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Said B, Nuwagira E, Liyoyo A, Arinaitwe R, Gitige C, Mushagara R, Buzaare P, Chongolo A, Jjunju S, Twesigye P, Boulware DR, Conaway M, Null M, Thomas TA, Heysell SK, Moore CC, Muzoora C, Mpagama SG. Early empiric anti- Mycobacterium tuberculosis therapy for sepsis in sub-Saharan Africa: a protocol of a randomised clinical trial. BMJ Open 2022; 12:e061953. [PMID: 35667721 PMCID: PMC9171283 DOI: 10.1136/bmjopen-2022-061953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Sub-Saharan Africa shoulders the highest burden of global sepsis and associated mortality. In high HIV and tuberculosis (TB) prevalent settings such as sub-Saharan Africa, TB is the leading cause of sepsis. However, anti-TB therapy is often delayed and may not achieve adequate blood concentrations in patients with sepsis. Accordingly, this multisite randomised clinical trial aims to determine whether immediate and/or increased dose anti-TB therapy improves 28-day mortality for participants with HIV and sepsis in Tanzania or Uganda. METHODS AND ANALYSIS This is a phase 3, multisite, open-label, randomised controlled clinical 2×2 factorial superiority trial of (1) immediate initiation of anti-TB therapy and (2) sepsis-specific dose anti-TB therapy in addition to standard of care antibacterials for adults with HIV and sepsis admitted to hospital in Tanzania or Uganda. The primary endpoint is 28-day mortality. A sample size of 436 participants will provide 80% power for testing each of the main effects of timing and dose on 28-day mortality with a two-sided significance level of 5%. The expected main effect for absolute risk reduction is 13% and the expected OR for risk reduction is 1.58. ETHICS AND DISSEMINATION This clinical trial will determine the optimal content, dosing and timing of antimicrobial therapy for sepsis in high HIV and TB prevalent settings. The study is funded by the National Institutes of Health in the US. Institutional review board approval was conferred by the University of Virginia, the Tanzania National Institute for Medical Research, and the Uganda National Council for Science and Technology. Study results will be published in peer-reviewed journals and in the popular press of Tanzania and Uganda. We will also present our findings to the Community Advisory Boards that we convened during study preparation. TRIAL REGISTRATION NUMBER ClinicalTrials.gov (NCT04618198).
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Affiliation(s)
- Bibie Said
- Department of Medicine, Kibong'oto Infectious Diseases Hospital, Sanya Juu, United Republic of Tanzania
| | - Edwin Nuwagira
- Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Alphonce Liyoyo
- Department of Medicine, Kibong'oto Infectious Diseases Hospital, Sanya Juu, United Republic of Tanzania
| | - Rinah Arinaitwe
- Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Catherine Gitige
- Department of Medicine, Kibong'oto Infectious Diseases Hospital, Sanya Juu, United Republic of Tanzania
| | - Rhina Mushagara
- Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Peter Buzaare
- Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Anna Chongolo
- Department of Medicine, Kibong'oto Infectious Diseases Hospital, Sanya Juu, United Republic of Tanzania
| | - Samuel Jjunju
- Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Precious Twesigye
- Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - David R Boulware
- University of Minnesota Medical School Twin Cities, Minneapolis, Minnesota, USA
| | - Mark Conaway
- Department of Public Health Sciences, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Megan Null
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
| | - Tania A Thomas
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
| | - Scott K Heysell
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
| | - Christopher C Moore
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
| | - Conrad Muzoora
- Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Stellah G Mpagama
- Department of Medicine, Kibong'oto Infectious Diseases Hospital, Sanya Juu, United Republic of Tanzania
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Lewis JM, Mphasa M, Keyala L, Banda R, Smith EL, Duggan J, Brooks T, Catton M, Mallewa J, Katha G, Gordon SB, Faragher B, Gordon MA, Rylance J, Feasey NA. A Longitudinal, Observational Study of Etiology and Long-Term Outcomes of Sepsis in Malawi Revealing the Key Role of Disseminated Tuberculosis. Clin Infect Dis 2022; 74:1840-1849. [PMID: 34407175 PMCID: PMC9155594 DOI: 10.1093/cid/ciab710] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Sepsis protocols in sub-Saharan Africa are typically extrapolated from high-income settings, yet sepsis in sub-Saharan Africa is likely caused by distinct pathogens and may require novel treatment strategies. Data to guide such strategies are lacking. We aimed to define causes and modifiable factors associated with sepsis outcomes in Blantyre, Malawi, in order to inform the design of treatment strategies tailored to sub-Saharan Africa. METHODS We recruited 225 adults who met a sepsis case definition defined by fever and organ dysfunction in an observational cohort study at a single tertiary center. Etiology was defined using culture, antigen detection, serology, and polymerase chain reaction. The effect of treatment on 28-day outcomes was assessed using Bayesian logistic regression. RESULTS There were 143 of 213 (67%) participants living with human immunodeficiency virus (HIV). We identified a diagnosis in 145 of 225 (64%) participants, most commonly tuberculosis (TB; 34%) followed by invasive bacterial infections (17%), arboviral infections (13%), and malaria (9%). TB was associated with HIV infection, whereas malaria and arboviruses with the absence of HIV infection. Antituberculous chemotherapy was associated with survival (adjusted odds ratio for 28-day death, 0.17; 95% credible interval, 0.05-0.49 for receipt of antituberculous therapy). Of those with confirmed etiology, 83% received the broad-spectrum antibacterial ceftriaxone, but it would be expected to be active in only 24%. CONCLUSIONS Sepsis in Blantyre, Malawi, is caused by a range of pathogens; the majority are not susceptible to the broad-spectrum antibacterials that most patients receive. HIV status is a key determinant of etiology. Novel antimicrobial strategies for sepsis tailored to sub-Saharan Africa, including consideration of empiric antituberculous therapy in individuals living with HIV, should be developed and trialed.
