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THE ETIOLOGY OF FEBRILE ILLNESS IN ADULTS PRESENTING TO PATAN HOSPITAL IN KATHMANDU, NEPAL

In Nepal, many infections remain poorly characterized, partly due to limited diagnostic facilities. We studied consecutive febrile adults presenting to a general hospital in Kathmandu, Nepal. Of the 876 patients enrolled, enteric fever and pneumonia were the most common clinical diagnoses. Putative pathogens were identified in 323 (37%) patients, the most common being Salmonella enterica serotype Typhi and S. enterica serotype Paratyphi A (117), Rickettsia typhi (97), Streptococcus pneumoniae (53), Leptospira spp. (36), and Orientia tsutsugamushi (28). Approximately half of the Salmonella isolates were resistant to nalidixic acid. No clinical predictors were identified to reliably distinguish between the different infections. These findings confirm the heavy burden of enteric fever and pneumonia in Kathmandu, and highlight the importance of murine typhus, scrub typhus, and leptospirosis. Given the lack of reliable clinical predictors, the development of cheap and accurate diagnostic tests are likely to be of great clinical utility in this setting.

Received September 6, 2003. Accepted for publication November 11, 2003.

Acknowledgments: This study would not have been possible without the support and contributions of Bishwa N. Shrestha, Ram Babu Shrestha, the doctors, nurses and health workers of the Emergency and Outpatient Departments, and other clinical, laboratory, and administrative staff at Patan Hospital. We are also thankful for the significant contributions provided by Mitra N. Vaidya and the transport staff at Walter Reed/Armed Forces Research Institute of Medical Sciences Research Unit-Nepal (Kathmandu, Napal); Timothy Endy (Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand); William R. Jarvis (Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA); Paul Levett and Mary Bajani (Meningitis and Special Pathogens Branch, Division of Bacterial and Mycotic Diseases, Centers for Disease Control and Prevention, Atlanta, GA); Celeste McKnight and Rachel Addison (Duke University Clinical Microbiology Laboratory, Durham, NC); Sheryl Young and Trevor Anderson (Microbiology Unit, Canterbury Health Laboratories, Christchurch, New Zealand); and Dr. Asha Pun, Becton Dickinson, PanBio, Integrated Diagnostics, and Binax kindly donated blood culture bottles, serology tests, and urinary antigen tests, respectively. This work was presented in part at the 50th Annual Meeting of the American Society of Tropical Medicine and Hygiene, Atlanta, GA, November 11–15, 2001 (abstract 45) and the Eighth Conference of the International Society of Travel Medicine, New York, NY, May 7–11, 2003 (abstract FC03.04).

Financial support: The study was supported by a Centers for Disease Control and Prevention (CDC) grant to Lennox K. Archibald to study and characterize the epidemiology and microbiology of fever and bloodstream infections in adult inpatient populations in less-developed countries. The grant was part of CDC’s broader initiative to characterize and control emerging infections.

Authors’ addresses: David R. Murdoch, Microbiology Unit, Canter-bury Health Laboratories, PO Box 151, Christchurch, New Zealand, Telephone: 64-3-364-1530, Fax: 64-3-364-0238, E-mail: david.murdoch{at}cdhb.govt.nz. Christopher W. Woods and L. Barth Reller, Clinical Microbiology Laboratory, Box 3938, Duke University Medical Center, Durham, NC 27710. USA. Mark D. Zimmerman, Ram Hari Belbase, Andrew J. Keenan, and Buddha Basnyat, Patan Hospital, PO Box 126, Kathmandu, Nepal. Peter M. Dull, Division of Infectious Diseases, Emory University, 69 Jesse Hill, Jr. Drive, SE, Atlanta, GA 30303. Robert McNair Scott, Walter Reed/Armed Forces Research Institute of Medical Sciences Research Unit-Nepal, Field Unit, Department of Virology, Armed Forces Research Institute of Medical Sciences, 315/6 Rajvithi Road, Bangkok 10400, Thailand. Lennox K. Archibald, Regeneration Technologies, Inc, PO Box 2650, Alachua, FL 32616.

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