A Prospective Study of the Causes of Febrile Illness Requiring Hospitalization in Children in Cambodia

Kheng Chheng,Nicole Stoesser,Paul Kitsutani,Ngoun Chanpheaktra,Borann Sar,Soeng Sona,Nguyen Hanh Uyen,Varun Kumar,Le Van Tan,Premjit Amornchai,Stuart D Blacksell,Catrin E Moore,Christopher M Parry,Daniel Paris,Michael J Carter,Hor Putchhat,H Rogier Van Doorn,Sin Reaksmey,Nicholas P J Day,Kate Emary,Vanaporn Wuthiekanun

doi:10.1371/journal.pone.0060634

Abstract

BackgroundFebrile illnesses are pre-eminent contributors to morbidity and mortality among children in South-East Asia but the causes are poorly understood. We determined the causes of fever in children hospitalised in Siem Reap province, Cambodia.Methods and FindingsA one-year prospective study of febrile children admitted to Angkor Hospital for Children, Siem Reap. Demographic, clinical, laboratory and outcome data were comprehensively analysed. Between October 12th 2009 and October 12th 2010 there were 1225 episodes of febrile illness in 1180 children. Median (IQR) age was 2.0 (0.8–6.4) years, with 850 (69%) episodes in children <5 years. Common microbiological diagnoses were dengue virus (16.2%), scrub typhus (7.8%), and Japanese encephalitis virus (5.8%). 76 (6.3%) episodes had culture-proven bloodstream infection, including Salmonella enterica serovar Typhi (22 isolates, 1.8%), Streptococcus pneumoniae (13, 1.1%), Escherichia coli (8, 0.7%), Haemophilus influenzae (7, 0.6%), Staphylococcus aureus (6, 0.5%) and Burkholderia pseudomallei (6, 0.5%). There were 69 deaths (5.6%), including those due to clinically diagnosed pneumonia (19), dengue virus (5), and melioidosis (4). 10 of 69 (14.5%) deaths were associated with culture-proven bloodstream infection in logistic regression analyses (odds ratio for mortality 3.4, 95% CI 1.6–6.9). Antimicrobial resistance was prevalent, particularly in S. enterica Typhi, (where 90% of isolates were resistant to ciprofloxacin, and 86% were multi-drug resistant). Comorbid undernutrition was present in 44% of episodes and a major risk factor for acute mortality (OR 2.1, 95% CI 1.1–4.2), as were HIV infection and cardiac disease.ConclusionWe identified a microbiological cause of fever in almost 50% of episodes in this large study of community-acquired febrile illness in hospitalized children in Cambodia. The range of pathogens, antimicrobial susceptibility, and co-morbidities associated with mortality described will be of use in the development of rational guidelines for infectious disease treatment and control in Cambodia and South-East Asia.

Highlights

Febrile illness in children is a common cause of admission to hospital globally, with significant associated morbidity and mortality [1]
We identified a microbiological cause of fever in almost 50% of episodes in this large study of communityacquired febrile illness in hospitalized children in Cambodia
The range of pathogens, antimicrobial susceptibility, and comorbidities associated with mortality described will be of use in the development of rational guidelines for infectious disease treatment and control in Cambodia and South-East Asia

Summary

Introduction

Febrile illness in children is a common cause of admission to hospital globally, with significant associated morbidity and mortality [1]. In developing countries this is frequently compounded by low rates of immunisation, untreated co-morbidities, and late presentations [2]. The Kingdom of Cambodia lies in South-East Asia and has a mortality rate in children aged ,5 years of 54/1000 live births [7]. This has halved over the last decade but remains one of the highest in the region. We determined the causes of fever in children hospitalised in Siem Reap province, Cambodia

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Discussion

Conclusion