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Etiologies of Illness Among Patients Meeting Integrated Management of Adolescent and Adult Illness District Clinician Manual Criteria for Severe Infections in Northern Tanzania: Implications for Empiric Antimicrobial Therapy

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  • Division of Infectious Diseases and International Health, Department of Medicine, Duke University, Durham, North Carolina; Department of Medicine, Kilimanjaro Christian Medical Centre, Moshi, Tanzania; Kilimanjaro Christian Medical University College, Tumaini University, Moshi, Tanzania; Duke Global Health Institute, Duke University, Durham, North Carolina; Centre for International Health, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand

We describe the laboratory-confirmed etiologies of illness among participants in a hospital-based febrile illness cohort study in northern Tanzania who retrospectively met Integrated Management of Adolescent and Adult Illness District Clinician Manual (IMAI) criteria for septic shock, severe respiratory distress without shock, and severe pneumonia, and compare these etiologies against commonly used antimicrobials, including IMAI recommendations for emergency antibacterials (ceftriaxone or ampicillin plus gentamicin) and IMAI first-line recommendations for severe pneumonia (ceftriaxone and a macrolide). Among 423 participants hospitalized with febrile illness, there were 25 septic shock, 37 severe respiratory distress without shock, and 109 severe pneumonia cases. Ceftriaxone had the highest potential utility of all antimicrobials assessed, with responsive etiologies in 12 (48%) septic shock, 5 (14%) severe respiratory distress without shock, and 19 (17%) severe pneumonia illnesses. For each syndrome 17–27% of participants had etiologic diagnoses that would be non-responsive to ceftriaxone, but responsive to other available antimicrobial regimens including amphotericin for cryptococcosis and histoplasmosis; anti-tuberculosis therapy for bacteremic disseminated tuberculosis; or tetracycline therapy for rickettsioses and Q fever. We conclude that although empiric ceftriaxone is appropriate in our setting, etiologies not explicitly addressed in IMAI guidance for these syndromes, such as cryptococcosis, histoplasmosis, and tetracycline-responsive bacterial infections, were common.

Author Notes

* Address correspondence to John A. Crump, Adjunct Professor of Medicine, Pathology, and Global Health, Division of Infectious Diseases and International Health, Department of Medicine, Duke University Medical Center, Box 102359, Durham, NC 27710. E-mail: john.crump@duke.edu

Financial support: Funding support received for this work includes the International Studies on AIDS Associated Co-infections (ISAAC) award, a United States National Institutes of Health (NIH) funded program (U01 AI062563). Investigator support was received from NIH awards ISAAC (to J.A.C., V.P.M., J.A.B.); AIDS International Training and Research Program (D43 PA-03-018 to J.A.C., V.P.M., J.A.B.; D43 TW009595 to J.A.B); Duke Clinical Trials Unit and Clinical Research Sites (U01 AI069484 to J.A.C., V.P.M., J.A.B.); the Center for HIV/AIDS Vaccine Immunology (U01 AI067854 to J.A.C., J.A.B.); the joint NIH-NSF Ecology and Evolution of Infectious Disease program and the UK Economic and Social Research Council and Biotechnology and Biological Sciences Research Council (R01 TW009237 to J.A.C., V.P.M.); and the Fogarty International Center Global Health Fellowship Program R25TW009343 (M.P.R.). Investigator support was also received from Health Resources and Services Administration T84HA21123 (J.A.B.).

Disclosure: Presented in part at the 63rd American Society of Tropical Medicine and Hygiene annual meeting, New Orleans, LA, 2–6 November 2014, abstract 1881.

Authors' addresses: Matthew P. Rubach, Department of Pathology, University of Utah, Salt Lake City, UT, E-mail: matthew.rubach@hsc.utah.edu. Venance P. Maro, Department of Internal Medicine, Kilimanjaro Christian Medical Centre, Moshi, Tanzania, E-mail: venmaro@ymail.com. John A. Bartlett, Department of Internal Medicine, Duke University, Durham, NC, E-mail: john.bartlett@duke.edu. John A. Crump, Department of Medicine, Duke University, Durham, NC, E-mail: john.crump@duke.edu.

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