Abstract
SummaryBackgroundBacterial bloodstream infection is a common cause of morbidity and mortality in sub-Saharan Africa, yet few facilities are able to maintain long-term surveillance. The Malawi-Liverpool-Wellcome Trust Clinical Research Programme has done sentinel surveillance of bacteraemia since 1998. We report long-term trends in bloodstream infection and antimicrobial resistance from this surveillance.MethodsIn this surveillance study, we analysed blood cultures that were routinely taken from adult and paediatric patients with fever or suspicion of sepsis admitted to Queen Elizabeth Central Hospital, Blantyre, Malawi from 1998 to 2016. The hospital served an urban population of 920 000 in 2016, with 1000 beds, although occupancy often exceeds capacity. The hospital admits about 10 000 adults and 30 000 children each year. Antimicrobial susceptibility tests were done by the disc diffusion method according to British Society of Antimicrobial Chemotherapy guidelines. We used the Cochran-Armitage test for trend to examine trends in rates of antimicrobial resistance, and negative binomial regression to examine trends in icidence of bloodstream infection over time.FindingsBetween Jan 1, 1998, and Dec 31, 2016, we isolated 29 183 pathogens from 194 539 blood cultures. Pathogen detection decreased significantly from 327·1/100 000 in 1998 to 120·2/100 000 in 2016 (p<0·0001). 13 366 (51·1%) of 26 174 bacterial isolates were resistant to the Malawian first-line antibiotics amoxicillin or penicillin, chloramphenicol, and co-trimoxazole; 68·3% of Gram-negative and 6·6% of Gram-positive pathogens. The proportions of non-Salmonella Enterobacteriaceae with extended spectrum beta-lactamase (ESBL) or fluoroquinolone resistance rose significantly after 2003 to 61·9% in 2016 (p<0·0001). Between 2003 and 2016, ESBL resistance rose from 0·7% to 30·3% in Escherichia coli, from 11·8% to 90·5% in Klebsiella spp and from 30·4% to 71·9% in other Enterobacteriaceae. Similarly, resistance to ciprofloxacin rose from 2·5% to 31·1% in E coli, from 1·7% to 70·2% in Klebsiella spp and from 5·9% to 68·8% in other Enterobacteriaceae. By contrast, more than 92·0% of common Gram-positive pathogens remain susceptible to either penicillin or chloramphenicol. Meticillin-resistant Staphylococcus aureus (MRSA) was first reported in 1998 at 7·7% and represented 18·4% of S aureus isolates in 2016.InterpretationThe rapid expansion of ESBL and fluoroquinolone resistance among common Gram-negative pathogens, and the emergence of MRSA, highlight the growing challenge of bloodstream infections that are effectively impossible to treat in this resource-limited setting.FundingWellcome Trust, H3ABionet, Southern Africa Consortium for Research Excellence (SACORE).
Highlights
Bloodstream infection is a leading cause of morbidity and mortality in both adults and children in sub-Saharan Africa.[1]
We present the largest bacteraemia and antimicrobial resistance surveillance dataset yet collected from sub-Saharan Africa and describe trends in bloodstream infection in both adults and children presenting to a major urban teaching hospital in Malawi over a 19-year period
Severe sepsis, or septic shock were suspected in patients with tachycardia (≥90 beats per minute), hypotension, tachypnoea, or delirium. 3–10 mL of blood was taken from children with non-focal febrile illness who tested negative for malaria, who were severely ill with suspected sepsis, or who failed initial malaria treatment and remained febrile.[18]
Summary
Bloodstream infection is a leading cause of morbidity and mortality in both adults and children in sub-Saharan Africa.[1] In this region, the high burden of bacterial bloodstream infection has been strongly associated with the high prevalence of HIV, malaria, and malnutrition.[1,2,3,4] The clinical effect of bloodstream infections in sub-Saharan Africa is exacerbated by the inadequacy of diagnostic facilities, precluding both timely diagnosis of severe bacterial infection and implementation of appropriate antimicrobial therapy.[5]. Since 1998, sentinel bacteraemia surveillance has been done at Queen Elizabeth Central Hospital (QECH), Blantyre, Malawi, a setting with a high prevalence of HIV, malaria, and malnutrition.[6] Blantyre is one of two principal cities in Malawi and the population of its urban and peri-urban rural areas expanded rapidly during the study period. QECH is one of the largest government hospitals in Malawi and is the only public hospital providing free medical care to Blantyre city, serving an urban population of 920 000 in 2016. Ceftriaxone was not widely available in the city or district of Blantyre outside www.thelancet.com/infection Vol 17 October 2017
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