A complete blood count and tourniquet test may be useful to differentiate dengue from other AFIs.
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Affiliation(s)
- Olga D Lorenzi
- Dengue Branch, Division of Vector-Borne Diseases, Centers for Disease Control and Prevention, San Juan, Puerto Rico.
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Phe T, Vlieghe E, Reid T, Harries AD, Lim K, Thai S, De Smet B, Veng C, Kham C, Ieng S, van Griensven J, Jacobs J. Does HIV status affect the aetiology, bacterial resistance patterns and recommended empiric antibiotic treatment in adult patients with bloodstream infection in Cambodia? Trop Med Int Health 2013; 18:485-94. [PMID: 23294446 DOI: 10.1111/tmi.12060] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVE The microbiologic causes of bloodstream infections (BSI) may differ between HIV-positive and HIV-negative patients and direct initial empiric antibiotic treatment (i.e. treatment before culture results are available). We retrospectively assessed community-acquired BSI episodes in adults in Cambodia according to HIV status for spectrum of bacterial pathogens, antibiotic resistance patterns and appropriateness of empiric antibiotics. METHODS Blood cultures were systematically performed in patients suspected of BSI in a referral hospital in Phnom Penh, Cambodia. Data were collected between 1 January 2009 and 31 December 2011. RESULTS A total of 452 culture-confirmed episodes of BSI were recorded in 435 patients, of whom 17.9% and 82.1% were HIV-positive and HIV-negative, respectively. Escherichia coli accounted for one-third (n = 155, 32.9%) of 471 organisms, with similar rates in both patient groups. Staphylococcus aureus and Salmonella cholereasuis were more frequent in HIV-positive vs. HIV-negative patients (17/88 vs. 38/383 (P = 0.02) and 10/88 vs. 5/383 (P < 0.001)). Burkholderia pseudomallei was more common in HIV-negative than in HIV-positive patients (39/383 vs. 2/88, P < 0.001). High resistance rates among commonly used antibiotics were observed, including 46.6% ceftriaxone resistance among E. coli isolates. Empiric antibiotic treatments were similarly appropriate in both patient groups but did not cover antibiotic-resistant E. coli (both patient groups), S. aureus (both groups) and B. pseudomallei (HIV-negative patients). CONCLUSION The present data do not warrant different empiric antibiotic regimens for HIV-positive vs. HIV-negative patients in Cambodia. The overall resistance rates compromise the appropriateness of the current treatment guidelines.
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Affiliation(s)
- Thong Phe
- Infectious Diseases Department, Sihanouk Hospital Center of HOPE, Phnom Penh, Cambodia.
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van Lettow M, Åkesson A, Martiniuk ALC, Ramsay A, Chan AK, Anderson ST, Harries AD, Corbett E, Heyderman RS, Zachariah R, Bedell RA. Six-month mortality among HIV-infected adults presenting for antiretroviral therapy with unexplained weight loss, chronic fever or chronic diarrhea in Malawi. PLoS One 2012. [PMID: 23185278 PMCID: PMC3501502 DOI: 10.1371/journal.pone.0048856] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background In sub-Saharan Africa, early mortality is high following initiation of antiretroviral therapy (ART). We investigated 6-month outcomes and factors associated with mortality in HIV-infected adults being assessed for ART initiation and presenting with weight loss, chronic fever or diarrhea, and with negative TB sputum microscopy. Methods A prospective cohort study was conducted in Malawi, investigating mortality in relation to ART uptake, microbiological findings and treatment of opportunistic infection (OIs), 6 months after meeting ART eligibility criteria. Results Of 469 consecutive adults eligible for ART, 74(16%) died within 6 months of enrolment, at a median of 41 days (IQR 20–81). 370(79%) started ART at a median time of 18 days (IQR 7–40) after enrolment. Six-month case-fatality rates were higher in patients with OIs; 25/121(21%) in confirmed/clinical TB and 10/50(20%) with blood stream infection (BSI) compared to 41/308(13%) in patients with no infection identified. Median TB treatment start was 27 days (IQR 17–65) after enrolment and mortality [8 deaths (44%)] was significantly higher among 18 culture-positive patients with delayed TB diagnosis compared to patients diagnosed clinically and treated promptly with subsequent culture confirmation [6/34 (18%);p = 0.04]. Adjusted multivariable analysis, excluding deaths in the first 21 days, showed weight loss >10%, low CD4 count, severe anemia, laboratory-only TB diagnosis, and not initiating ART to be independently associated with increased risk of death. Conclusions Mortality remains high among chronically ill patients eligible for ART. Prompt initiation of ART is vital: more than half of deaths were among patients who never started ART. Diagnostic and treatment delay for TB was strongly associated with risk of death. More than half of deaths occurred without identification of a specific infection. ART programmes need access to rapid point-of-care-diagnostic tools for OIs. The role of early empiric OI treatment in this population requires further evaluation in clinical trials.
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Enrichment of HIV-1 subtype AD recombinants in a Ugandan cohort of severely septic patients. PLoS One 2012; 7:e48356. [PMID: 23144755 PMCID: PMC3483180 DOI: 10.1371/journal.pone.0048356] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2012] [Accepted: 09/24/2012] [Indexed: 12/03/2022] Open
Abstract
Background Several population-wide HIV-1 subtype distribution studies in Uganda have evaluated relatively healthy clinic patients. Given the differences in HIV-1 disease progression based on subtype, we examined HIV-1 subtype distribution and disease outcomes among hospitalized patients with severe sepsis. Methods Patients with severe sepsis were enrolled at two hospitals in Uganda. Data collected included demographics, Karnofsky scores, highly active antiretroviral therapy (HAART) use, HIV-1 serostatus, CD4+ T cell concentration, whole blood lactate concentration, and blood cultures. HIV-1 subtypes were determined by sequencing parts of the gag and env genes, followed by phylogenetic analysis. Results Of the 267 patients evaluated, 228 (85.4%) were HIV infected. The predominant HIV-1 subtypes were A (46%), D (17%), and AD recombinants (30%). HIV-1 subtypes B, C, and other recombinants were uncommon. Patients infected with HIV-1 subtypes A, D and AD viruses were similar in demographics, CD4+ T cell concentration, HAART use, Karnofsky scores, whole blood lactate concentration, and positive blood cultures. There was no difference in 30-day mortality from severe sepsis between the 3 groups (p = 0.99). Conclusion A high proportion of HIV-1 subtypes A and AD recombinants was observed in this cohort of severely septic patients. The proportion of AD recombinants was higher in this cohort than in previous cohorts of Ugandan HIV-1 patients. No difference in baseline demographics, clinical factors or 30-day mortality was seen across HIV-subtypes.
