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Gavey R, Stewart AGA, Bagshaw R, Smith S, Vincent S, Hanson J. Respiratory manifestations of rickettsial disease in tropical Australia; Clinical course and implications for patient management. Acta Trop 2025; 266:107631. [PMID: 40306563 DOI: 10.1016/j.actatropica.2025.107631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2025] [Revised: 04/15/2025] [Accepted: 04/24/2025] [Indexed: 05/02/2025]
Abstract
BACKGROUND Rickettsial infections have a global distribution and can cause life-threatening disease. Respiratory symptoms can be a harbinger of a more complicated disease course. However, the clinical associations - and the clinical course - of patients with rickettsial disease and respiratory involvement are incompletely defined. METHODS This was a retrospective study of all patients with a diagnosis of scrub typhus or Queensland tick typhus (QTT) managed at Cairns Hospital in tropical Australia, between 1st January 1997 and 31st October 2023. We determined the demographic, clinical, radiological and laboratory associations of respiratory involvement which was defined as any acute abnormality of lung parenchyma identified on thoracic imaging during their hospitalisation that did not have another more likely explanation. We compared the clinical course of patients with a rickettsial infection who did - and did not - have respiratory involvement. RESULTS There were 226 individuals included in the analysis, 51/226 (22 %) had respiratory involvement, including 18/59 (31 %) with QTT and 33/167 (20 %) with scrub typhus, p = 0.09. The imaging findings were heterogenous: 33/51 (65 %) had predominantly alveolar changes, 18/51 (35 %) had interstitial changes and 12/51 (24 %) had a pleural effusion. Those with respiratory involvement were older than individuals without respiratory involvement (median (interquartile range (IQR)) age 51 (37-65) years versus 38 (25-51) years (p = 0.0001). However, most patients (27/51, 53 %) with respiratory involvement had no comorbidity and were younger than 60. Patients with respiratory involvement were more likely to require ICU admission that patients without respiratory involvement (19/51 (38 %) versus 6/175 (3 %) p < 0.001) and 9/51 (18 %) with respiratory involvement required mechanical ventilation. Patients with respiratory involvement were also more likely to require vasopressor support (14/51, 27 % versus 4/175, 2 %, p < 0.001) and renal replacement therapy (4/51, 8 % versus 1/175, 0.6 %, p = 0.01) than patients without respiratory involvement. There were 2/226 (1 %) individuals who died from their rickettsial infection (1 scrub typhus and 1 QTT) during the study period, both had respiratory involvement. CONCLUSIONS Respiratory involvement is common in individuals with rickettsial infection in tropical Australia and is associated with a greater risk of life-threatening disease.
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Affiliation(s)
- Roderick Gavey
- Department of Medicine, Cairns Hospital, Cairns, Queensland 4870, Australia
| | - Alexandra G A Stewart
- Infectious Diseases Unit, Royal Brisbane and Women's Hospital, Brisbane, Queensland 4029, Australia
| | - Richard Bagshaw
- Department of Medicine, Cairns Hospital, Cairns, Queensland 4870, Australia
| | - Simon Smith
- Department of Medicine, Cairns Hospital, Cairns, Queensland 4870, Australia
| | - Stephen Vincent
- Department of Medicine, Cairns Hospital, Cairns, Queensland 4870, Australia
| | - Josh Hanson
- Department of Medicine, Cairns Hospital, Cairns, Queensland 4870, Australia; Kirby Institute, University of New South Wales, Kensington, New South Wales 2033, Australia.
