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Antibiotic Therapy in Adults with Malaria (ANTHEM): High Rate of Clinically Significant Bacteremia in Hospitalized Adults Diagnosed with Falciparum Malaria

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  • 1 Insein General Hospital, Yangon, Myanmar;
  • 2 University of Medicine 2, Yangon, Myanmar;
  • 3 Department of Medical Care, Ministry of Health and Sports, Nay Pyi Taw, Myanmar;
  • 4 Menzies School of Health Research, Charles Darwin University, Darwin, Australia;
  • 5 Kirby Institute, University of New South Wales, Sydney, Australia

It has been believed that concomitant bacteremia is uncommon in adults hospitalized with falciparum malaria. Accordingly, the World Health Organization treatment guidelines presently only recommended additional antibacterial therapy in these patients if they have a clinical syndrome compatible with serious bacterial infection. Admission blood cultures were collected from 20 consecutive adults in Myanmar, hospitalized with a positive immunochromatographic test and blood film, suggesting a diagnosis of falciparum malaria; four (20%) had bacteremia with a clinically significant pathogen. These case series’ data were pooled with a previously published multicenter study from Myanmar which had also collected blood cultures in adults hospitalized with a diagnosis of falciparum malaria. Among 87 patients in the two studies, 13 (15%) had clinically significant bacteremia on admission, with Gram-negative organisms in 10 (77%) and Staphylococcus aureus in the remaining three (23%). Bacteremic patients had more severe disease than non-bacteremic patients (median [interquartile range] respiratory coma acidosis malaria score 2 [1–4] versus 1 [1–2], P = 0.02) and were more likely to die (2/13 [15%] versus 1/74 [1%], P = 0.01). However, bacterial coinfection was suspected clinically in a minority of bacteremic patients (5/13 [38%] compared with 13/70 [19%] of non-bacteremic patients, P = 0.11). Concomitant bacteremia in adults diagnosed with falciparum malaria may be more common than previously believed and is difficult to identify clinically in resource-poor settings. Death is more common in these patients, suggesting that clinicians should have a lower threshold for commencing empirical antibacterial therapy in adults diagnosed with falciparum malaria in these locations than is presently recommended.

Author Notes

Address correspondence to Josh Hanson, The Kirby Institute, University of New South Wales, Wallace Wurth Bldg., Kensington, Sydney, NSW 2052, Australia. E-mail: jhanson@kirby.unsw.edu.au

Financial support: This study was funded by the National Health and Medical Research Council of Australia (Program Grant 1037304 and Fellowships to NMA (Menzies) [1042072] and JH [1054195]).

Authors’ addresses: Ne Myo Aung and Mar Mar Kyi, Insein General Hospital, Yangon, Myanmar, and University of Medicine 2, Yangon, Myanmar, E-mails: drnaymyoaung@gmail.com and drmmkyi@gmail.com. Phyo Pyae Nyein, Thu Ya Htut, and Zaw Win Htet, Insein General Hospital, Yangon, Myanmar, E-mails: phyopyaenyein@gmail.com, thuyahtut999@gmail.com, and zawwinhtet1991@gmail.com. Tint Tint Kyi, Department of Medical Care, Ministry of Health and Sports, Nay Pyi Taw, Myanmar, E-mail: tinttint.kyi@gmail.com. Nicholas M. Anstey, Menzies School of Health Research, Charles Darwin University, Darwin, Australia, E-mail: nicholas.anstey@menzies.edu.au. Josh Hanson, University of Medicine 2, Yangon, Myanmar, Menzies School of Health Research, Charles Darwin University, Darwin, Australia, and Kirby Institute, University of New South Wales, Sydney, Australia, E-mail: jhanson@kirby.unsw.edu.au.

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