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Severe febrile illness in adult hospital admissions in Tanzania: a prospective study in an area of high malaria transmission. Trans R Soc Trop Med Hyg 2012; 106:688-95. [PMID: 23022040 DOI: 10.1016/j.trstmh.2012.08.006] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2011] [Revised: 08/07/2012] [Accepted: 08/07/2012] [Indexed: 11/21/2022] Open
Abstract
Severe febrile illness is a major cause of adult hospital admission in Africa. Studies of non-malarial fever come largely from children or from high HIV prevalence settings. This prospective study of adult admissions with severe febrile illness in a malaria-endemic area with moderate/low HIV prevalence investigated admission diagnosis as well as final diagnosis based on results of investigations. Severe malaria was the admission diagnosis in 148/198 (74.7%) cases. Plasmodium falciparum was identified in 38/188 (20.2%) admissions and 26/198 (13.1%) were bacteraemic, with 13/25 (52%) prescribed empirical antibiotics. HIV was equally common among those with (16/37; 43.2%) and without P. falciparum (50/138; 36.2%) (p=0.44). In 6/22 (27.3%) deaths, blood cultures were positive for a pathogen, with Streptococcus pneumoniae, Escherichia coli and non-Typhi Salmonella predominating. Chest radiography was suspicious for bacterial/mycobacterial disease in 5/22 additional deaths. Systemic inflammatory response syndrome criteria were more sensitive but less specific than WHO severe malaria criteria for predicting mortality. Malaria is overdiagnosed in adults with severe febrile illness and was not associated with mortality in the absence of co-infection in this high-incidence setting. Adults with severe febrile illness should be tested for malaria and HIV using rapid, sensitive tests. Early antibiotic use should be promoted. Improved diagnostics for invasive bacterial disease are needed.
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Bedell RA, Anderson STB, van Lettow M, Akesson A, Corbett EL, Kumwenda M, Chan AK, Heyderman RS, Zachariah R, Harries AD, Ramsay AR. High prevalence of tuberculosis and serious bloodstream infections in ambulatory individuals presenting for antiretroviral therapy in Malawi. PLoS One 2012; 7:e39347. [PMID: 22761767 PMCID: PMC3382251 DOI: 10.1371/journal.pone.0039347] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2011] [Accepted: 05/23/2012] [Indexed: 11/29/2022] Open
Abstract
Background Tuberculosis (TB) and serious bloodstream infections (BSI) may contribute to the high early mortality observed among patients qualifying for antiretroviral therapy (ART) with unexplained weight loss, chronic fever or chronic diarrhea. Methods and Findings A prospective cohort study determined the prevalence of undiagnosed TB or BSI among ambulatory HIV-infected adults with unexplained weight loss and/or chronic fever, or diarrhea in two routine program settings in Malawi. Subjects with positive expectorated sputum smears for AFB were excluded. Investigations Bacterial and mycobacterial blood cultures, cryptococcal antigen test (CrAg), induced sputum (IS) for TB microscopy and solid culture, full blood count and CD4 lymphocyte count. Among 469 subjects, 52 (11%) had microbiological evidence of TB; 50 (11%) had a positive (non-TB) blood culture and/or positive CrAg. Sixty-five additional TB cases were diagnosed on clinical and radiological grounds. Nontyphoidal Salmonellae (NTS) were the most common blood culture pathogens (29 cases; 6% of participants and 52% of bloodstream isolates). Multivariate analysis of baseline clinical and hematological characteristics found significant independent associations between oral candidiasis or lymphadenopathy and TB, marked CD4 lymphopenia and NTS infection, and severe anemia and either infection, but low positive likelihood ratios (<2 for all combinations). Conclusions We observed a high prevalence of TB and serious BSI, particularly NTS, in a program cohort of chronically ill HIV-infected outpatients. Baseline clinical and hematological characteristics were inadequate predictors of infection. HIV clinics need better rapid screening tools for TB and BSI. Clinical trials to evaluate empiric TB or NTS treatment are required in similar populations.
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Muwonge A, Kankya C, Johansen TB, Djønne B, Godfroid J, Biffa D, Edvardsen V, Skjerve E. Non-tuberculous mycobacteria isolated from slaughter pigs in Mubende district, Uganda. BMC Vet Res 2012; 8:52. [PMID: 22564290 PMCID: PMC3490772 DOI: 10.1186/1746-6148-8-52] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2011] [Accepted: 05/07/2012] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND The importance of infections caused by non-tuberculous mycobacteria (NTM) in animals and humans has gained considerable recognition during the past few years. In the developed world, where pig production is extensively practiced, studies on mycobacterial infections and related control strategies have received increasing attention. The infections are reported to be caused by a wide spectrum of NTM. Unfortunately, these infections have been less recognized in sub-Saharan Africa owing to lack of awareness and systematic studies. In this study we aimed at isolating and identifying species of mycobacteria involved in causing infections in slaughter pigs in Mubende district of Uganda. Furthermore we wanted to identify factors associated with infection prevalence in the study area. METHODS A total of 363 lymph nodes were collected and cultured for the presence of mycobacteria. Isolates were identified by 16S rDNA gene sequencing. A questionnaire survey was administered to identify production related factors associated with infection prevalence. Data were assembled and analysed using descriptive statistics and mixed effects logistic regression analysis. RESULTS Mycobacteria were detected in 39 % (143/363) of the examined lymph nodes, 63 % (59/93) of lymph nodes with gross lesions typical of mycobacteriosis and 31% (84/270) of lymph nodes with no visible lesions. Nineteen per cent of the isolated mycobacteria were identified as Mycobacterium (M) avium, of these 78% and 22% were M. avium sub sp. Hominissuis and avium respectively. Other mycobacterial species included M. senuense (16%), M. terrae (7%) and M. asiaticum (6%). This study found free range systems (OR = 3.0; P = 0.034) and use of water from valley dams (OR = 2.0; P = 0.049) as factors associated with high prevalence of mycobacteria in slaughter pigs. CONCLUSIONS This study demonstrated a high prevalence of NTM infections among slaughter pigs in Mubende district of Uganda. M. avium was the most prevalent of all NTM isolated and identified. Free range system of pig management and valley dam water were the most significant factors associated with NTM prevalence in Mubende district. These findings could be of a major public health concern given that it is in a predominantly pork consuming population with 18% HIV/AIDS prevalence. Therefore, stringent post-mortem inspection at the slaughter houses is of paramount importance to reduce human exposure.
