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

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. C., Heyderman, R. S. and Gordon, S. B.

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.

April 12, 2019
Year of publication
Resource types
Journal and research articles
pneumonia, early detection, antituberculosis treatment, HIV mortality

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