Review
Community-acquired bloodstream infections in Africa: a systematic review and meta-analysis

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Summary

Data on the prevalence and causes of community-acquired bloodstream infections in Africa are scarce. We searched three databases for studies that prospectively studied patients admitted to hospital with at least a blood culture, and found 22 eligible studies describing 58 296 patients, of whom 2051 (13·5%) of 15 166 adults and 3527 (8·2%) of 43 130 children had bloodstream infections. 1643 (29·1%) non-malaria bloodstream infections were due to Salmonella enterica (58·4% of these non-typhoidal Salmonella), the most prevalent isolate overall and in adults, and 1031 (18·3% overall) were due to Streptococcus pneumoniae, the most common isolate in children. Other common isolates included Staphylococcus aureus (531 infections; 9·5%) and Escherichia coli (412; 7·3%). Mycobacterium tuberculosis complex accounted for 166 (30·7%) of 539 isolates in seven studies that used mycobacterial culture techniques. HIV infection was associated with any bloodstream infection, particularly with S enterica and M tuberculosis complex bacteraemia. Where recorded, patients with bloodstream infections had an in-hospital case fatality of 18·1%. Our results show that bloodstream infections are common and associated with high mortality. Improved clinical microbiology services and reassessment of empirical treatment guidelines that account for the epidemiology of bloodstream infections might contribute to better outcomes.

Introduction

Febrile illness is a leading reason for admission to hospital in Africa,1, 2, 3, 4 and rates of febrile illness are fuelled by the HIV epidemic.5, 6, 7, 8, 9 Despite the major contribution of infectious diseases to hospital admission, the availability of diagnostic microbiology services for bloodstream infections other than malaria is often limited by cost, infrastructure, and personnel constraints.10, 11 Consequently, health-care workers must often rely on syndrome-oriented empirical approaches to treatment and might underestimate or overestimate the likelihood of certain diseases, risking poor clinical outcomes and the promotion of antimicrobial resistance.12, 13, 14 Understanding the causes and prevalence of community-acquired bloodstream infection, which is associated with high risk of death, can inform efforts to improve health outcomes in Africa and promote the meeting of millennium development goals for the reduction of child mortality and HIV/AIDS, malaria, and tuberculosis.

Early studies of bloodstream infections in children admitted to African hospitals suggest that the prevalence of bacterial bloodstream infections among inpatients with fever or clinical sepsis exceeds that described in wealthier regions2, 15, 16, 17, 18 and that bacteraemia is a common cause of illness both in areas of high and low malaria prevalence. Gram-negative organisms, particularly Salmonella enterica, rival or exceed Gram-positive organisms in importance in several published reports on bloodstream infections in both adults and children from African countries.19, 20, 21, 22 In recent years, use of blood culture to assess seriously ill patients infected with HIV has led to a growing understanding of their increased risk of a range of invasive bacterial and fungal diseases, including Streptococcus pneumoniae, disseminated tuberculosis, cryptococcosis, and Salmonella bacteraemia caused by non-typhoidal Salmonella.4, 23, 24, 25, 26, 27

We sought to review studies that used blood culture to identify non-malaria bloodstream infections among prospectively sampled adults and children with predefined, replicable, inclusion criteria admitted to hospitals in Africa, and then to aggregate these data to better quantify the prevalence of bloodstream infections and document the most commonly isolated organisms overall and among different subgroups. We postulated that bloodstream infections would be identified among many patients admitted to hospital in Africa, S enterica would be among the most commonly isolated pathogens, and that age, presence of HIV infection, and features of illness would affect the prevalence of bloodstream infections and predominant organisms isolated.

Section snippets

Search strategy and selection criteria

We searched two major scientific databases (PubMed and Embase) and one topical database (African Healthline) with terms defined with the assistance of a library science technologist (Megan Von Isenburg). PubMed was searched with the search string: “Africa and (fever or fevers or bacteremia or bacteremias or septicemia or septicemias) limit humans”. Embase was searched by use of the terms: “Africa” (exploded to all subheadings) and “fever/” or “fever.mp” or “fevers.mp” or “bacteremia/” or

Results

The online database search done on June 11, 2009, yielded 10 412 articles, 7596 of which were unique articles located in at least one of the three databases (figure 1): 3366 were unique to PubMed, 1244 unique to Embase, and 180 unique to African Healthline. Most of these articles were excluded on the basis of a primary topical focus other than assessment of suspected infection in patients admitted to hospital; others were excluded because of the type of study or population. 87 full-text

Discussion

Bacterial or fungal bloodstream infections are common among prospectively sampled adults and children admitted to hospital in Africa, with a mean prevalence of 13·4% (range 8·5–38·2%) among those with fever and 7·4% (4·2–16·9%) among all admissions irrespective of fever history. These data underscore the importance of considering bacterial or fungal bloodstream infections in the differential diagnosis of all patients admitted to hospital, particularly those who are febrile. Our findings suggest

Search strategy and selection criteria

These are detailed in the Methods section.

References (118)

  • CF Gilks et al.

    Life-threatening bacteraemia in HIV-1 seropositive adults admitted to hospital in Nairobi, Kenya

    Lancet

    (1990)
  • E Kassa-Kelembho et al.

    Bacteremia in adults admitted to the Department of Medicine of Bangui Community Hospital (Central African Republic)

    Acta Trop

    (2003)
  • P Lepage et al.

    Community-acquired bacteraemia in African children

    Lancet

    (1987)
  • LC McDonald et al.

    Unrecognised Mycobacterium tuberculosis bacteraemia among hospital inpatients in less developed countries

    Lancet

    (1999)
  • EU Rosen

    The disease profile of hospitalized Third World urban black adolescents

    J Adolesc Health Care

    (1985)
  • PL Petit et al.