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Affiliation(s)
- Adrian Muwonge
- Centre for Epidemiology and Biostatistics, Norwegian School of Veterinary Science, P.O. Box 8146 Dep, 0033, Oslo, Norway
| | - Clovice Kankya
- Centre for Epidemiology and Biostatistics, Norwegian School of Veterinary Science, P.O. Box 8146 Dep, 0033, Oslo, Norway
- Department of Biosecurity, Ecosystems and Public Health (BEP), College Of Veterinary Medicine, Animal Resources & Biosecurity Makerere University, P.O. Box 7062, Kampala, Uganda
| | - Tone B Johansen
- Norwegian Veterinary Institute, P.O. Box 750, N-0106, Oslo, Norway
| | - Berit Djønne
- Norwegian Veterinary Institute, P.O. Box 750, N-0106, Oslo, Norway
| | - Jacques Godfroid
- Section for Arctic Veterinary Medicine, Norwegian School of Veterinary Science, Stakkevollveien 9010, Tromsø, Norway
| | - Demelash Biffa
- College of Medicine, University of Arizona, 1656 E. Mabel St, P.O. Box 245221, Tucson, AZ, 85724, USA
| | - Vigdis Edvardsen
- Norwegian Veterinary Institute, P.O. Box 750, N-0106, Oslo, Norway
| | - Eystein Skjerve
- Centre for Epidemiology and Biostatistics, Norwegian School of Veterinary Science, P.O. Box 8146 Dep, 0033, Oslo, Norway
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Crump JA, Ramadhani HO, Morrissey AB, Saganda W, Mwako MS, Yang LY, Chow SC, Njau BN, Mushi GS, Maro VP, Reller LB, Bartlett JA. Bacteremic disseminated tuberculosis in sub-saharan Africa: a prospective cohort study. Clin Infect Dis 2012; 55:242-50. [PMID: 22511551 DOI: 10.1093/cid/cis409] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Disseminated tuberculosis is a major health problem in countries where generalized human immunodeficiency virus (HIV) infection epidemics coincide with high tuberculosis incidence rates; data are limited on patient outcomes beyond the inpatient period. METHODS We enrolled consecutive eligible febrile inpatients in Moshi, Tanzania, from 10 March 2006 through 28 August 2010; those with Mycobacterium tuberculosis bacteremia were followed up monthly for 12 months. Survival, predictors of bacteremic disseminated tuberculosis, and predictors of death were assessed. Antiretroviral therapy (ART) and tuberculosis treatment were provided. RESULTS A total of 508 participants were enrolled; 29 (5.7%) had M. tuberculosis isolated by blood culture. The median age of all study participants was 37.4 years (range, 13.6-104.8 years). Cough lasting >1 month (odds ratio [OR], 13.5; P< .001), fever lasting >1 month (OR, 7.8; P = .001), weight loss of >10% (OR, 10.0; P = .001), lymphadenopathy (OR 6.8; P = .002), HIV infection (OR, undefined; P < .001), and lower CD4 cell count and total lymphocyte count were associated with bacteremic disseminated tuberculosis. Fifty percent of participants with M. tuberculosis bacteremia died within 36 days of enrollment. Lower CD4 cell count (OR, 0.88; P = .049) and lower total lymphocyte count (OR, 0.76; P = .050) were associated with death. Magnitude of mycobacteremia tended to be higher among those with lower CD4 cell counts, but did not predict death. CONCLUSIONS In the era of free ART and access to tuberculosis treatment, almost one half of patients with M. tuberculosis bacteremia may die within a month of hospitalization. Simple clinical assessments can help to identify those with the condition. Advanced immunosuppression predicts death. Efforts should focus on early diagnosis and treatment of HIV infection, tuberculosis, and disseminated disease.
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Affiliation(s)
- John A Crump
- Division of Infectious Diseases and International Health, Department of Medicine, Duke University Medical Center, Durham, NC 27710, USA
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Kankya C, Muwonge A, Djønne B, Munyeme M, Opuda-Asibo J, Skjerve E, Oloya J, Edvardsen V, Johansen TB. Isolation of non-tuberculous mycobacteria from pastoral ecosystems of Uganda: public health significance. BMC Public Health 2011; 11:320. [PMID: 21575226 PMCID: PMC3123205 DOI: 10.1186/1471-2458-11-320] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2010] [Accepted: 05/16/2011] [Indexed: 12/19/2022] Open
Abstract
Background The importance of non-tuberculous mycobacteria (NTM) infections in humans and animals in sub-Saharan Africa at the human-environment-livestock-wildlife interface has recently received increased attention. NTM are environmental opportunistic pathogens of humans and animals. Recent studies in pastoral ecosystems of Uganda detected NTM in humans with cervical lymphadenitis and cattle with lesions compatible with bovine tuberculosis. However, little is known about the source of these mycobacteria in Uganda. The aim of this study was to isolate and identify NTM in the environment of pastoral communities in Uganda, as well as assess the potential risk factors and the public health significance of NTM in these ecosystems. Method A total of 310 samples (soil, water and faecal from cattle and pigs) were examined for mycobacteria. Isolates were identified by the INNO-Lipa test and by 16S rDNA sequencing. Additionally, a questionnaire survey involving 231 pastoralists was conducted during sample collection. Data were analysed using descriptive statistics followed by a multivariable logistic regression analysis. Results Forty-eight isolates of NTM were detected; 25.3% of soil samples, 11.8% of water and 9.1% from animal faecal samples contained mycobacteria. Soils around water sources were the most contaminated with NTM (29.8%). Of these samples, M. fortuitum-peregrinum complex, M. avium complex, M. gordonae, and M. nonchromogenicum were the most frequently detected mycobacteria. Drinking untreated compared to treated water (OR = 33), use of valley dam versus stream water for drinking and other domestic use (OR = 20), sharing of water sources with wild primates compared to antelopes (OR = 4.6), sharing of water sources with domestic animals (OR = 5.3), and close contact with cattle or other domestic animals (OR = 13.8) were the most plausible risk factors for humans to come in contact with NTM in the environment. Conclusions The study detected a wide range of potentially pathogenic NTM from the environment around the pastoral communities in Uganda. Drinking untreated water and living in close contact with cattle or other domestic animals may be risk factors associated with the possibility of humans and animals acquiring NTM infections from these ecosystems.