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Affiliation(s)
- Joseph M Lewis
- Malawi Liverpool Wellcome Programme, Blantyre, Malawi
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, United Kingdom
| | | | - Lucy Keyala
- Malawi Liverpool Wellcome Programme, Blantyre, Malawi
| | - Rachel Banda
- Malawi Liverpool Wellcome Programme, Blantyre, Malawi
| | - Emma L Smith
- Malawi Liverpool Wellcome Programme, Blantyre, Malawi
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Jackie Duggan
- Rare and Imported Pathogens Laboratory, Public HealthEngland, United Kingdom
| | - Tim Brooks
- Rare and Imported Pathogens Laboratory, Public HealthEngland, United Kingdom
| | - Matthew Catton
- Rare and Imported Pathogens Laboratory, Public HealthEngland, United Kingdom
| | - Jane Mallewa
- College of Medicine, University of Malawi, Malawi
| | - Grace Katha
- College of Medicine, University of Malawi, Malawi
| | - Stephen B Gordon
- Malawi Liverpool Wellcome Programme, Blantyre, Malawi
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Brian Faragher
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Melita A Gordon
- Malawi Liverpool Wellcome Programme, Blantyre, Malawi
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, United Kingdom
| | - Jamie Rylance
- Malawi Liverpool Wellcome Programme, Blantyre, Malawi
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Nicholas A Feasey
- Malawi Liverpool Wellcome Programme, Blantyre, Malawi
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
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Bonnewell JP, Rubach MP, Madut DB, Carugati M, Maze MJ, Kilonzo KG, Lyamuya F, Marandu A, Kalengo NH, Lwezaula BF, Mmbaga BT, Maro VP, Crump JA. Performance Assessment of the Universal Vital Assessment Score vs Other Illness Severity Scores for Predicting Risk of In-Hospital Death Among Adult Febrile Inpatients in Northern Tanzania, 2016-2019. JAMA Netw Open 2021; 4:e2136398. [PMID: 34913982 PMCID: PMC8678687 DOI: 10.1001/jamanetworkopen.2021.36398] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 09/26/2021] [Indexed: 12/26/2022] Open
Abstract
Importance Severity scores are used to improve triage of hospitalized patients in high-income settings, but the scores may not translate well to low- and middle-income settings such as sub-Saharan Africa. Objective To assess the performance of the Universal Vital Assessment (UVA) score, derived in 2017, compared with other illness severity scores for predicting in-hospital mortality among adults with febrile illness in northern Tanzania. Design, Setting, and Participants This prognostic study used clinical data collected for the duration of hospitalization among patients with febrile illness admitted to Kilimanjaro Christian Medical Centre or Mawenzi Regional Referral Hospital in Moshi, Tanzania, from September 2016 through May 2019. All adult and pediatric patients with a history of fever within 72 hours or a tympanic temperature of 38.0 °C or higher at screening were eligible for enrollment. Of 3761 eligible participants, 1132 (30.1%) were enrolled in the parent study; of those, 597 adults 18 years or older were included in this analysis. Data were analyzed from December 2019 to September 2021. Exposures Modified Early Warning Score (MEWS), National Early Warning Score (NEWS), quick Sequential Organ Failure Assessment (qSOFA), Systemic Inflammatory Response Syndrome (SIRS) assessment, and UVA. Main Outcomes and Measures The main outcome was in-hospital mortality during the same hospitalization as the participant's enrollment. Crude risk ratios and 95% CIs for in-hospital death were calculated using log-binomial risk regression for proposed score cutoffs for each of the illness severity scores. The area under the receiver operating characteristic curve (AUROC) for estimating the risk of in-hospital death was calculated for each score. Results Among 597 participants, the median age was 43 years (IQR, 31-56 years); 300 participants (50.3%) were female, 198 (33.2%) were HIV-infected, and in-hospital death occurred in 55 (9.2%). By higher risk score strata for each score, compared with lower risk strata, risk ratios for in-hospital death were 3.7 (95% CI, 2.2-6.2) for a MEWS of 5 or higher; 2.7 (95% CI, 0.9-7.8) for a NEWS of 5 or 6; 9.6 (95% CI, 4.2-22.2) for a NEWS of 7 or higher; 4.8 (95% CI, 1.2-20.2) for a qSOFA score of 1; 15.4 (95% CI, 3.8-63.1) for a qSOFA score of 2 or higher; 2.5 (95% CI, 1.2-5.2) for a SIRS score of 2 or higher; 9.1 (95% CI, 2.7-30.3) for a UVA score of 2 to 4; and 30.6 (95% CI, 9.6-97.8) for a UVA score of 5 or higher. The AUROCs, using all ordinal values, were 0.85 (95% CI, 0.80-0.90) for the UVA score, 0.81 (95% CI, 0.75-0.87) for the NEWS, 0.75 (95% CI, 0.69-0.82) for the MEWS, 0.73 (95% CI, 0.67-0.79) for the qSOFA score, and 0.63 (95% CI, 0.56-0.71) for the SIRS score. The AUROC for the UVA score was significantly greater than that for all other scores (P < .05 for all comparisons) except for NEWS (P = .08). Conclusions and Relevance This prognostic study found that the NEWS and the UVA score performed favorably compared with other illness severity scores in predicting in-hospital mortality among a hospitalized cohort of adults with febrile illness in northern Tanzania. Given its reliance on readily available clinical data, the UVA score may have utility in the triage and prognostication of patients admitted to the hospital with febrile illness in low- to middle-income settings such as sub-Saharan Africa.