    Analysis of hospital records in four African countries, 1975–1990, with emphasis on infectious diseases

    J Trop Med Hyg

    (1995)
  • JD Campbell et al.

    Invasive pneumococcal infections among hospitalized children in Bamako, Mali

    Pediatr Infect Dis J

    (2004)
  • RP Peters et al.

    A prospective study of bloodstream infections as cause of fever in Malawi: clinical predictors and implications for management

    Trop Med Int Health

    (2004)
  • K Floyd et al.

    Admission trends in a rural South African hospital during the early years of the HIV epidemic

    JAMA

    (1999)
  • AP Kengne et al.

    HIV/AIDS occurrence in the main university teaching hospital in Cameroon: audit of the 2001 activities of the service of internal medicine

    J Int Assoc Physicians AIDS Care (Chic Ill)

    (2007)
  • D Bradshaw et al.

    South African cause-of-death profile in transition—1996 and future trends

    S Afr Med J

    (2002)
  • S Ole-Nguyaine et al.

    HIV-associated morbidity, mortality and diagnostic testing opportunities among inpatients at a referral hospital in northern Tanzania

    Ann Trop Med Parasitol

    (2004)
  • LK Archibald et al.

    Clinical microbiology in developing countries

    Emerg Infect Dis

    (2001)
  • CA Petti et al.

    Laboratory medicine in Africa: a barrier to effective health care

    Clin Infect Dis

    (2006)
  • BA Perkins et al.

    Evaluation of an algorithm for integrated management of childhood illness in an area of Kenya with high malaria transmission

    Bull World Health Organ

    (1997)
  • M English et al.

    Hypothetical performance of syndrome-based management of acute paediatric admissions of children aged more than 60 days in a Kenyan district hospital

    Bull World Health Organ

    (2003)
  • JA Idoko et al.

    A prospective study of septicaemia in Zaria, northern Nigeria

    East Afr Med J

    (1986)
  • RA Haddon et al.

    Bacteraemia in febrile children presenting to a paediatric emergency department

    Med J Aust

    (1999)
  • KO Alausa et al.

    Septicaemia in the tropics: a prospective epidemiological study of 146 patients with a high case fatality rate

    Scand J Infect Dis

    (1977)
  • GO Akpede et al.

    Relative contribution of bacteraemia and malaria to acute fever without localizing signs of infection in under-five children

    J Trop Pediatr

    (1991)
  • OO Ayoola et al.

    Aetiological agents, clinical features and outcome of septicaemia in infants in Ibadan

    West Afr J Med

    (2003)
  • LK Archibald et al.

    Epidemiology of bloodstream infections in a bacille Calmette-Guerin-vaccinated pediatric population in Malawi

    J Infect Dis

    (2003)
  • DJ Vugia et al.

    Pathogens and predictors of fatal septicemia associated with human immunodeficiency virus infection in Ivory Coast, west Africa

    J Infect Dis

    (1993)
  • H Norrgren et al.

    Increased prevalence of HIV-2 infection in hospitalized patients with severe bacterial diseases in Guinea-Bissau

    Scand J Infect Dis

    (1997)
  • AD Grant et al.

    Natural history and spectrum of disease in adults with HIV/AIDS in Africa

    AIDS

    (1997)
  • FN Ssali et al.

    A prospective study of community-acquired bloodstream infections among febrile adults admitted to Mulago Hospital in Kampala, Uganda

    J Acquir Immune Defic Syndr Hum Retrovirol

    (1998)
  • G Arthur et al.

    Trends in bloodstream infections among human immunodeficiency virus-infected adults admitted to a hospital in Nairobi, Kenya, during the last decade

    Clin Infect Dis

    (2001)
  • DF Stroup et al.

    Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis Of Observational Studies in Epidemiology (MOOSE) group

    JAMA

    (2000)
  • AIDS epidemic update

  • EA Adejuyigbe et al.

    Bacterial isolates in the sick young infant in Ile-Ife, Nigeria

    J Trop Pediatr

    (2004)
  • S Afifi et al.

    Hospital-based surveillance for acute febrile illness in Egypt: a focus on community-acquired bloodstream infections

    Am J Trop Med Hyg

    (2005)
  • AK Ako-Nai et al.

    Bacterial isolates involved in cases of septicaemia in a Nigerian hospital

    East Afr Med J

    (1990)
  • GO Akpede et al.

    Pattern of infections in children under-six years old presenting with convulsions associated with fever of acute onset in a children's emergency room in Benin City, Nigeria

    J Trop Pediatr

    (1993)
  • X Anglaret et al.

    Pattern of bacterial diseases in a cohort of HIV-1 infected adults receiving cotrimoxazole prophylaxis in Abidjan, Côte d'Ivoire

    AIDS

    (2003)
  • IA Angyo et al.

    Predominant bacterial agents of childhood septicaemia in Jos

    Niger J Med

    (2001)
  • LK Archibald et al.

    Fatal Mycobacterium tuberculosis bloodstream infections in febrile hospitalized adults in Dar es Salaam, Tanzania

    Clin Infect Dis

    (1998)
  • LK Archibald et al.

    A hospital-based prevalence survey of bloodstream infections in febrile patients in Malawi: implications for diagnosis and therapy

    J Infect Dis

    (2000)
  • JO Ashiru et al.

    Gram negative septicaemia in Ibadan, Nigeria

    East Afr Med J

    (1986)
  • OO Ayoola et al.

    Concurrent bacteraemia and malaria in febrile Nigerian infants

    Trop Doct

    (2005)
  • OO Ayoola et al.

    Predictors of bacteraemia among febrile infants in Ibadan, Nigeria

    J Health Popul Nutr

    (2002)
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