TY - JOUR
T1 - Etiology and Risk Factors for Mortality in an Adult Community-acquired Pneumonia Cohort in Malawi
AU - Aston, Stephen J.
AU - Ho, Antonia
AU - Jary, Hannah
AU - Huwa, Jacqueline
AU - Mitchell, Tamara
AU - Ibitoye, Sarah
AU - Greenwood, Simon
AU - Joekes, Elizabeth
AU - Daire, Arthur
AU - Mallewa, Jane
AU - Everett, Dean
AU - Nyirenda, Mulinda
AU - Faragher, Brian
AU - Mwandumba, Henry C.
AU - Heyderman, Robert S.
AU - Gordon, Stephen B.
N1 - Funding Information:
Supported by a Wellcome Trust award (grant 099962, S.J.A.). A Strategic award from the Wellcome Trust supports the Malawi–Liverpool–Wellcome Trust Clinical Research Program. The respiratory pathogen molecular diagnostic assays were partly supported by a grant from the CDC (1 U01 IP000848). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Funding Information:
Supported by a Wellcome Trust award (grant 099962, S.J.A.). A Strategic award from the Wellcome Trust supports the Malawi?Liverpool?Wellcome Trust Clinical Research Program. The respiratory pathogen molecular diagnostic assays were partly supported by a grant from the CDC (1 U01 IP000848). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Publisher Copyright:
Copyright © 2019 by the American Thoracic Society
PY - 2019/8/1
Y1 - 2019/8/1
N2 - Rationale: In the context of rapid antiretroviral therapy rollout and an increasing burden of noncommunicable diseases, there are few contemporary data describing the etiology and outcome of community-acquired pneumonia (CAP) in sub-Saharan Africa. Objectives: To describe the current etiology of CAP in Malawi and identify risk factors for mortality. Methods: We conducted a prospective observational study of adults hospitalized with CAP to a teaching hospital in Blantyre, Malawi. Etiology was defined by blood culture, Streptococcus pneumoniae urinary antigen detection, sputum mycobacterial culture and Xpert MTB/RIF, and nasopharyngeal aspirate multiplex PCR. Measurements and Main Results: In 459 patients (285 [62.1%] males; median age, 34.7 [interquartile range, 29.4–41.9] yr), 30-day mortality was 14.6% (64/439) and associated with male sex (adjusted odds ratio, 2.60 [95% confidence interval, 1.17–5.78]), symptom duration greater than 7 days (2.78 [1.40–5.54]), tachycardia (2.99 [1.48–6.06]), hypoxemia (4.40 [2.03–9.51]), and inability to stand (3.59 [1.72–7.50]). HIV was common (355/453; 78.4%), frequently newly diagnosed (124/355; 34.9%), but not associated with mortality. S. pneumoniae (98/458; 21.4%) and Mycobacterium tuberculosis (75/326; 23.0%) were the most frequently identified pathogens. Viral infection occurred in 32.6% (148/454) with influenza (40/454; 8.8%) most common. Bacterial–viral coinfection occurred in 9.1% (28/307). Detection of M. tuberculosis was associated with mortality (adjusted odds ratio, 2.44 [1.19–5.01]). Conclusions: In the antiretroviral therapy era, CAP in Malawi remains predominantly HIV associated, with a large proportion attributable to potentially vaccine-preventable pathogens. Strategies to increase early detection and treatment of tuberculosis and improve supportive care, in particular the correction of hypoxemia, should be evaluated in clinical trials to address CAP-associated mortality.
AB - Rationale: In the context of rapid antiretroviral therapy rollout and an increasing burden of noncommunicable diseases, there are few contemporary data describing the etiology and outcome of community-acquired pneumonia (CAP) in sub-Saharan Africa. Objectives: To describe the current etiology of CAP in Malawi and identify risk factors for mortality. Methods: We conducted a prospective observational study of adults hospitalized with CAP to a teaching hospital in Blantyre, Malawi. Etiology was defined by blood culture, Streptococcus pneumoniae urinary antigen detection, sputum mycobacterial culture and Xpert MTB/RIF, and nasopharyngeal aspirate multiplex PCR. Measurements and Main Results: In 459 patients (285 [62.1%] males; median age, 34.7 [interquartile range, 29.4–41.9] yr), 30-day mortality was 14.6% (64/439) and associated with male sex (adjusted odds ratio, 2.60 [95% confidence interval, 1.17–5.78]), symptom duration greater than 7 days (2.78 [1.40–5.54]), tachycardia (2.99 [1.48–6.06]), hypoxemia (4.40 [2.03–9.51]), and inability to stand (3.59 [1.72–7.50]). HIV was common (355/453; 78.4%), frequently newly diagnosed (124/355; 34.9%), but not associated with mortality. S. pneumoniae (98/458; 21.4%) and Mycobacterium tuberculosis (75/326; 23.0%) were the most frequently identified pathogens. Viral infection occurred in 32.6% (148/454) with influenza (40/454; 8.8%) most common. Bacterial–viral coinfection occurred in 9.1% (28/307). Detection of M. tuberculosis was associated with mortality (adjusted odds ratio, 2.44 [1.19–5.01]). Conclusions: In the antiretroviral therapy era, CAP in Malawi remains predominantly HIV associated, with a large proportion attributable to potentially vaccine-preventable pathogens. Strategies to increase early detection and treatment of tuberculosis and improve supportive care, in particular the correction of hypoxemia, should be evaluated in clinical trials to address CAP-associated mortality.
KW - Africa south of the Sahara
KW - Community-acquired pneumonia
KW - HIV
KW - Pulmonary tuberculosis
KW - Streptococcus pneumoniae
UR - http://www.scopus.com/inward/record.url?scp=85065913663&partnerID=8YFLogxK
U2 - 10.1164/rccm.201807-1333OC
DO - 10.1164/rccm.201807-1333OC
M3 - Article
C2 - 30625278
AN - SCOPUS:85065913663
SN - 1073-449X
VL - 200
SP - 359
EP - 369
JO - American Journal of Respiratory and Critical Care Medicine
JF - American Journal of Respiratory and Critical Care Medicine
IS - 3
ER -
