African Journals Online
Malawi Medical Journal

The Journal of the College of Medicine
and  Medical Association of Malawi

Volume 15 No 2, 2003
ABSTRACTS

Patient outcome in adults with pneumococcal meningitis or bacteraemia admitted to QECH

SB Gordon

Abstract

Pneumococcal infections are common in Malawian adults.  We set out to determine which factors influence in-hospital mortality and long-term survival among these patients.  Features of history and examination, inpatient mortality and long-term survival were described among consecutively admitted QECH patients with S. pneumoniae in blood or CSF.   217 patients with pneumococcal disease were studied over an 18-month period.  Among these, 158 of 167 consenting to testing (95%) were HIV positive.  Inpatient mortality was 65% for pneumococcal meningitis (n=64), 20% for pneumococcaemic pneumonia (n=92) and 26% for patients with pneumococcaemia without localising signs (n=43).  Lowered conscious level (OR 5.8, p<0.001), hypotension(OR 4.8, p=0.04) and age exceeding 55 years (OR 3.8, p=0.001) at presentation were associated with inpatient death but not long-term outcome in survivors.  Outpatient death was associated with multilobar chest signs (HR 2.1, p=0.01), oral candidiasis (HR 1.8, p=0.03) and severe anaemia (HR 3.9, p=0.005) as an inpatient.  In conclusion, most patients with pneumococcal disease in Malawi have severe disease, HIV co-infection and a poor prognosis.  At discharge patients with multilobar chest signs or anaemia are at particular risk.

Causes and outcome of bacterial meningitis in Malawian children

EM Molyneux, AL Walsh, H Forsyth, M Tembo, J Mwenechanya, K Kayira, L Bwanaisa, A Njobvu, G Malenga

Abstract

598 children with bacterial meningitis were admitted to the paediatric wards of the Queen Elizabeth Central Hospital (QECH), Blantyre, Malawi from July 1997 – March 2001. Patients were followed up at 1 and 6 months after hospital discharge when physical, neurological, developmental and hearing assessments were made. The most common causes of pyogenic meningitis were Streptococcus pneumoniae (40%), Haemophilus influenzae type b (28%), Neisseria meningitidis (11%), Salmonella species (5%). There was no growth on culture in 13% of cases. The overall mortality was 31% and 38% were left with significant sequelae. Indicators for a poor prognosis were younger age, lower coma score on admission, bacterial cause, nutritional status and HIV positivity.

Non-typhoidal salmonella (NTS) bacteraemia in Malawian adults: a severe, recrudescent, HIV-associated illness

MA Gordon, HT Banda, M Gondwe, SB Gordon, AL Walsh, A Phiri, CF Gilks, CA Hart, ME Molyneux

Abstract

Non-typhoidal salmonella (NTS) bacteraemia is a common, recurrent illness in HIV-infected African adults.  We aimed to describe the presentation and outcome of NTS bacteraemia, the pattern of recurrence, and to determine whether recurrence results from re‑infection or recrudescence. 100 consecutive adult inpatients with NTS bacteraemia in Blantyre, Malawi were treated with chloramphenicol (500mg qid for 14 days). Survivors were prospectively followed to detect bacteraemic recurrence. Index and recurrent isolates were typed by antibiogram, pulsed field gel electrophoresis and plasmid analysis to distinguish recrudescence from re-infection. Inpatient mortality was 47%, and 1-year mortality was 77%. 77/78 cases were HIV positive. Anaemia was associated with inpatient death, and several features of AIDS were associated with poor outpatient survival. Among survivors, 43% (19/44) had a first recurrence of NTS bacteraemia at 23-186 days. Among these, 26% (5/19) developed multiple recurrences up to 245 days. No recurrence was seen after 245 days, despite follow‑up for up to 609 days (median 214). Suppurative infections were not found at presentation, and were only seen twice at recurrence. Index and recurrent paired isolates were identical by phenotyping and genotyping, consistent with recrudescence, rather than re‑infection. NTS bacteraemia has a high mortality (47%) and recurrence rate (43%) in HIV-infected African adults. Recurrence is caused by recrudescence rather than re-infection. Since focal infections were rarely found, recrudescence may often be a consequence of intracellular tissue sequestration. There is an urgent need for improved primary treatment and secondary prophylaxis in Africa.