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Affiliation(s)
- Clovice Kankya
- Department of Veterinary Public Health, School of Veterinary Medicine, Makerere University, PO Box 7062, Kampala, Uganda.
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Munseri PJ, Talbot EA, Bakari M, Matee M, Teixeira JP, von Reyn CF. The bacteraemia of disseminated tuberculosis among HIV-infected patients with prolonged fever in Tanzania. ACTA ACUST UNITED AC 2011; 43:696-701. [DOI: 10.3109/00365548.2011.577802] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Muyanja SZ, Larke N, Rutebarika D, Kaddu I, Nakubulwa S, Levin J, Grosskurth H, Miiro G. Decreasing trends of bacteraemia among HIV-infected Ugandan adults: incidence, aetiology, clinical outcomes and effect of antiretroviral therapy in a semi-urban setting (2000-2008). Trop Med Int Health 2011; 16:756-65. [DOI: 10.1111/j.1365-3156.2011.02754.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Varma JK, McCarthy KD, Tasaneeyapan T, Monkongdee P, Kimerling ME, Buntheoun E, Sculier D, Keo C, Phanuphak P, Teeratakulpisarn N, Udomsantisuk N, Dung NH, Lan NTN, Yen NTB, Cain KP. Bloodstream infections among HIV-infected outpatients, Southeast Asia. Emerg Infect Dis 2011; 16:1569-75. [PMID: 20875282 PMCID: PMC3294385 DOI: 10.3201/eid1610.091686] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Jay K Varma
- Thailand Ministry of Public Health-US Centers for Disease Control and Prevention Collaboration, Nonthaburi, Thailand.
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High rate of pneumococcal bacteremia in a prospective cohort of older children and adults in an area of high HIV prevalence in rural western Kenya. BMC Infect Dis 2010; 10:186. [PMID: 20573224 PMCID: PMC2901359 DOI: 10.1186/1471-2334-10-186] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2010] [Accepted: 06/23/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Although causing substantial morbidity, the burden of pneumococcal disease among older children and adults in Africa, particularly in rural settings, is not well-characterized. We evaluated pneumococcal bacteremia among 21,000 persons > or =5 years old in a prospective cohort as part of population-based infectious disease surveillance in rural western Kenya from October 2006-September 2008. METHODS Blood cultures were done on patients meeting pre-defined criteria--severe acute respiratory illness (SARI), fever, and admission for any reason at a referral health facility within 5 kilometers of all 33 villages where surveillance took place. Serotyping of Streptococcus pneumoniae was done by latex agglutination and quellung reaction and antibiotic susceptibility testing was done using broth microdilution. We extrapolated incidence rates based on persons with compatible illnesses in the surveillance population who were not cultured. We estimated rates among HIV-infected persons based on community HIV prevalence. We projected the national burden of pneumococcal bacteremia cases based on these rates. RESULTS Among 1,301 blood cultures among persons > or =5 years, 52 (4%) yielded pneumococcus, which was the most common bacteria isolated. The yield was higher among those > or =18 years than 5-17 years (6.9% versus 1.6%, p < 0.001). The highest yield was for inpatients with SARI (10%), compared with SARI outpatients (3%) and acute febrile outpatients (1%). Serotype 1 pneumococcus was most common (42% isolates) and 71% were serotypes included in the 10-valent pneumococcal conjugate vaccine (PCV10). Non-susceptibility to beta-lactam antibiotics was low (<5%), but to trimethoprim-sulfamethoxazole was high (>95%). The crude rate of pneumococcal bacteremia was 129/100,000 person-years, and the adjusted rate was 419/100,000 person-years. Nineteen (61%) of 31 patients with HIV results were HIV-positive. The adjusted rate among HIV-infected persons was 2,399/100,000 person-years (Rate ratio versus HIV-negative adults, 19.7, 95% CI 12.4-31.1). We project 58,483 cases of pneumococcal bacteremia will occur in Kenyan adults in 2010. CONCLUSIONS Pneumococcal bacteremia rates were high among persons > or =5 years old, particularly among HIV-infected persons. Ongoing surveillance will document if expanded use of highly-active antiretroviral treatment for HIV and introduction of PCV10 for Kenyan children (anticipated in late 2010) result in substantial secondary benefits by reducing pneumococcal disease in adults.
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Community-acquired bloodstream infections in Africa: a systematic review and meta-analysis. THE LANCET. INFECTIOUS DISEASES 2010; 10:417-32. [PMID: 20510282 DOI: 10.1016/s1473-3099(10)70072-4] [Citation(s) in RCA: 467] [Impact Index Per Article: 33.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Data on the prevalence and causes of community-acquired bloodstream infections in Africa are scarce. We searched three databases for studies that prospectively studied patients admitted to hospital with at least a blood culture, and found 22 eligible studies describing 58 296 patients, of whom 2051 (13.5%) of 15 166 adults and 3527 (8.2%) of 43 130 children had bloodstream infections. 1643 (29.1%) non-malaria bloodstream infections were due to Salmonella enterica (58.4% of these non-typhoidal Salmonella), the most prevalent isolate overall and in adults, and 1031 (18.3% overall) were due to Streptococcus pneumoniae, the most common isolate in children. Other common isolates included Staphylococcus aureus (531 infections; 9.5%) and Escherichia coli (412; 7.3%). Mycobacterium tuberculosis complex accounted for 166 (30.7%) of 539 isolates in seven studies that used mycobacterial culture techniques. HIV infection was associated with any bloodstream infection, particularly with S enterica and M tuberculosis complex bacteraemia. Where recorded, patients with bloodstream infections had an in-hospital case fatality of 18.1%. Our results show that bloodstream infections are common and associated with high mortality. Improved clinical microbiology services and reassessment of empirical treatment guidelines that account for the epidemiology of bloodstream infections might contribute to better outcomes.