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Affiliation(s)
- John P. Bonnewell
- Department of Pathology, Duke University Medical Center, Durham, North Carolina
- Division of Infectious Diseases and International Health, Department of Medicine, Duke University Medical Center, Durham, North Carolina
- Duke Global Health Institute, Duke University, Durham, North Carolina
| | - Matthew P. Rubach
- Division of Infectious Diseases and International Health, Department of Medicine, Duke University Medical Center, Durham, North Carolina
- Duke Global Health Institute, Duke University, Durham, North Carolina
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Programme in Emerging Infectious Diseases, Duke–National University of Singapore Medical School, Singapore
| | - Deng B. Madut
- Division of Infectious Diseases and International Health, Department of Medicine, Duke University Medical Center, Durham, North Carolina
- Duke Global Health Institute, Duke University, Durham, North Carolina
| | - Manuela Carugati
- Division of Infectious Diseases and International Health, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Michael J. Maze
- Department of Medicine, University of Otago, Dunedin, New Zealand
- Centre for International Health, University of Otago, Dunedin, New Zealand
| | - Kajiru G. Kilonzo
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Kilimanjaro Christian Medical University College, Tumaini University, Moshi, Tanzania
| | - Furaha Lyamuya
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Kilimanjaro Christian Medical University College, Tumaini University, Moshi, Tanzania
| | | | | | | | - Blandina T. Mmbaga
- Duke Global Health Institute, Duke University, Durham, North Carolina
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Kilimanjaro Christian Medical University College, Tumaini University, Moshi, Tanzania
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania
| | - Venance P. Maro
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Kilimanjaro Christian Medical University College, Tumaini University, Moshi, Tanzania
| | - John A. Crump
- Division of Infectious Diseases and International Health, Department of Medicine, Duke University Medical Center, Durham, North Carolina
- Duke Global Health Institute, Duke University, Durham, North Carolina
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Department of Medicine, University of Otago, Dunedin, New Zealand
- Centre for International Health, University of Otago, Dunedin, New Zealand
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Blum LS, Karia FP, Msoka EF, Oshosen Mwanga M, Crump JA, Rubach MP. An In-Depth Examination of Reasons for Autopsy Acceptance and Refusal in Northern Tanzania. Am J Trop Med Hyg 2020; 103:1670-1680. [PMID: 32748779 DOI: 10.4269/ajtmh.20-0029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Uncertainty about the causes of death (COD) in low- and middle-income countries (LMICs) has been recognized as a constraint to global health and development. Although complete diagnostic autopsy (CDA) is the best way to assess COD, it is uncommon in LMICs because of low investment priority and assumptions about poor acceptability. Social science research was conducted from May 2016 through July 2017 to examine issues related to acceptability of CDAs in northern Tanzania where autopsy was being offered in two referral hospitals to assess COD associated with febrile illness. Initial formative research entailed 29 key informant interviews, seven observations of burial practices, and four group discussions. In-depth interviews were conducted with families of deceased, including nine families that accepted and 11 families that refused CDA. The formative research identified concepts related to death, understandings of CDA, and cultural practices and psychosocial considerations associated with death that informed the authorization process. Most families who accepted CDA cited the desire to get clarity regarding the COD as a primary reason for acceptance. An unexpected finding was that CDA is perceived as a means to determine witchcraft involvement, a common explanation for COD and a common reason for postmortem acceptance. Death resulting from chronic illness or conditions presumed to have a clinical diagnosis were reasons for CDA to be viewed as unnecessary. The timing, way families were approached, and content of information shared during authorization influenced acceptance and refusal of CDA. Findings show that CDAs can be acceptable in settings where traditional disease models prevail.
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Affiliation(s)
| | - Francis P Karia
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania.,Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | | | | | - John A Crump
- Centre for International Health, University of Otago, Dunedin, New Zealand.,Duke Global Health Institute, Duke University, Durham, North Carolina.,Division of Infectious Diseases and International Health, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Matthew P Rubach
- Duke Global Health Institute, Duke University, Durham, North Carolina.,Division of Infectious Diseases and International Health, Department of Medicine, Duke University Medical Center, Durham, North Carolina
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Kishimbo P, Sogone NM, Kalokola F, Mshana SE. Prevalence of gram negative bacteria causing community acquired pneumonia among adults in Mwanza City, Tanzania. Pneumonia (Nathan) 2020; 12:7. [PMID: 32775174 PMCID: PMC7409501 DOI: 10.1186/s41479-020-00069-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 06/07/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Community acquired pneumonia (CAP) in adults is still a common and serious illness in the sub-Saharan Africa. Identification of the pathogens is crucial in the management of CAP. This study was done to determine the common bacterial pathogens, treatment outcomes and associated factors for microbiological confirmed CAP among adults attending the Bugando Medical Centre and Sekou Toure hospital in the city of Mwanza, Tanzania. METHODS This was a hospital based cross sectional study involving patients with community acquired pneumonia attending Bugando Medical Centre and Sekou Toure regional Hospital. Demographic and other data were collected using standardized data collection tool. Sputum culture was done followed by identification of the isolates and antibiotics susceptibility testing. RESULTS A total of 353 patients were enrolled in the study. Out of 353 sputum samples, 265(75%) were of good quality. Of 353 non-repetitive sputum cultures, 72/353 (20.4, 95% CI: 16.2-24.6) were positive for the bacterial pathogens with five patients having more than one pathogen. Good quality sputa had significantly higher yield of pathogenic bacteria than poor quality sputa (26.1% vs.3.4%, P = 0.001). The majority 64 (83.1%) of the isolates were gram negative bacteria. Common bacteria isolated were Klebsiella pneumoniae 23/77(29.9%), Streptococcus pyogenes 10/77 (13.0%), Pseudomonas aeruginosa 9/77 (11.7%) and Escherichia coli 7/77 (9.1%). Of 23 K. pneumoniae isolates, 20/23 (87.0%) were resistant to ceftriaxone. Resistance to ceftriaxone was found to be associated with prolongation of CAP symptoms (p = 0.009). CONCLUSION Gram negative bacteria resistant to ampicillin, amoxicillin/clavulanic acid and ceftriaxone were most frequently isolated bacteria among adults' patients with CAP attending BMC and Sekou Toure hospital. Routine sputum culture should be performed to guide appropriate treatment of CAP among adults in developing countries.