Surveillance of invasive infections in children and adults admitted to QECH, Blantyre, 1996 - 2002

LK Wilson, A Phiri, D Soko, M Mbvwinji, AL Walsh, ME Molyneux

Abstract

This is a report of blood and CSF isolates from the adult medical and paediatric wards of QECH, Blantyre, cultured and identified at the Wellcome Trust Research Laboratories during 1996-2002. The commonest causes of adult and childhood bacteraemia were

non-typhoidal Salmonella (35% of all blood isolates for adults and children) and Streptococcus pneumoniae (14% and 13% respectively).  Cryptococcus neoformans was the commonest isolate from CSF of adults with meningitis (67%) but was very rare in children. S.pneumoniae was the commonest cause of bacterial meningitis in children and adults (38% and 28% of all CSF isolates respectively). Haemophilus influenzae type b was also a common cause of meningitis in children (27%). Data of in vitro antibiotic sensitivity are also reported. A major concern is the recent marked rise of chloramphenicol resistance among Salmonella enteritidis and Salmonella typhimurium to over 80% resistance.  

Clinical indicators of mycobacteraemia in adults admitted to hospital in Blantyre

DK Lewis, RPH Peters, MJ Schijffelen, GRF Joaki, AL Walsh, JG Kublin, J Kumwenda, S Kampondeni, ME Molyneux, EE Zijlstra

Abstract

The aims of the study were to measure the prevalence and outcome of mycobacteraemia in febrile hospitalised adults; to determine what proportion could be identified using routine methods; to assess clinical indicators of mycobacteraemia and the usefulness of a diagnostic trial of anti-TB treatment. We prospectively examined adults with fever or a history of fever admitted to adult medical wards of QECH, Blantyre. All had blood cultured for bacteria and mycobacteria, chest x-ray and sputum smears. M. tuberculosis was the commonest blood isolate, affecting 57 of 344 patients (17%). In 44 (77%) patients with mycobacteraemia, TB was identified using routine investigations; in only 6 (11%) it was not suspected. Strong clinical indicators of mycobacteraemia were anaemia, HIV seropositivity, cough, chronic fever, and a clinical diagnosis of AIDS on the day of admission. Of nine patients selected for a therapeutic trial of TB treatment, six had mycobacteraemia, of whom five died during the trial. Mortality on short course chemotherapy, on the TB ward after one month, was similar whether patients had mycobacteramia (21%) or not (32%). TB can be identified with routine methods in most patients with mycobacteraemia. If treated, mycobacteraemia has as good an early outcome as TB without mycobacteraemia. Strengthening of basic facilities is likely to improve detection and treatment of mycobacterial disease.

Antibiotic resistance in bacteria - an emerging public health problem

OO Komolafe

Abstract

The discovery and eventual introduction of anti-microbial agents to clinical medicine was one of the greatest medical triumphs of the twentieth century that revolutionized the treatment of bacterial diseases.  However, the gradual emergence of populations of antibiotic-resistant bacteria resulting from use, misuse and outright abuse of antibiotics has today become a major public health problem of global proportions.  This review paper examines the origins and molecular epidemiology of resistance genes, global picture of antibacterial resistance, factors that favour its spread, strategies for its control, problems of control and the consequences of failure to contain antibiotic resistance in bacteria.

Hidden risks for pneumonia in Malawi

DG Fullerton, SB Gordon

Abstract

Domestic smoke exposure and early HIV infection are critical but unseen risk factors for pneumonia.  This paper reviews how recent research in Malawi and elsewhere contributes to an understanding of the possible immunological mechanisms underlying these risks.