Bloodstream Infections and Frequency of Pretreatment Associated With Age and Hospitalization Status in Sub-Saharan Africa

Chelsea Nichols, Ligia Maria Cruz Espinoza, Vera von Kalckreuth, Peter Aaby, Muna Ahmed El Tayeb, Mohammad Ali, Abraham Aseffa, Morten Bjerregaard-Andersen, Robert F. Breiman, Leonard Cosmas, John A. Crump, Denise Myriam Dekker, Amy Gassama Sow, Nagla Gasmelseed, Julian T. Hertz, Justin Im, Leon Parfait Kabore, Karen H. Keddy, Frank Konings, Sandra Valborg Løfberg, Christian G. Meyer, Joel M. Montgomery, Aissatou Niang, Andriamampionona Njariharinjakamampionona, Beatrice Olack, Gi Deok Pak, Ursula Panzner, Jin Kyung Park, Se Eun Park, Henintsoa Rabezanahary, Jean Philibert Rakotondrainiarivelo, Raphaël Rakotozandrindrainy, Tiana Mirana Raminosoa, Matthew P. Rubach, Mekonnen Teferi, Hye Jin Seo, Arvinda Sooka, Abdramane Soura, Adama Tall, Trevor Toy, Biruk Yeshitela, John D. Clemens, Thomas F. Wierzba, Stephen Baker, and Florian Marks
Publication year: 

Background. The clinical diagnosis of bacterial bloodstream infections (BSIs) in sub-Saharan Africa is routinely confused with malaria due to overlapping symptoms. The Typhoid Surveillance in Africa Program (TSAP) recruited febrile inpatients and outpatients of all ages using identical study procedures and enrollment criteria, thus providing an opportunity to assess disease etiology and pretreatment patterns among children and adults.

Methods. Inpatients and outpatients of all ages with tympanic or axillary temperatures of ≥38.0 or ≥37.5°C, respectively, and inpatients only reporting fever within the previous 72 hours were eligible for recruitment. All recruited patients had one blood sample drawn and cultured for microorganisms. Data from 11 TSAP surveillance sites in nine different countries were used in the analysis. Bivariate analysis was used to compare frequencies of pretreatment and BSIs in febrile children (<15 years old) and adults (≥15 years old) in each country. Pooled Cochran Mantel–Haenszel odds ratios (ORs) were calculated for overall trends.

Results. There was no significant difference in the odds of a culture-proven BSI between children and adults among inpatients or outpatients. Among both inpatients and outpatients, children had significantly higher odds of having a contaminated blood culture compared with adults. Using country-pooled data, child outpatients had 66% higher odds of havingSalmonella Typhi in their bloodstream than adults (OR, 1.66; 95% confidence interval [CI], 1.01–2.73). Overall, inpatient children had 59% higher odds of pretreatment with analgesics in comparison to inpatient adults (OR, 1.59; 95% CI, 1.28–1.97).

Conclusions. The proportion of patients with culture-proven BSIs in children compared with adults was similar across the TSAP study population; however, outpatient children were more likely to haveSalmonella Typhi infections than outpatient adults. This finding points to the importance of including outpatient facilities in surveillance efforts, particularly for the surveillance of typhoid fever. Strategies to reduce contamination among pediatric blood cultures are needed across the continent to prevent the misdiagnosis of BSI cases in children.