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Affiliation(s)
- Peter Kishimbo
- Department of Internal Medicine, Weill Bugando School of Medicine, Mwanza, Tanzania
| | - Nyambura Moremi Sogone
- National Health Laboratory Quality Assurance and Training Centre, Dar es Salaam, Tanzania
| | - Fredrick Kalokola
- Department of Internal Medicine, Weill Bugando School of Medicine, Mwanza, Tanzania
| | - Stephen E Mshana
- Department of Microbiology/Immunology, Weill Bugando School of Medicine, Mwanza, Tanzania
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Halliday JEB, Carugati M, Snavely ME, Allan KJ, Beamesderfer J, Ladbury GAF, Hoyle DV, Holland P, Crump JA, Cleaveland S, Rubach MP. Zoonotic causes of febrile illness in malaria endemic countries: a systematic review. THE LANCET. INFECTIOUS DISEASES 2020; 20:e27-e37. [PMID: 32006517 PMCID: PMC7212085 DOI: 10.1016/s1473-3099(19)30629-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 10/03/2019] [Accepted: 10/29/2019] [Indexed: 01/04/2023]
Abstract
Fever is one of the most common reasons for seeking health care globally and most human pathogens are zoonotic. We conducted a systematic review to describe the occurrence and distribution of zoonotic causes of human febrile illness reported in malaria endemic countries. We included data from 53 (48·2%) of 110 malaria endemic countries and 244 articles that described diagnosis of 30 zoonoses in febrile people. The majority (17) of zoonoses were bacterial, with nine viruses, three protozoa, and one helminth also identified. Leptospira species and non-typhoidal salmonella serovars were the most frequently reported pathogens. Despite evidence of profound data gaps, this Review reveals widespread distribution of multiple zoonoses that cause febrile illness. Greater understanding of the epidemiology of zoonoses in different settings is needed to improve awareness about these pathogens and the management of febrile illness.
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Affiliation(s)
- Jo E B Halliday
- Boyd Orr Centre for Population and Ecosystem Health, Institute of Biodiversity, Animal Health and Comparative Medicine, University of Glasgow, Glasgow, UK.
| | - Manuela Carugati
- Division of Infectious Diseases, Duke University Medical Center, Durham, NC, USA; Kilimanjaro Christian Medical Centre, Moshi, Tanzania; Division of Infectious Diseases, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Michael E Snavely
- Washington University in St Louis School of Medicine, St Louis, MO, USA
| | - Kathryn J Allan
- Boyd Orr Centre for Population and Ecosystem Health, Institute of Biodiversity, Animal Health and Comparative Medicine, University of Glasgow, Glasgow, UK
| | - Julia Beamesderfer
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Georgia A F Ladbury
- Boyd Orr Centre for Population and Ecosystem Health, Institute of Biodiversity, Animal Health and Comparative Medicine, University of Glasgow, Glasgow, UK
| | - Deborah V Hoyle
- Roslin Institute and Royal (Dick) School of Veterinary Studies, Edinburgh, UK
| | - Paul Holland
- Boyd Orr Centre for Population and Ecosystem Health, Institute of Biodiversity, Animal Health and Comparative Medicine, University of Glasgow, Glasgow, UK
| | - John A Crump
- Division of Infectious Diseases, Duke University Medical Center, Durham, NC, USA; Kilimanjaro Christian Medical Centre, Moshi, Tanzania; Centre for International Health, University of Otago, Dunedin, New Zealand; Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Sarah Cleaveland
- Boyd Orr Centre for Population and Ecosystem Health, Institute of Biodiversity, Animal Health and Comparative Medicine, University of Glasgow, Glasgow, UK
| | - Matthew P Rubach
- Division of Infectious Diseases, Duke University Medical Center, Durham, NC, USA; Kilimanjaro Christian Medical Centre, Moshi, Tanzania; Duke Global Health Institute, Duke University, Durham, NC, USA; Programme in Emerging Infectious Diseases, Duke-National University of Singapore Medical School, Singapore
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Lewis JM, Feasey NA, Rylance J. Aetiology and outcomes of sepsis in adults in sub-Saharan Africa: a systematic review and meta-analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:212. [PMID: 31186062 PMCID: PMC6558702 DOI: 10.1186/s13054-019-2501-y] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 05/29/2019] [Indexed: 12/29/2022]
Abstract
Background Aetiology and outcomes of sepsis in sub-Saharan Africa (sSA) are poorly described; we performed a systematic review and meta-analysis to summarise the available data. Methods Systematic searches of PubMed and Scopus were undertaken to identify prospective studies recruiting adults (> 13 years) with community-acquired sepsis in sSA post-2000. Random effects meta-analysis of in-hospital and 30-day mortality was undertaken and available aetiology data also summarised by random effects meta-analysis. Results Fifteen studies of 2800 participants were identified. Inclusion criteria were heterogeneous. The majority of patients were HIV-infected, and Mycobacterium tuberculosis was the most common cause of blood stream infection where sought. Pooled in-hospital mortality for Sepsis-2-defined sepsis and severe sepsis was 19% (95% CI 12–29%) and 39% (95% CI 30–47%) respectively, and sepsis mortality was associated with the proportion of HIV-infected participants. Mortality and morbidity data beyond 30 days were absent. Conclusions Sepsis in sSA is dominated by HIV and tuberculosis, with poor outcomes. Optimal antimicrobial strategies, including the role of tuberculosis treatment, are unclear. Long-term outcome data are lacking. Standardised sepsis diagnostic criteria that are easily applied in low-resource settings are needed to establish an evidence base for sepsis management in sSA. Electronic supplementary material The online version of this article (10.1186/s13054-019-2501-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Joseph M Lewis
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK. .,Malawi Liverpool Wellcome Clinical Research Programme, Blantyre, Malawi.