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Mayanja BN, Todd J, Hughes P, Van der Paal L, Mugisha JO, Atuhumuza E, Tabuga P, Maher D, Grosskurth H. Septicaemia in a population-based HIV clinical cohort in rural Uganda, 1996-2007: incidence, aetiology, antimicrobial drug resistance and impact of antiretroviral therapy. Trop Med Int Health 2010; 15:697-705. [DOI: 10.1111/j.1365-3156.2010.02528.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Severe sepsis in two Ugandan hospitals: a prospective observational study of management and outcomes in a predominantly HIV-1 infected population. PLoS One 2009; 4:e7782. [PMID: 19907656 PMCID: PMC2771355 DOI: 10.1371/journal.pone.0007782] [Citation(s) in RCA: 110] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2009] [Accepted: 10/10/2009] [Indexed: 01/20/2023] Open
Abstract
Background Sepsis likely contributes to the high burden of infectious disease morbidity and mortality in low income countries. Data regarding sepsis management in sub-Saharan Africa are limited. We conducted a prospective observational study reporting the management and outcomes of severely septic patients in two Ugandan hospitals. We describe their epidemiology, management, and clinical correlates for mortality. Methodology/Results Three-hundred eighty-two patients fulfilled enrollment criteria for a severe sepsis syndrome. Vital signs, management and laboratory results were recorded. Outcomes measured included in-hospital and post-discharge mortality. Most patients were HIV-infected (320/377, 84.9%) with a median CD4+ T cell (CD4) count of 52 cells/mm3 (IQR, 16–131 cells/mm3). Overall mortality was 43.0%, with 23.7% in-hospital mortality (90/380) and 22.3% post-discharge mortality (55/247). Significant predictors of in-hospital mortality included admission Glasgow Coma Scale and Karnofsky Performance Scale (KPS), tachypnea, leukocytosis and thrombocytopenia. Discharge KPS and early fluid resuscitation were significant predictors of post-discharge mortality. Among HIV-infected patients, CD4 count was a significant predictor of post-discharge mortality. Median volume of fluid resuscitation within the first 6 hours of presentation was 500 mLs (IQR 250–1000 mls). Fifty-two different empiric antibacterial regimens were used during the study. Bacteremic patients were more likely to die in hospital than non-bacteremic patients (OR 1.83, 95% CI = 1.01–3.33). Patients with Mycobacterium tuberculosis (MTB) bacteremia (25/249) had higher in-hospital mortality (OR 1.97, 95% CI = 1.19–327) and lower median CD4 counts (p = 0.001) than patients without MTB bacteremia. Conclusion Patients presenting with sepsis syndromes to two Ugandan hospitals had late stage HIV infection and high mortality. Bacteremia, especially from MTB, was associated with increased in-hospital mortality. Most clinical predictors of in-hospital mortality were easily measurable and can be used for triaging patients in resource-constrained settings. Procurement of low cost and high impact treatments like intravenous fluids and empiric antibiotics may help decrease sepsis-associated mortality in resource-constrained settings.
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Kigozi BK, Sumba S, Mudyope P, Namuddu B, Kalyango J, Karamagi C, Odere M, Katabira E, Mugyenyi P, Ssali F. The effect of AIDS defining conditions on immunological recovery among patients initiating antiretroviral therapy at Joint Clinical Research Centre, Uganda. AIDS Res Ther 2009; 6:17. [PMID: 19630949 PMCID: PMC2731026 DOI: 10.1186/1742-6405-6-17] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2009] [Accepted: 07/24/2009] [Indexed: 11/11/2022] Open
Abstract
Background Many HIV-infected patients only access health care once they have developed advanced symptomatic disease resulting from AIDS Defining Conditions (ADCs). We carried out a study to establish the effect of ADCs on immunological recovery among patients initiated on antiretroviral therapy (ART). Methods A retrospective cohort of 427 HIV-1 patients who were initiated on ART between January 2002 and December 2006 was studied. Data on ADCs was retrieved from Joint Clinical Research Centre (JCRC) data base and backed up by chart reviews. We employed Kaplan-Meier survival curves to estimate median time to 50 CD4 cells/μl from the baseline value to indicate a good immunological recovery process. Cox proportional hazard models were used at multivariate analysis. Results The median time to gaining 50 CD4 cells/μl from the baseline value after ART initiation was longer in the ADC (9.3 months) compared to the non-ADC group (6.9 months) (log rank test, p = 0.027). At multivariate analysis after adjusting for age, sex, baseline CD4 count, baseline HIV viral load, total lymphocyte count and adherence level, factors that shortened the median time to immunological recovery after ART initiation were belonging to the non-ADC group (HR = 1.31; 95% CI: 1.03–1.28, p = 0.028), adherence to ART of ≥ 95% (HR = 2.22; 95% CI: 1.57–3.15, p = 0.001) and a total lymphocyte count ≥ 1200 cells/mm3 (HR = 1.84; 95% CI: 1.22–2.78, p = 0.003). A low baseline CD4 count of ≤ 200 cells/μl (HR = 0.52; 95% CI: 0.37–0.77, p = 0.001) was associated with a longer time to immunological recovery. There was no interaction between low CD4 counts and ADC group. Conclusion Patients with ADCs take longer to regain their CD4 counts due to the defect in the immune system. This may prolong their risk of morbidity and mortality.
