Infections and antibiotic resistance in Malawian children 6-59 months old hospitalized with severe acute malnutrition
Background: Severe acute malnutrition (SAM) is strongly associated with mortality in young children, and infections are thought to be a major driver of that mortality. The World Health Organization (WHO) therefore recommends that all children hospitalized with SAM receive empiric intravenous broad-s...
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| Main Authors: | , , , , , , , , , , |
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| Format: | Article |
| Language: | English |
| Published: |
Elsevier
2025-03-01
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| Series: | International Journal of Infectious Diseases |
| Online Access: | http://www.sciencedirect.com/science/article/pii/S1201971224007094 |
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| Summary: | Background: Severe acute malnutrition (SAM) is strongly associated with mortality in young children, and infections are thought to be a major driver of that mortality. The World Health Organization (WHO) therefore recommends that all children hospitalized with SAM receive empiric intravenous broad-spectrum antibiotics. Most data on the burden of infections in children with SAM are outdated given recent dramatic changes in antimicrobial resistance (AMR) and HIV epidemiology. The aim of this study was to give a contemporary description of the prevalence of treatable infections and AMR in children hospitalized with SAM. Methods: This prospective cohort study enrolled children 6-59 months old hospitalized with SAM at a tertiary referral hospital in Malawi. The prevalence of various infections was estimated with a combination of routine testing and clinical diagnoses, plus study-specific testing that included: blood and urine cultures; gastric aspirate Xpert MTB/RIF Ultra; and for participants with concern for central nervous system infection, cell counts, microscopy, culture, and Xpert MTB/RIF Ultra on cerebrospinal fluid. Results: From February 2023 to January 2024, 212 participants were enrolled. Mean age was 21 months, 48% were female, and 12% were HIV-infected. In-hospital mortality rate was 11%. The composite outcome of serious bacterial infection (SBI: bacteremia, meningitis, or pneumonia) was found in 24% of participants, and SBI was strongly associated with mortality (odds ratio, OR: 3.4; 95% confidence interval, CI: 1.4-8.3). Tuberculosis disease (TB) was diagnosed in 9% and was also associated with mortality (OR: 3.4, 95% CI: 1.1-10.4). Blood cultures detected likely pathogens for 10% of participants. Urine for culture was obtained on 136 participants and 20% had urinary tract infection (UTI). For the bacteria isolated from bacteremia and UTI cases, resistance to first-line antibiotics was 88% for ampicillin and 41% for gentamicin, and 38% for second-line antibiotics (third-generation cephalosporins). Discussion: This contemporary evaluation of infections in children hospitalized with SAM at a single site in Malawi reconfirms high rates of SBI, UTI, and TB that have been demonstrated in older studies of this vulnerable population in other settings. Given the persistently high mortality of children hospitalized with SAM and the demonstrated association of mortality with SBI and TB, more research is urgently needed to improve early diagnosis and optimized treatment of these deadly infections. High rates of resistance to first- and second-line antibiotics raises the question of whether alternative empiric antibiotics should be recommended in SAM. Conclusion: These results support the WHO recommendation of treating children hospitalized with SAM with empiric broad spectrum antibiotics. To improve antibiotic stewardship, better tools are needed to identify those children at high risk for severe infection (including TB). In addition, reconsideration of the recommended empiric antibiotic regimens may be required to reflect increases in the prevalence of AMR. |
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| ISSN: | 1201-9712 |