| | - Nicholas A Feasey
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK.,Malawi Liverpool Wellcome Clinical Research Programme, Blantyre, Malawi
| | - Jamie Rylance
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK.,Malawi Liverpool Wellcome Clinical Research Programme, Blantyre, Malawi
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Salifu SP, Bukari ARA, Frangoulidis D, Wheelhouse N. Current perspectives on the transmission of Q fever: Highlighting the need for a systematic molecular approach for a neglected disease in Africa. Acta Trop 2019; 193:99-105. [PMID: 30831112 DOI: 10.1016/j.actatropica.2019.02.032] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 02/28/2019] [Accepted: 02/28/2019] [Indexed: 01/08/2023]
Abstract
Q fever is a bacterial worldwide zoonosis (except New Zealand) caused by the Gram-negative obligate intracellular bacterium Coxiella burnetii (C. burnetii). The bacterium has a large host range including arthropods, wildlife and companion animals and is frequently identified in human and livestock populations. In humans, the disease can occur as either a clinically acute or chronic aetiology, affecting mainly the lungs and liver in the acute disease, and heart valves when chronic. In livestock, Q fever is mainly asymptomatic; however, the infection can cause abortion, and the organism is shed in large quantities, where it can infect other livestock and humans. The presence of Q fever in Africa has been known for over 60 years, however while our knowledge of the transmission routes and risk of disease have been well established in many parts of the world, there is a significant paucity of knowledge across the African continent, where it remains a neglected zoonosis. Our limited knowledge of the disease across the African sub-continent have relied largely upon observational (sero) prevalence studies with limited focus on the molecular epidemiology of the disease. This review highlights the need for systematic studies to understand the routes of C. burnetii infection, and understand the disease burden and risk factors for clinical Q fever in both humans and livestock. With such knowledge gaps filled, the African continent could stand a better chance of eradicating Q fever through formulation and implementation of effective public health interventions.
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Dahn CM, Wijesekera O, Garcia GE, Karasek K, Jacquet GA. Acute care for the three leading causes of mortality in lower-middle-income countries: A systematic review. Int J Crit Illn Inj Sci 2018; 8:117-142. [PMID: 30181970 PMCID: PMC6116305 DOI: 10.4103/ijciis.ijciis_22_18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
According to the World Health Organization, the three leading causes of mortality in lower-middle-income countries (LMIC) are ischemic heart disease (IHD), stroke, and lower respiratory infections (LRIs), causing 111.8, 68.8, and 51.5 annual deaths per 100,000, respectively. Due to barriers to healthcare, patients frequently present in critical stages of these diseases. Measured implementations in critical care in LMIC have been published; however, the literature has not been formally reviewed. We performed a systematic review of the literature indexed in PubMed as of October 2017. Abstracts were limited to human studies in English, French, and Spanish, conducted in LMIC, and containing quantitative data on acute care of IHD, stroke, and LRI. The search resulted in 4994 unique abstracts. Through multiple rounds of screening using criteria determined a priori, 161 manuscripts were identified: 38 for IHD, 20 for stroke, 26 for adult LRI, and 78 for pediatric LRI. These studies, predominantly from Asia, demonstrate successful diagnostic and treatment measures used in providing acute care for patients in LMIC. Given that, only four manuscripts originated in Central or South America, original research from these areas is lacking. IHD, stroke, and LRIs are significant causes of mortality, especially in LMIC. Diagnostic and therapeutic interventions for IHD (monitoring, medications, thrombolytics, percutaneous intervention, coronary artery bypass graft), stroke (therapeutic hypothermia, medications, and thrombolytics), and LRI (oxygen saturation measurement, diagnostic ultrasound, administration of oxygen, appropriate antibiotics, and other medications) have been studied in LMIC and published.
