Antimicrobial Resistant Organisms in Sepsis at a Referral Hospital in Malawi

Abstract

Background: There are scarce data describing the etiology and clinical sequelae of sepsis in LMICs. In particular, the prevalence of antibiotic resistant organisms is not well characterized. This study describes the prevalence of sepsis amongst critically ill patients, antibiotic stewardship, and the prevalence of antimicrobial resistant pathogens at a referral hospital in Malawi. Methods: We conducted an observational prospective cohort study of adults admitted to the ICU or HDU of a referral hospital in Malawi from January 29 to March 15, 2018. We stratified the cohort based on the prevalence of sepsis, defined by a qSOFA score ≥2 plus suspected infection. We measured clinical characteristics, blood and urine cultures, and antimicrobial sensitivities from positive cultures. Findings: During the study period, 103 patients were admitted and 76 patients were analyzed. The cohort was 47% male, and the median age 30 years (IQR, 23-40). Most participants (74%) had initiated antibiotics prior to study recruitment, commensurate with a suspicion of infection in 68% of patients. Four blood cultures (5%) were positive, two from patients with sepsis. All blood bacterial isolates were multi-drug resistant. Of seven patients with urinary tract infection, three had sepsis secondary to multi-drug resistant bacteria. Hospital mortality for patients with sepsis was 73% versus 22% for non-septic patients (p=0·001). Interpretation: Mortality associated with sepsis in the ICU and HDUs at this Malawi hospital is high. Bacteremia was infrequently detected, but isolated pathogens were multi-drug resistant. These data highlight the need for laboratory infrastructure to guide antibiotic stewardship in Malawi. Funding Statement: This study was supported in part by the NIH Fogarty International Center Postdoctoral Research Fellowship to Dr. Prin and by the Friedman Award from Columbia University College of Physicians and Surgeons to Dr. Onofrey. Declaration of Interests: The authors declare no conflicts of interest. Ethics Approval Statement: The study protocol was approved by the National Health Sciences Research Council of Malawi and the Institutional Review Boards of both American universities with which the study was affiliated, and the requirement for written informed consent was waived by all ethics oversight bodies.