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Outcome of Patients With Pneumococcal Bacteremia at Mulago Hospital, Kampala. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2009. [DOI: 10.1097/ipc.0b013e31819d85b1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Comparaison du milieu mycobacteria growth indicator tube et des milieux solides pour l’isolement des mycobactéries du complexe tuberculosis à partir d’hémocultures. ACTA ACUST UNITED AC 2009; 57:44-50. [DOI: 10.1016/j.patbio.2008.05.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2008] [Accepted: 05/16/2008] [Indexed: 11/23/2022]
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Mtunthama N, Gordon SB, Kusimbwe T, Zijlstra EE, Molyneux ME, French N. Blood culture collection technique and pneumococcal surveillance in Malawi during the four year period 2003-2006: an observational study. BMC Infect Dis 2008; 8:137. [PMID: 18854024 PMCID: PMC2576305 DOI: 10.1186/1471-2334-8-137] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2008] [Accepted: 10/14/2008] [Indexed: 12/02/2022] Open
Abstract
Background Blood culture surveillance will be used for assessing the public health effectiveness of pneumococcal conjugate vaccines in Africa. Between 2003 and 2006 we assessed blood culture outcome and performance in adult patients in the central public hospital in Blantyre, Malawi, before and after the introduction of a dedicated nurse led blood culture team. Methods A prospective observational study. Results Following the introduction of a specialised blood culture team in 2005, the proportion of contaminated cultures decreased (19.6% in 2003 to 5.0% in 2006), blood volume cultured increased and pneumococcal recovery increased significantly from 2.8% of all blood cultures to 6.1%. With each extra 1 ml of blood cultured the odds of recovering a pneumococcus increased by 18%. Conclusion Standardisation and assessment of blood culture performance (blood volume and contamination rate) should be incorporated into pneumococcal disease surveillance activities where routine blood culture practice is constrained by limited resources.
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Affiliation(s)
- Neema Mtunthama
- Malawi-Liverpool-Liverpool Wellcome Trust Laboratories, Blantyre, Malawi.
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Gordon MA. Salmonella infections in immunocompromised adults. J Infect 2008; 56:413-22. [PMID: 18474400 DOI: 10.1016/j.jinf.2008.03.012] [Citation(s) in RCA: 297] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2008] [Revised: 03/25/2008] [Accepted: 03/31/2008] [Indexed: 12/11/2022]
Abstract
Clinical syndromes caused by Salmonella infection in humans are divided into typhoid fever, caused by Salmonella typhi and Salmonella paratyphi, and a range of clinical syndromes, including diarrhoeal disease, caused by a large number of non-typhoidal salmonella serovars (NTS). Typhoid is a human-restricted and highly adapted invasive disease, but shows little association with immunocompromise. In contrast, NTS have a broad vertebrate host range, epidemiology that often involves food animals, and have a dramatically more severe and invasive presentation in immunocompromised adults, in particular in the context of HIV. Immunocompromise among adults, including underlying severe or progressive disease, chronic granulomatous disease, defects or blockade of specific cytokines (particularly IL-12/IL-23/IL-17 and TNF), and HIV, is associated with suppurative foci and with primary bacteraemic disease, which may be recurrent. These patients have markedly increased mortality. Worldwide, invasive recurrent NTS bacteraemia associated with advanced HIV disease is a huge problem, and the epidemiology in this context may be more human-restricted than in other settings. This review will describe the presentation and pathogenesis of NTS in different categories of immunocompromised adults, contrasted to typhoid fever.
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Affiliation(s)
- Melita A Gordon
- Division of Gastroenterology, Henry Wellcome Laboratories, Nuffield Building, Crown Street, Liverpool University L69 3GE, UK.
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Bloodstream infections among human immunodeficiency virus-infected adult patients: epidemiology and risk factors for mortality. Eur J Clin Microbiol Infect Dis 2008; 27:969-76. [DOI: 10.1007/s10096-008-0531-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2008] [Accepted: 04/01/2008] [Indexed: 11/26/2022]
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Moore CC, Jacob ST, Pinkerton R, Meya DB, Mayanja-Kizza H, Reynolds SJ, Scheld WM. Point-of-care lactate testing predicts mortality of severe sepsis in a predominantly HIV type 1-infected patient population in Uganda. Clin Infect Dis 2008; 46:215-22. [PMID: 18171253 DOI: 10.1086/524665] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Prediction of mortality may improve management and outcomes of patients with sepsis in resource-limited settings. Therefore, we evaluated the ability of a hand-held portable whole-blood lactate (PWBL) analyzer to predict mortality of patients who are admitted to the hospital with severe sepsis. METHODS A prospective observational study enrolled 253 patients at a national referral hospital in Uganda. Inclusion criteria required (1) >or=2 systemic inflammatory response syndrome criteria or thermodysregulation, (2) hypotension, and (3) suspected infection. A subset of 72 patients had PWBL and standard laboratory serum lactate measured. The primary measured outcome was in-hospital mortality. RESULTS Fifty-nine (81.9%) of 72 evaluated patients were infected with human immunodeficiency virus type 1. The in-hospital mortality rate was 25.7% (18 of 70), and the in- and outpatient mortality at 30 days was 41.6% (30 of 72). PWBL was positively associated with in-hospital but not outpatient mortality (P=.001). The receiver operating characteristic area under the curve for PWBL was 0.81 (P=.081). The optimal PWBL concentration for predicting in-hospital mortality (sensitivity, 88.3%; specificity, 71.2%) was >or=4.0 mmol/L. Patients with a PWBL concentration >or=4.0 mmol/L died while in the hospital substantially more often (50.0%) than did those with a PWBL concentration <4.0 mmol/L (7.5%) (odds ratio, 12.3; 95% confidence interval, 3.5-48.9; [P=.001). Standard laboratory serum lactate results were inconsistent and less predictive of mortality than were those of PWBL in a multiple logistic regression model. CONCLUSION A PWBL concentration >or=4.0 mmol/L predicts with 81% accuracy a 7-fold higher mortality of patients with sepsis than does a PWBL concentration <4.0 mmol/L. PWBL testing would be useful in places where clinical decisions are limited by lack of laboratory infrastructure and poor reliability.
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Affiliation(s)
- Christopher C Moore
- Department of Internal Medicine, Division of Infectious Diseases and International Health, University of Virginia Health System, Charlottesville, VA 22908, USA.