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Affiliation(s)
- Cassidy M Dahn
- Department of Critical Care Medicine, Einstein/Montefiore Medical Center, Bronx, NY, USA
| | | | - Grace E. Garcia
- Department of Emergency Medicine, Boston Medical Center, Boston, MA, USA
| | - Konrad Karasek
- Department of Emergency Medicine, Boston Medical Center, Boston, MA, USA
| | - Gabrielle A. Jacquet
- Boston University School of Medicine, Boston, MA, USA
- Department of Emergency Medicine, Boston Medical Center, Boston, MA, USA
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11
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Schroeder LF, Guarner J, Amukele TK. Essential Diagnostics for the Use of World Health Organization Essential Medicines. Clin Chem 2018; 64:1148-1157. [PMID: 29871869 DOI: 10.1373/clinchem.2017.275339] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 04/27/2018] [Indexed: 11/06/2022]
Abstract
BACKGROUND There are numerous barriers to achieving high-quality laboratory diagnostic testing in resource-limited countries. These include inconsistent supply chains, variable quality of diagnostic devices, lack of human and financial resources, the ever-growing list of available tests, and a historical reliance on syndromic treatment algorithms. A list of essential diagnostics based on an accepted standard like the WHO Essential Medicines List (EML) could coordinate stakeholders in the strengthening of laboratory capacity globally. METHODS To aid in the creation of an essential diagnostics list (EDL), we identified laboratory test indications from expert databases for the safe and effective use of WHO EML medicines. In all, 446 EML medicines were included in the study. We identified 279 conditions targeted by these medicines, spanning communicable and noncommunicable diseases (e.g., HIV, diabetes mellitus). RESULTS We found 325 unique diagnostic tests, across 2717 indications, associated with the identified conditions or their associated medicines. The indications were divided into 10 categories: toxicity (865), diagnosis (591), monitoring (379), dosing/safety (325), complications (217), pathophysiology (154), differential diagnosis (97), comorbidities (53), drug-susceptibility testing (22), and companion diagnostic testing (14). We also created a sublist of 74 higher-priority tests to help define the core of the EDL. CONCLUSIONS An EDL such as we describe here could align the global health community to solve the problems impeding equitable access to high-quality diagnostic testing in support of the global health agenda.
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Affiliation(s)
- Lee F Schroeder
- Department of Pathology, University of Michigan School of Medicine, Ann Arbor, MI;
| | - Jeannette Guarner
- Department of Pathology and Laboratory Medicine, Emory University, Atlanta, GA
| | - Timothy K Amukele
- Department of Pathology and Laboratory Medicine, Johns Hopkins University, Baltimore, MD
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12
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Robinson ML, Manabe YC. Reducing Uncertainty for Acute Febrile Illness in Resource-Limited Settings: The Current Diagnostic Landscape. Am J Trop Med Hyg 2017; 96:1285-1295. [PMID: 28719277 DOI: 10.4269/ajtmh.16-0667] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
AbstractDiagnosing the cause of acute febrile illness in resource-limited settings is important-to give the correct antimicrobials to patients who need them, to prevent unnecessary antimicrobial use, to detect emerging infectious diseases early, and to guide vaccine deployment. A variety of approaches are yielding more rapid and accurate tests that can detect more pathogens in a wider variety of settings. After decades of slow progress in diagnostics for acute febrile illness in resource-limited settings, a wave of converging advancements will enable clinicians in resource-limited settings to reduce uncertainty for the diagnosis of acute febrile illness.
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Affiliation(s)
- Matthew L Robinson
- Division of Infectious Disease, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Yukari C Manabe
- Division of Infectious Disease, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
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13
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Moore CC, Hazard R, Saulters KJ, Ainsworth J, Adakun SA, Amir A, Andrews B, Auma M, Baker T, Banura P, Crump JA, Grobusch MP, Huson MAM, Jacob ST, Jarrett OD, Kellett J, Lakhi S, Majwala A, Opio M, Rubach MP, Rylance J, Michael Scheld W, Schieffelin J, Ssekitoleko R, Wheeler I, Barnes LE. Derivation and validation of a universal vital assessment (UVA) score: a tool for predicting mortality in adult hospitalised patients in sub-Saharan Africa. BMJ Glob Health 2017; 2:e000344. [PMID: 29082001 PMCID: PMC5656117 DOI: 10.1136/bmjgh-2017-000344] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 06/12/2017] [Accepted: 07/05/2017] [Indexed: 12/23/2022] Open
Abstract
Background Critical illness is a leading cause of morbidity and mortality in sub-Saharan Africa (SSA). Identifying patients with the highest risk of death could help with resource allocation and clinical decision making. Accordingly, we derived and validated a universal vital assessment (UVA) score for use in SSA. Methods We pooled data from hospital-based cohort studies conducted in six countries in SSA spanning the years 2009–2015. We derived and internally validated a UVA score using decision trees and linear regression and compared its performance with the modified early warning score (MEWS) and the quick sepsis-related organ failure assessment (qSOFA) score. Results Of 5573 patients included in the analysis, 2829 (50.8%) were female, the median (IQR) age was 36 (27–49) years, 2122 (38.1%) were HIV-infected and 996 (17.3%) died in-hospital. The UVA score included points for temperature, heart and respiratory rates, systolic blood pressure, oxygen saturation, Glasgow Coma Scale score and HIV serostatus, and had an area under the receiver operating characteristic curve (AUC) of 0.77 (95% CI 0.75 to 0.79), which outperformed MEWS (AUC 0.70 (95% CI 0.67 to 0.71)) and qSOFA (AUC 0.69 (95% CI 0.67 to 0.72)). Conclusion We identified predictors of in-hospital mortality irrespective of the underlying condition(s) in a large population of hospitalised patients in SSA and derived and internally validated a UVA score to assist clinicians in risk-stratifying patients for in-hospital mortality. The UVA score could help improve patient triage in resource-limited environments and serve as a standard for mortality risk in future studies.
