Abstract
Fever is typically treated empirically in rural Mozambique. We examined the distribution and antimicrobial susceptibility patterns of bacterial pathogens isolated from blood-culture specimens, and clinical characteristics of ambulatory HIV-infected febrile patients with and without bacteremia. This analysis was nested within a larger prospective observational study to evaluate the performance of new Mozambican guidelines for fever and anemia in HIV-infected adults (clinical trial registration NCT01681914, www.clinicaltrials.gov); the guidelines were designed to be used by non-physician clinicians who attended ambulatory HIV-infected patients in very resource-constrained peripheral health units. In 2012 (April-September), we recruited 258 HIV-infected adults with documented fever or history of recent fever in three sites within Zambézia Province, Mozambique. Although febrile patients were routinely tested for malaria, blood culture capacity was unavailable in Zambézia prior to study initiation. We confirmed bacteremia in 39 (15.1%) of 258 patients. The predominant organisms were non-typhoid Salmonella, nearly all resistant to multiple first-line antibiotics (ampicillin, chloramphenicol, and trimethoprim-sulfamethoxazole). Features most associated with bacteremia included higher temperature, lower CD4+ T-lymphocyte count, lower hemoglobin, and headache. Introduction of blood cultures allowed us to: 1) confirm bacteremia in a substantial proportion of patients; 2) tailor specific antimicrobial therapy for confirmed bacteremia based on known susceptibilities; 3) make informed choices of presumptive antibiotics for patients with suspected bacteremia; and 4) construct a preliminary clinical profile to help clinicians determine who would most likely benefit from presumptive bacteremia treatment. Our findings demonstrate that in resource-limited settings, there is urgent need to expand local microbiologic capacity to better identify and treat cases of bacteremia in HIV-infected and other patients, and to support surveillance. Data on the prevalence and susceptibility patterns of important pathogens can guide national formulary and prescribing practices.
Highlights
Bacterial bloodstream infections cause substantial morbidity and mortality in HIV-infected African patients; case-fatality ratios over 50% have been reported [1,2,3,4,5,6,7,8]
The overall prevalence of bloodstream infections in febrile hospitalized African adults has been estimated at 13.5%, with the majority caused by bacteria; the odds ratio for association between HIV infection and bloodstream infection has been reported as 3.4 (p,0.001) in the region based on a systematic review of the available literature [9]
Marked immunosuppression resulting from delays in seeking or receiving antiretroviral therapy (ART) likely contributed to this higher bacteremia burden [1,8,10]
Summary
Bacterial bloodstream infections cause substantial morbidity and mortality in HIV-infected African patients; case-fatality ratios over 50% have been reported [1,2,3,4,5,6,7,8]. The overall prevalence of bloodstream infections in febrile hospitalized African adults has been estimated at 13.5%, with the majority caused by bacteria; the odds ratio for association between HIV infection and bloodstream infection has been reported as 3.4 (p,0.001) in the region based on a systematic review of the available literature [9]. Prior to the introduction of antiretroviral therapy (ART) in Africa, hospital-based studies showed bacteremia to be three times more common and five times more likely to cause death in HIV positive vs non-HIV positive patients [2,9]. The annual incidence of invasive NTS in HIV-infected African adults may be as high as 7,500/100,000 [11] these estimates are based on relatively small numbers of studies, given the size of the continent and the heterogeneity of its HIV-infected subpopulations
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