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Martinson NA, Karstaedt A, Venter WDF, Omar T, King P, Mbengo T, Marais E, McIntyre J, Chaisson RE, Hale M. Causes of death in hospitalized adults with a premortem diagnosis of tuberculosis: an autopsy study. AIDS 2007; 21:2043-50. [PMID: 17885294 DOI: 10.1097/qad.0b013e3282eea47f] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To ascertain the immediate and underlying causes of death in adults who died in hospital with a premortem diagnosis of tuberculosis. DESIGN Causes of death were assessed independently by internists and pathologists in 50 adults admitted to two Soweto hospitals who died 24 h or more after admission. Detailed record reviews and complete autopsies, including HIV tests when not performed premortem, were performed. In addition, a variety of postmortem microbiological tests were performed. RESULTS Forty-seven patients had HIV infection; all were antiretroviral naive. Their median age was 34.5 years, median CD4 cell count was 48 cells/microl and median length of hospitalization before death was 6 days. Autopsy confirmed the premortem diagnosis of tuberculosis in 37 HIV-infected patients (79%), whereas 10 (21%) did not demonstrate tuberculosis. Bronchopneumonia and cytomegalovirus pneumonitis were the leading pathologies in these 10 patients. In 47 HIV-infected cadavers immediate or contributory causes of death were: extensive pulmonary tuberculosis, 32 (68%); disseminated tuberculosis, 28 (60%); bacterial pneumonia, 13 (26%); cytomegalovirus pneumonitis in seven (15%); cytomegalovirus DNA was found in 31 (66%) and Pneumocystis pneumonia was found in five cadavers (11%). The lung, followed by lymph nodes, liver and kidney, were the commonest sites of tuberculosis. Mycobacterium tuberculosis was cultured from 19 spleens, one of which was multidrug resistant, and Salmonella spp. was cultured from 11 splenic specimens. CONCLUSION We demonstrated disseminated, extensive tuberculosis associated with advanced HIV disease. Severe bacterial infections, including salmonellosis, were the leading co-morbidity, suggesting that hospitalized HIV-infected adults in whom tuberculosis is suspected may benefit from broad-spectrum antibiotic therapy.
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Affiliation(s)
- Neil A Martinson
- Johns Hopkins University Center for TB Research, Baltimore, Maryland, USA.
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Manosuthi W, Chottanapand S, Thongyen S, Chaovavanich A, Sungkanuparph S. Survival rate and risk factors of mortality among HIV/tuberculosis-coinfected patients with and without antiretroviral therapy. J Acquir Immune Defic Syndr 2006; 43:42-6. [PMID: 16885778 DOI: 10.1097/01.qai.0000230521.86964.86] [Citation(s) in RCA: 188] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The impact of antiretroviral therapy (ART) on survival among patients coinfected with HIV and tuberculosis (TB) has not been well established. METHODS A retrospective cohort study was conducted among HIV-infected patients with TB between January 2000 and December 2004. Patients were categorized into ART+ group (received ART) and ART- group (did not receive ART) and were followed until April 2005. RESULTS A total of 1003 patients were identified; 411 in ART+ group and 592 in ART- group. Median (interquartile range) CD4 count was 53 (20-129) cells/mm3. Survival rates at 1, 2, and 3 years after TB diagnosis were 96.1%, 94.0%, and 87.7% for ART+ group and 44.4%, 19.2%, and 9.3% for ART- group (log-rank test, P<0.001). Cox proportional hazard model showed that ART was associated with lower mortality rate; gastrointestinal TB and multidrug resistant TB were associated with higher mortality rate (P<0.05). Among patients in ART+ group, the patients who delayed ART>or=6 months after TB diagnosis had a higher mortality rate than those who initiated ART<6 months after TB diagnosis (P 0.018, hazard ratio=2.651, 95% confidence interval=1.152-6.102). CONCLUSIONS Antiretroviral therapy substantially reduces mortality rate among HIV/TB-coinfected patients. Initiation of ART within 6 months of TB diagnosis is associated with greater survival.
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Affiliation(s)
- Weerawat Manosuthi
- Bamrasnaradura Infectious Diseases Institute, Ministry of Public Health, Nonthaburi and Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand.
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Archibald LK, Pallangyo K, Kazembe P, Reller LB. Blood culture contamination in Tanzania, Malawi, and the United States: a microbiological tale of three cities. J Clin Microbiol 2006; 44:4425-9. [PMID: 17021063 PMCID: PMC1698400 DOI: 10.1128/jcm.01215-06] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
We conducted retrospective, comparative analyses of contamination rates for cultures of blood obtained in the emergency rooms of Muhimbili National Hospital (MNH) in Dar es Salaam, Tanzania; Lilongwe Central Hospital (LCH) in central Malawi; and the Duke University Medical Center (DUMC) in the United States. None of the emergency room patients had indwelling intravascular devices at the time that the blood samples for cultures were obtained. In addition, we reviewed the contamination rates for a cohort of patients already hospitalized in the DUMC inpatient medical service, most of whom had indwelling intravascular devices. The bloodstream infection rates among the patients at MNH (n=513) and LCH (n=486) were similar (approximately 28%); the contamination rates at the two hospitals were 1.3% (7/513) and 0.8% (4/486), respectively. Of 54 microorganisms isolated from cultures of blood collected in the DUMC emergency room, 26 (48%) were identified as skin contaminants. Cultures of blood collected in the DUMC emergency room were significantly more likely to yield growth of contaminants than the cultures of blood collected in the emergency rooms at MNH and LCH combined (26/332 versus 11/1,003; P<0.0001) or collected in the DUMC inpatient medical service (26/332 versus 7/283; P<0.01). For the MNH and LCH blood cultures, lower contamination rates were observed when skin was disinfected with isopropyl alcohol plus tincture of iodine rather than isopropyl alcohol plus povidone-iodine. In conclusion, blood culture contamination was minimized in sub-Saharan African hospitals with substantially limited resources through scrupulous attention to aseptic skin cleansing and improved venipuncture techniques. Application of these principles when blood samples for culture are obtained in U.S. hospital emergency rooms should help mitigate blood culture contamination rates and the unnecessary microbiology workup of skin contaminants.
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Affiliation(s)
- Lennox K Archibald
- Duke University Medical Center, Durham, NC, USA, and Lilongwe Central Hospital, Malawi.
