Abstract
BackgroundFebrile illness is the commonest cause of hospitalization in children <5 years in sub-Saharan Africa, and bacterial bloodstream infections and malaria are major causes of death.MethodsFrom March 2017 to July 2018, we enrolled 2,226 children aged 0–5 years hospitalized due to fever in four major public hospitals of Dar es Salaam, namely, Amana, Temeke, and Mwananyamala Regional Hospitals and Muhimbili National Hospital. We recorded social demographic and clinical data, and we performed blood-culture and HIV-antibody testing. We used qPCR to quantify Plasmodium falciparum parasitaemia and Matrix-Assisted Laser Desorption/Ionization-Time of Flight (MALDI-TOF) to identify bacterial isolates. Disk diffusion method was used for antimicrobial susceptibility testing.ResultsNineteen percent of the children (426/2,226) had pathogens detected from blood. Eleven percent (236/2,226) of the children had bacteraemia/fungaemia and 10% (204/2,063) had P. falciparum malaria. Ten children had concomitant malaria and bacteraemia. Gram-negative bacteria (64%) were more frequent than Gram-positive (32%) and fungi (4%). Over 50% of Gram-negative bacteria were extended-spectrum beta-lactamase (ESBL) producers and multidrug resistant. Methicillin resistant Staphylococcus aureus (MRSA) was found in 11/42 (26.2%). The most severe form of clinical malaria was associated with high parasitaemia (>four million genomes/μL) of P. falciparum in plasma. Overall, in-hospital death was 4% (89/2,146), and it was higher in children with bacteraemia (8%, 18/227) than malaria (2%, 4/194, p = 0.007). Risk factors for death were bacteraemia (p = 0.03), unconsciousness at admission (p < 0.001), and admission at a tertiary hospital (p = 0.003).ConclusionCompared to previous studies in this region, our study showed a reduction in malaria prevalence, a decrease in in-hospital mortality, and an increase in antimicrobial resistance (AMR) including ESBLs and multidrug resistance. An increase of AMR highlights the importance of continued strengthening of diagnostic capability and antimicrobial stewardship programs. We also found malaria and bacteraemia contributed equally in causing febrile illness, but bacteraemia caused higher in-hospital death. The most severe form of clinical malaria was associated with P. falciparum parasitaemia.
Highlights
Bloodstream infections (BSI) are the commonest causes of hospital admissions and deaths in children in sub-Saharan Africa (Bahwere et al, 2001; Campbell et al, 2004; Peters et al, 2004; Bryce et al, 2005; Feikin et al, 2011; Maze et al, 2018)
The present study provides updated information on the contribution of bacteria, fungi, and malaria in severe febrile illness among children admitted in four major hospitals of Dar es Salaam, Tanzania
Despite using a very sensitive molecular method (Hofmann et al, 2015), our study found a low prevalence of malaria (10%) compared to 22% in the year 2001/2002 and 25% in 2009 using microscopy and PCR, respectively, in previous studies among children admitted with febrile illness in the Dar es Salaam region (Blomberg et al, 2005; Strom et al, 2013)
Summary
Bloodstream infections (BSI) are the commonest causes of hospital admissions and deaths in children in sub-Saharan Africa (Bahwere et al, 2001; Campbell et al, 2004; Peters et al, 2004; Bryce et al, 2005; Feikin et al, 2011; Maze et al, 2018). Determining bacterial or fungal infections in BSI is fundamental to management of severe BSI based on etiology This is challenging in low-income countries because available and affordable diagnostic services for BSI other than malaria is limited by both infrastructure and cost (Archibald and Reller, 2001; Petti et al, 2006). Febrile illness is the commonest cause of hospitalization in children
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