Concomitant bacteremia in adults with severe falciparum malaria

Background

Approximately 6% of children hospitalised with severe falciparum malaria in Africa are also bacteremic. It is therefore recommended that all children with severe malaria should receive broad spectrum antibiotics in addition to parenteral artesunate. Empirical antibiotics are not recommended currently for adults with severe malaria.

Methods

Blood cultures were performed on sequential prospectively studied adult patients with strictly defined severe falciparum malaria admitted to a single referral centre in Vietnam between 1991 and 2003.

Results

In 845 Vietnamese adults with severe falciparum malaria admission blood cultures were positive in 9 (1.07%: 95%CI 0.37 to 1.76%); S. aureus 2, S. pyogenes 1, S. Typhi 3, Non-typhoid Salmonella 1, K. pneumoniae 1, H. influenzae type b 1. Bacteremic patients presented usually with a combination of jaundice, acute renal failure and high malaria parasitemia. Four bacteremic patients died compared with 108 (12.9%) of 836 non-bacteremic severe malaria patients; risk ratio 3.44 (95%CI 1.62 to 7.29). In patients with >20% parasitemia the prevalence of concomitant bacteremia was 5.2% (4/76: 95%CI 0.2 to 10.3%) compared with 0.65% (5/769: 0.08 to 1.2%) in patients with <20% parasitemia, a risk ratio of 8.1 (2.2 to 29.5).

Conclusions

In contrast to children, the prevalence of concomitant bacteremia in adults with severe malaria is low. Administration of empirical antibiotics, in addition to artesunate, is warranted in the small subgroup of patients with very high parasitemias, emphasising the importance of quantitative blood smear microscopy assessment, but it is not indicated in the majority of adults with severe falciparum malaria.