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Affiliation(s)
- Christopher C Moore
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
| | - Riley Hazard
- College of Arts and Sciences, University of Virginia, Charlottesville, Virginia, USA
| | - Kacie J Saulters
- Department of Medicine, Georgetown University, Washington, District of Columbia, USA
| | - John Ainsworth
- Healthsystem Information Technology, University of Virginia Health Systems, Charlottesville, Virginia, USA
| | - Susan A Adakun
- Department of Medicine, Mulago National Referral and Teaching Hospital, Kampala, Uganda
| | - Abdallah Amir
- Department of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Ben Andrews
- Institute for Global Health, Vanderbilt University, Nashville, Tennessee, USA
| | - Mary Auma
- Department of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Tim Baker
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Patrick Banura
- Department of Pediatrics, Masaka Regional Referral Hospital, Masaka, Uganda
| | - John A Crump
- Centre for International Health, University of Otago, Dunedin, New Zealand
| | - Martin P Grobusch
- Center of Tropical Medicine and Travel Medicine, University of Amsterdam, Amsterdam, The Netherlands
| | - Michaëla A M Huson
- Center of Tropical Medicine and Travel Medicine, University of Amsterdam, Amsterdam, The Netherlands
| | - Shevin T Jacob
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Olamide D Jarrett
- Department of Medicine, University of Illinois at Chicago School of Medicine, Chicago, Illinois, USA
| | - John Kellett
- Department of Acute and Emergency Medicine, University of Southern Denmark, Odense, Denmark
| | | | - Albert Majwala
- Department of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Martin Opio
- Department of Medicine, Kitovu Hospital, Masaka, Uganda
| | - Matthew P Rubach
- Division of Infectious Diseases and International Health, Duke University Medical Center, Durham, North Carolina, USA
| | - Jamie Rylance
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - W Michael Scheld
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
| | - John Schieffelin
- Departments of Pediatrics and Internal Medicine, Tulane University, New Orleans, Louisiana, USA
| | - Richard Ssekitoleko
- Department of Medicine, Mulago National Referral and Teaching Hospital, Kampala, Uganda
| | - India Wheeler
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Laura E Barnes
- Department of Systems and Information Engineering, University of Virginia, Charlottesville, USA
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14
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Zhang HL, Mnzava KW, Mitchell ST, Melubo ML, Kibona TJ, Cleaveland S, Kazwala RR, Crump JA, Sharp JP, Halliday JEB. Mixed Methods Survey of Zoonotic Disease Awareness and Practice among Animal and Human Healthcare Providers in Moshi, Tanzania. PLoS Negl Trop Dis 2016; 10:e0004476. [PMID: 26943334 PMCID: PMC4778930 DOI: 10.1371/journal.pntd.0004476] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Accepted: 01/30/2016] [Indexed: 12/12/2022] Open
Abstract
Background Zoonoses are common causes of human and livestock illness in Tanzania. Previous studies have shown that brucellosis, leptospirosis, and Q fever account for a large proportion of human febrile illness in northern Tanzania, yet they are infrequently diagnosed. We conducted this study to assess awareness and knowledge regarding selected zoonoses among healthcare providers in Moshi, Tanzania; to determine what diagnostic and treatment protocols are utilized; and obtain insights into contextual factors contributing to the apparent under-diagnosis of zoonoses. Methodology/Results We conducted a questionnaire about zoonoses knowledge, case reporting, and testing with 52 human health practitioners and 10 livestock health providers. Immediately following questionnaire administration, we conducted semi-structured interviews with 60 of these respondents, using the findings of a previous fever etiology study to prompt conversation. Sixty respondents (97%) had heard of brucellosis, 26 (42%) leptospirosis, and 20 (32%) Q fever. Animal sector respondents reported seeing cases of animal brucellosis (4), rabies (4), and anthrax (3) in the previous 12 months. Human sector respondents reported cases of human brucellosis (15, 29%), rabies (9, 18%) and anthrax (6, 12%). None reported leptospirosis or Q fever cases. Nineteen respondents were aware of a local diagnostic test for human brucellosis. Reports of tests for human leptospirosis or Q fever, or for any of the study pathogens in animals, were rare. Many respondents expressed awareness of malaria over-diagnosis and zoonoses under-diagnosis, and many identified low knowledge and testing capacity as reasons for zoonoses under-diagnosis. Conclusions This study revealed differences in knowledge of different zoonoses and low case report frequencies of brucellosis, leptospirosis, and Q fever. There was a lack of known diagnostic services for leptospirosis and Q fever. These findings emphasize a need for improved diagnostic capacity alongside healthcare provider education and improved clinical guidelines for syndrome-based disease management to provoke diagnostic consideration of locally relevant zoonoses in the absence of laboratory confirmation. Zoonoses are diseases that are naturally transmitted between animals and humans. In Tanzania, research has shown that several zoonoses, including brucellosis, leptospirosis, and Q fever, are common, but under-diagnosed, causes of human illness. We conducted a mixed methods survey, combining quantitative and qualitative research techniques, of healthcare providers in Moshi, Tanzania. Four (40%) of 10 animal sector respondents and 15 (29%) of 52 human sector respondents reported seeing brucellosis cases in the past 12 months, while none reported cases of leptospirosis or Q fever. Nineteen (31%) respondents reported awareness of a local diagnostic test for human brucellosis, while one reported locally available diagnostic tests for human leptospirosis and Q fever. One (2%) respondent reported a locally available animal brucellosis test, and none reported tests for leptospirosis or Q fever in animals. Many respondents mentioned a lack of diagnostic testing resources during interviews. Our findings suggest that diagnostic testing capacity improvements alongside public health campaigns and healthcare provider education are key steps toward improving recognition and accurate diagnosis of zoonoses in this setting. An improved understanding of healthcare provider awareness, perceptions, and practices regarding zoonoses is critical for the design of effective programs to improve diagnosis and treatment of these diseases.
