Aetiology and Risk Factors for Mortality in an Adult Community-Acquired Pneumonia Cohort in Malawi.

Stephen J. Aston; Antonia Ho; Hannah Jary; Jacqueline Huwa; Tamara Mitchell; Sarah Ibitoye; Simon Greenwood; Elizabeth Joekes; Arthur Daire; Jane Mallewa; Dean Everett; Mulinda Nyirenda; Brian Faragher; Henry Mwandumba; Robert S. Heyderman; Stephen Gordon

doi:10.1164/rccm.201807-1333oc

Aetiology and Risk Factors for Mortality in an Adult Community-Acquired Pneumonia Cohort in Malawi.

Stephen J. Aston, Antonia Ho, Hannah Jary, Jacqueline Huwa, Tamara Mitchell, Sarah Ibitoye, Simon Greenwood, Elizabeth Joekes, Arthur Daire, Jane Mallewa, Dean Everett, Mulinda Nyirenda, Brian Faragher, Henry Mwandumba, Robert S. Heyderman, Stephen Gordon

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Abstract

RATIONALE

In the context of rapid antiretroviral therapy (ART) rollout and an increasing burden of non-communicable diseases, there are few contemporary data describing the aetiology and outcome of community-acquired pneumonia (CAP) in sub-Saharan Africa.

OBJECTIVES

To describe the current aetiology of CAP in Malawi and identify risk factors for mortality.

METHODS

We conducted a prospective observational study of adults hospitalised with CAP to a teaching hospital in Blantyre, Malawi. Aetiology 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 [IQR: 29.4-41.9] years), 30-day mortality was 14.6% (64/439) and associated with male sex (adjusted odds ratio 2.60 [95% CI: 1.17-5.78]), symptom duration >7 days (2.78 [1.40-5.54]), tachycardia (2.99 [1.48-6.06]), hypoxaemia (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 co-infection occurred in 9.1% (28/307). Detection of M. tuberculosis was associated with mortality (aOR 2.44 [1.19-5.01]).

CONCLUSIONS

In the ART 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 hypoxaemia, should be evaluated in clinical trials to address CAP-associated mortality.

Original language	English
Pages (from-to)	359-369
Number of pages	11
Journal	American Journal of Respiratory and Critical Care Medicine
Volume	200
Issue number	3
Early online date	9 Jan 2019
DOIs	https://doi.org/10.1164/rccm.201807-1333oc
Publication status	Published - 1 Aug 2019

Keywords

Africa south of the Sahara
Community-acquired pneumonia
HIV
Pulmonary tuberculosis
Streptococcus pneumoniae

UN SDGs

This output contributes to the following UN Sustainable Development Goals (SDGs)

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CAP in malawiFinal published version, 514 KB

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Aston, S. J., Ho, A., Jary, H., Huwa, J., Mitchell, T., Ibitoye, S., Greenwood, S., Joekes, E., Daire, A., Mallewa, J., Everett, D., Nyirenda, M., Faragher, B., Mwandumba, H., Heyderman, R. S., & Gordon, S. (2019). Aetiology and Risk Factors for Mortality in an Adult Community-Acquired Pneumonia Cohort in Malawi. American Journal of Respiratory and Critical Care Medicine, 200(3), 359-369. https://doi.org/10.1164/rccm.201807-1333oc

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title = "Aetiology and Risk Factors for Mortality in an Adult Community-Acquired Pneumonia Cohort in Malawi.",

abstract = "RATIONALEIn the context of rapid antiretroviral therapy (ART) rollout and an increasing burden of non-communicable diseases, there are few contemporary data describing the aetiology and outcome of community-acquired pneumonia (CAP) in sub-Saharan Africa.OBJECTIVESTo describe the current aetiology of CAP in Malawi and identify risk factors for mortality.METHODSWe conducted a prospective observational study of adults hospitalised with CAP to a teaching hospital in Blantyre, Malawi. Aetiology 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 RESULTSIn 459 patients (285 [62.1\%] males; median age 34.7 [IQR: 29.4-41.9] years), 30-day mortality was 14.6\% (64/439) and associated with male sex (adjusted odds ratio 2.60 [95\% CI: 1.17-5.78]), symptom duration >7 days (2.78 [1.40-5.54]), tachycardia (2.99 [1.48-6.06]), hypoxaemia (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 co-infection occurred in 9.1\% (28/307). Detection of M. tuberculosis was associated with mortality (aOR 2.44 [1.19-5.01]).CONCLUSIONSIn the ART 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 hypoxaemia, should be evaluated in clinical trials to address CAP-associated mortality.",

