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Clinical predictors of bloodstream infections and mortality in hospitalized Malawian children

NORTON, ELIZABETH B. BS; ARCHIBALD, LENNOX K. MD; NWANYANWU, OKEY C. PHD; KAZEMBE, PETER N. MD; DOBBIE, HAMISH MB; RELLER, L. BARTH MD; JARVIS, WILLIAM R. MD; JASON, JANINE MD

The Pediatric Infectious Disease Journal: February 2004 - Volume 23 - Issue 2 - p 145-151
doi: 10.1097/01.inf.0000109258.82988.40
Original Studies

Background. In sub-Saharan Africa, bloodstream infections (BSI) are a major cause of pediatric mortality. Because of limited resources and facilities in these developing countries, treatment often must be based solely on clinical observations and patient history and includes the use of broad spectrum antimicrobials, a factor in the emergence of antibiotic resistance.

Methods. During July 28 through August 18, 1998 we analyzed clinical, epidemiologic and microbiologic data from a cohort of 225 hospitalized children in Malawi, Africa, to determine clinical indices associated with the presence/absence of BSI and/or mortality for use in settings with minimal microbiologic laboratory and intensive care facilities.

Results. BSI (n = 35 children) were associated with malnutrition, chronic cough, lethargy by history, lethargy on examination and oral thrush; 92% of children without these symptoms were BSI-negative. Mortality (21 of 173 children with known mortality status) was associated with malnutrition, lethargy on examination, prior receipt of antimalarials and acute decreased feeding. Of those with ≥2 of these indices 69% died; of those with <2 of the indices 94% survived. Infection with human immunodeficiency virus was not significantly related to either BSI or mortality status.

Conclusions. Malnutrition, but not HIV, was strongly related to both BSI and mortality. Assessment of these BSI and mortality indices at hospital admission provides rapid, cost-free indication of which children are most/least in need of empiric antimicrobial therapy or intensive observation, thereby maximizing appropriate use of antimicrobials and limited facilities while minimizing inappropriate antimicrobial usage.

From the HIV Immunology and Diagnostics Branch, Division of AIDS, STD and TB Laboratory Research (EBN, JJ), the Investigation and Prevention Branch, Division of Healthcare Quality and Promotion (LKA, WRJ), National Center for Infectious Diseases and The Office of Global Health (OCN), Centers for Disease Control, Department of Health and Human Services, US Public Health Service, Atlanta, GA; Lilongwe Central Hospital and Community Health Sciences Unit, Ministry of Health and Population, Lilongwe, Malawi (PNK, HD); and Duke University Medical Center, Durham, NC (LBR).

Accepted for publication Oct. 7, 2003.

Address for reprints: Elizabeth B. Norton, 3 Spanish Fort Blvd., New Orleans, LA 70124. Fax 504-454-0103; E-mail enorton@tulane.edu.

© 2004 Lippincott Williams & Wilkins, Inc.