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Affiliation(s)
- Helen L. Zhang
- Duke University Medical Center, Durham, North Carolina, United States of America
| | - Kunda W. Mnzava
- Nelson Mandela African Institute of Science and Technology, Arusha, Tanzania
- Sokoine University of Agriculture, Morogoro, Tanzania
| | - Sarah T. Mitchell
- Centre for International Health, University of Otago, Dunedin, New Zealand
| | - Matayo L. Melubo
- Nelson Mandela African Institute of Science and Technology, Arusha, Tanzania
- Sokoine University of Agriculture, Morogoro, Tanzania
| | - Tito J. Kibona
- Nelson Mandela African Institute of Science and Technology, Arusha, Tanzania
- Sokoine University of Agriculture, Morogoro, Tanzania
| | - Sarah Cleaveland
- Institute of Biodiversity, Animal Health and Comparative Medicine, University of Glasgow, Glasgow, United Kingdom
| | | | - John A. Crump
- Duke University Medical Center, Durham, North Carolina, United States of America
- Centre for International Health, University of Otago, Dunedin, New Zealand
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Joanne P. Sharp
- School of Geographical and Earth Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Jo E. B. Halliday
- Institute of Biodiversity, Animal Health and Comparative Medicine, University of Glasgow, Glasgow, United Kingdom
- * E-mail:
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15
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Penno EC, Crump JA, Baird SJ. Performance Requirements to Achieve Cost-Effectiveness of Point-of-Care Tests for Sepsis Among Patients with Febrile Illness in Low-Resource Settings. Am J Trop Med Hyg 2015. [PMID: 26195467 DOI: 10.4269/ajtmh.15-0082] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Bacterial sepsis is an important cause of mortality in low- and middle-income countries, yet distinguishing patients with sepsis from those with other illnesses remains a challenge. Currently, management decisions are based on clinical assessment using algorithms such as Integrated Management of Adolescent and Adult Illness. Efforts to develop and evaluate point-of-care tests (POCTs) for sepsis to guide decisions on the use of antimicrobials are underway. To establish the minimum performance characteristics of such a test, we varied the characteristics of a hypothetical POCT for sepsis required for it to be cost-effective and applied a decision tree model to a population of febrile patients presenting at the district hospital level in a low-resource setting. We used a case fatality probability of 20% for appropriately treated sepsis and of 50% for inappropriately treated sepsis. On the basis of clinical assessment for sepsis with established sensitivity of 0.83 and specificity of 0.62, we found that a POCT for sepsis with a sensitivity of 0.83 and a specificity of 0.94 was cost-effective, resulting in parity in survival but costing $1.14 less per live saved. A POCT with accuracy equivalent to the best malaria rapid diagnostic test was cheaper and more effective than clinical assessment.
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Affiliation(s)
- Erin C Penno
- Department of Preventive and Social Medicine, Centre for Health Systems, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand; Centre for International Health, University of Otago, Dunedin, New Zealand; Department of Global Health, Milken Institute School of Public Health, George Washington University, Washington, DC
| | - John A Crump
- Department of Preventive and Social Medicine, Centre for Health Systems, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand; Centre for International Health, University of Otago, Dunedin, New Zealand; Department of Global Health, Milken Institute School of Public Health, George Washington University, Washington, DC
| | - Sarah J Baird
- Department of Preventive and Social Medicine, Centre for Health Systems, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand; Centre for International Health, University of Otago, Dunedin, New Zealand; Department of Global Health, Milken Institute School of Public Health, George Washington University, Washington, DC
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16
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Penno EC, Baird SJ, Crump JA. Cost-Effectiveness of Surveillance for Bloodstream Infections for Sepsis Management in Low-Resource Settings. Am J Trop Med Hyg 2015; 93:850-60. [PMID: 26175032 DOI: 10.4269/ajtmh.15-0083] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Accepted: 05/29/2015] [Indexed: 10/23/2022] Open
Abstract
Bacterial sepsis is a leading cause of mortality among febrile patients in low- and middle-income countries, but blood culture services are not widely available. Consequently, empiric antimicrobial management of suspected bloodstream infection is based on generic guidelines that are rarely informed by local data on etiology and patterns of antimicrobial resistance. To evaluate the cost-effectiveness of surveillance for bloodstream infections to inform empiric management of suspected sepsis in low-resource areas, we compared costs and outcomes of generic antimicrobial management with management informed by local data on etiology and patterns of antimicrobial resistance. We applied a decision tree model to a hypothetical population of febrile patients presenting at the district hospital level in Africa. We found that the evidence-based regimen saved 534 more lives per 100,000 patients at an additional cost of $25.35 per patient, resulting in an incremental cost-effectiveness ratio of $4,739. This ratio compares favorably to standard cost-effectiveness thresholds, but should ultimately be compared with other policy-relevant alternatives to determine whether routine surveillance for bloodstream infections is a cost-effective strategy in the African context.
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Affiliation(s)
- Erin C Penno
- Department of Preventive and Social Medicine, Centre for Health Systems, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand; Department of Global Health, Milken Institute School of Public Health, George Washington University, Washington, D.C.; Centre for International Health, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Sarah J Baird
- Department of Preventive and Social Medicine, Centre for Health Systems, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand; Department of Global Health, Milken Institute School of Public Health, George Washington University, Washington, D.C.; Centre for International Health, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - John A Crump
- Department of Preventive and Social Medicine, Centre for Health Systems, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand; Department of Global Health, Milken Institute School of Public Health, George Washington University, Washington, D.C.; Centre for International Health, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
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