keywords = "Africa south of the Sahara, Community-acquired pneumonia, HIV, Pulmonary tuberculosis, Streptococcus pneumoniae",

author = "Aston, \{Stephen J.\} and Antonia Ho and Hannah Jary and Jacqueline Huwa and Tamara Mitchell and Sarah Ibitoye and Simon Greenwood and Elizabeth Joekes and Arthur Daire and Jane Mallewa and Dean Everett and Mulinda Nyirenda and Brian Faragher and Henry Mwandumba and Heyderman, \{Robert S.\} and Stephen Gordon",

year = "2019",

month = aug,

day = "1",

doi = "10.1164/rccm.201807-1333oc",

language = "English",

volume = "200",

pages = "359--369",

journal = "American Journal of Respiratory and Critical Care Medicine",

issn = "1073-449X",

publisher = "American Thoracic Society",

number = "3",

}

Aston, SJ, Ho, A, Jary, H, Huwa, J, Mitchell, T, Ibitoye, S, Greenwood, S, Joekes, E, Daire, A, Mallewa, J, Everett, D, Nyirenda, M, Faragher, B, Mwandumba, H, Heyderman, RS & Gordon, S 2019, 'Aetiology and Risk Factors for Mortality in an Adult Community-Acquired Pneumonia Cohort in Malawi.', American Journal of Respiratory and Critical Care Medicine, vol. 200, no. 3, pp. 359-369. https://doi.org/10.1164/rccm.201807-1333oc

TY - JOUR

T1 - Aetiology 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

AU - Heyderman, Robert S.

AU - Gordon, Stephen

PY - 2019/8/1

Y1 - 2019/8/1

N2 - RATIONALEIn the context of rapid antiretroviral therapy (ART) rollout and an increasing burden of non-communicable diseases, there are few contemporary data describing the aetiology and outcome of community-acquired pneumonia (CAP) in sub-Saharan Africa.OBJECTIVESTo describe the current aetiology of CAP in Malawi and identify risk factors for mortality.METHODSWe conducted a prospective observational study of adults hospitalised with CAP to a teaching hospital in Blantyre, Malawi. Aetiology 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 RESULTSIn 459 patients (285 [62.1%] males; median age 34.7 [IQR: 29.4-41.9] years), 30-day mortality was 14.6% (64/439) and associated with male sex (adjusted odds ratio 2.60 [95% CI: 1.17-5.78]), symptom duration >7 days (2.78 [1.40-5.54]), tachycardia (2.99 [1.48-6.06]), hypoxaemia (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 co-infection occurred in 9.1% (28/307). Detection of M. tuberculosis was associated with mortality (aOR 2.44 [1.19-5.01]).CONCLUSIONSIn the ART 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 hypoxaemia, should be evaluated in clinical trials to address CAP-associated mortality.

AB - RATIONALEIn the context of rapid antiretroviral therapy (ART) rollout and an increasing burden of non-communicable diseases, there are few contemporary data describing the aetiology and outcome of community-acquired pneumonia (CAP) in sub-Saharan Africa.OBJECTIVESTo describe the current aetiology of CAP in Malawi and identify risk factors for mortality.METHODSWe conducted a prospective observational study of adults hospitalised with CAP to a teaching hospital in Blantyre, Malawi. Aetiology 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 RESULTSIn 459 patients (285 [62.1%] males; median age 34.7 [IQR: 29.4-41.9] years), 30-day mortality was 14.6% (64/439) and associated with male sex (adjusted odds ratio 2.60 [95% CI: 1.17-5.78]), symptom duration >7 days (2.78 [1.40-5.54]), tachycardia (2.99 [1.48-6.06]), hypoxaemia (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 co-infection occurred in 9.1% (28/307). Detection of M. tuberculosis was associated with mortality (aOR 2.44 [1.19-5.01]).CONCLUSIONSIn the ART 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 hypoxaemia, 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

U2 - 10.1164/rccm.201807-1333oc

DO - 10.1164/rccm.201807-1333oc

M3 - Article

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 -

Aetiology and Risk Factors for Mortality in an Adult Community-Acquired Pneumonia Cohort in Malawi.

Abstract

Keywords

UN SDGs

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