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Mootsikapun P. Bacteremia in adult patients with acquired immunodeficiency syndrome in the northeast of Thailand. Int J Infect Dis 2006; 11:226-31. [PMID: 16815065 DOI: 10.1016/j.ijid.2006.02.010] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2005] [Revised: 02/03/2006] [Accepted: 02/08/2006] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Bacteremia is a frequent complication found in HIV-infected patients and is usually associated with a poor prognosis. This study was undertaken to describe the bacterial pathogens causing bacteremia in adult Thai HIV-infected patients, and hence to give guidance in the choice of empirical antimicrobials. METHODS Blood culture results at Srinagarind Hospital, Khon Kaen during the period January 1996 to December 2001 were retrospectively reviewed. RESULTS In HIV-infected and HIV-uninfected patients, 172 and 4082 episodes of bacteremia occurred, respectively. In HIV-infected patients, community-acquired and nosocomial bacteremia were found in 78.5% and 21.5%, respectively and most were monomicrobial. Gram-negative bacteria were the main pathogens isolated in both groups of bacteremia. Escherichia coli and methicillin-resistant Staphylococcus aureus were more common pathogens causing nosocomial bacteremia in HIV-infected patients, whereas Acinetobacter spp were more common in HIV-uninfected patients. Salmonella spp, especially Salmonella groups D and B, were the most common (62.2%) pathogen in community-acquired bacteremia in HIV-infected patients whereas Escherichia coli was the most common in HIV-uninfected patients. Only a few episodes of community-acquired bacteremia in HIV-infected patients had identified sources. Co-trimoxazole resistance was common in community-acquired bacteremia caused by Gram-negative bacilli in HIV-infected patients, with Salmonella group B being more resistant to co-trimoxazole than Salmonella group D (statistically significant, p<0.001). However, resistance rates to ceftriaxone and ofloxacin were low. CONCLUSIONS Bacteremia in adult HIV-infected patients was usually caused by Gram-negative bacilli in both community-acquired and nosocomial settings. Salmonella spp was the most common organism identified, especially Salmonella group B and D. Ceftriaxone or fluoroquinolones such as ofloxacin or ciprofloxacin should be used as the initial empiric therapy for HIV-infected patients with suspected bacteremia.
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Affiliation(s)
- Piroon Mootsikapun
- Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand 40002.
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Peters RPH, Zijlstra EE, Schijffelen MJ, Walsh AL, Joaki G, Kumwenda JJ, Kublin JG, Molyneux ME, Lewis DK. A prospective study of bloodstream infections as cause of fever in Malawi: clinical predictors and implications for management. Trop Med Int Health 2004; 9:928-34. [PMID: 15304000 DOI: 10.1111/j.1365-3156.2004.01288.x] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To determine the contribution of a blood culture service to the diagnosis of fever in a resource-poor setting and to identify clinical predictors of specific bloodstream infections (BSI). METHODS In a descriptive, prospective study at the Medical Wards at Queen Elizabeth Central Hospital, Blantyre, Malawi, we tried to identify a specific cause of fever in febrile patients, comparing the use of routinely available diagnostic methods with the same methods plus blood culture. Clinical predictors of specific BSIs were sought. RESULTS A total of 352 patients admitted with fever (axillary temperature > or =37.4 degrees C) or a history of fever within the last 4 days were enrolled. Tuberculosis (TB) was the diagnosis most commonly suspected initially on clinical grounds (28%), followed by lower respiratory tract infection (16%), malaria (12%) and gastroenteritis (5%). Blood cultures were positive in 128 patients (36%); Mycobacterium tuberculosis was the most commonly isolated organism (57 patients). In most cases the diagnosis of TB had already been made using routinely available diagnostic methods, including chest radiography. In all 16 cases of Streptococcus pneumoniae bacteraemia, infection with this agent was clinically suspected, usually on the basis of pulmonary symptoms and signs. In contrast, in 30 of 65 patients (65%) with non-typhi salmonellae (NTS) bacteraemia, there were no symptoms or signs specifically suggestive of this diagnosis. Fever > or =39 degrees C and splenomegaly predicted NTS bacteraemia with an odds ratio of 8.4 (95% confidence interval 3.4-20.6, P < 0.001). CONCLUSION BSIs are common among patients admitted with fever. While BSI with mycobacteraemia and S. pneumoniae can usually be predicted on clinical grounds and with routinely available diagnostic methods, NTS bacteraemia often presents as a primary BSI without localizing symptoms and signs. Splenomegaly in this population indicates NTS bacteraemia rather than malaria.
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Affiliation(s)
- Remco P H Peters
- Department of Medicine, College of Medicine, University of Malawi, Blantyre, Malawi.
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Feikin DR, Feldman C, Schuchat A, Janoff EN. Global strategies to prevent bacterial pneumonia in adults with HIV disease. THE LANCET. INFECTIOUS DISEASES 2004; 4:445-55. [PMID: 15219555 DOI: 10.1016/s1473-3099(04)01060-6] [Citation(s) in RCA: 119] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We examined the peer-reviewed literature on the burden of bacterial pneumonia and the effectiveness of interventions for its prevention among HIV-infected adults in developed and developing countries. Bacterial pneumonia rates were up to 25-fold higher among HIV-infected adults than in the general community, with rates increasing as CD4+ T-cell count decreases. In developed countries, cohort studies showed that highly active antiretroviral therapy (HAART) had the most consistent effect on reducing pneumonia. In a prospective cohort and case-control studies from these regions, pneumococcal polysaccharide vaccine reduced pneumococcal disease in certain subgroups, particularly those with higher CD4+ T cells/microL. In patients with fewer than 200 CD4+ T cells/microL, antimicrobial prophylaxis was usually effective in reducing pneumonia. In sub-Saharan Africa, randomised controlled trials concluded that co-trimoxazole prophylaxis decreased rates of bacterial pneumonia, but pneumococcal polysaccharide vaccine prevented neither pneumonia nor invasive pneumococcal disease. Although not yet fully evaluated in Africa, based on experience in industrialised nations, use of HAART in Africa may have substantial potential to prevent bacterial pneumonia.
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Affiliation(s)
- Daniel R Feikin
- Respiratory Diseases Branch, Division of Bacterial and Mycotic Diseases, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
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