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Lal S, Luangraj M, Keddie SH, Ashley EA, Baerenbold O, Bassat Q, Bradley J, Crump JA, Feasey NA, Green EW, Kain KC, Olaru ID, Lalloo DG, Roberts CH, Mabey DC, Moore CC, Hopkins H. Predicting mortality in febrile adults: comparative performance of the MEWS, qSOFA, and UVA scores using prospectively collected data among patients in four health-care sites in sub-Saharan Africa and South-Eastern Asia. EClinicalMedicine 2024; 77:102856. [PMID: 39416389 PMCID: PMC11474423 DOI: 10.1016/j.eclinm.2024.102856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2024] [Revised: 09/10/2024] [Accepted: 09/11/2024] [Indexed: 10/19/2024] Open
Abstract
Background Clinical severity scores can identify patients at risk of severe disease and death, and improve patient management. The modified early warning score (MEWS), the quick Sequential (Sepsis-Related) Organ Failure Assessment (qSOFA), and the Universal Vital Assessment (UVA) were developed as risk-stratification tools, but they have not been fully validated in low-resource settings where fever and infectious diseases are frequent reasons for health care seeking. We assessed the performance of MEWS, qSOFA, and UVA in predicting mortality among febrile patients in the Lao PDR, Malawi, Mozambique, and Zimbabwe. Methods We prospectively enrolled in- and outpatients aged ≥ 15 years who presented with fever (≥37.5 °C) from June 2018-March 2021. We collected clinical data to calculate each severity score. The primary outcome was mortality 28 days after enrolment. The predictive performance of each score was determined using area under the receiver operating curve (AUC). Findings A total of 2797 participants were included in this analysis. The median (IQR) age was 32 (24-43) years, 38% were inpatients, and 60% (1684/2797) were female. By the time of follow-up, 7% (185/2797) had died. The AUC (95% CI) for MEWS, qSOFA and UVA were 0.67 (0.63-0.71), 0.68 (0.64-0.72), and 0.82 (0.79-0.85), respectively. The AUC comparison found UVA outperformed both MEWS (p < 0.001) and qSOFA (p < 0.001). Interpretation We showed that the UVA score performed best in predicting mortality among febrile participants by the time follow-up compared with MEWS and qSOFA, across all four study sites. The UVA score could be a valuable tool for early identification, triage, and initial treatment guidance of high-risk patients in resource-limited clinical settings. Funding FCDO.
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Affiliation(s)
- Sham Lal
- Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Manophab Luangraj
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), Mahosot Hospital, Vientiane, Lao PDR, Laos
| | - Suzanne H. Keddie
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine (LSHTM), London, UK
| | - Elizabeth A. Ashley
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), Mahosot Hospital, Vientiane, Lao PDR, Laos
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Oliver Baerenbold
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine (LSHTM), London, UK
| | - Quique Bassat
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
- Pediatric Infectious Diseases Unit, Pediatrics Department, Hospital Sant Joan de Déu (University of Barcelona), Barcelona, Spain
- ICREA, Pg. Lluís Companys 23, Barcelona 08010, Spain
| | - John Bradley
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine (LSHTM), London, UK
| | - John A. Crump
- Centre for International Health, University of Otago, Dunedin, New Zealand
| | - Nicholas A. Feasey
- Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Edward W. Green
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Kevin C. Kain
- Sandra Rotman Centre for Global Health, MaRS Centre, Department of Medicine, University Health Network-Toronto General Hospital, University of Toronto, 101 College St TMDT 10-360A, Toronto, ON M5G 1L7, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
- Division of Infectious Diseases, University Health Network, Toronto, ON, Canada
| | - Ioana D. Olaru
- Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - David G. Lalloo
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Chrissy h. Roberts
- Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - David C.W. Mabey
- Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Christopher C. Moore
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, USA
| | - Heidi Hopkins
- Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
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Prinsloo C, Smith S, Law M, Hanson J. The Epidemiological, Clinical, and Microbiological Features of Patients with Burkholderia pseudomallei Bacteraemia-Implications for Clinical Management. Trop Med Infect Dis 2023; 8:481. [PMID: 37999600 PMCID: PMC10675116 DOI: 10.3390/tropicalmed8110481] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 10/21/2023] [Accepted: 10/23/2023] [Indexed: 11/25/2023] Open
Abstract
Patients with melioidosis are commonly bacteraemic. However, the epidemiological characteristics, the microbiological findings, and the clinical associations of Burkholderia pseudomallei bacteraemia are incompletely defined. All cases of culture-confirmed melioidosis at Cairns Hospital in tropical Australia between January 1998 and June 2023 were reviewed. The presence of bacteraemia was determined and correlated with patient characteristics and outcomes; 332/477 (70%) individuals in the cohort were bacteraemic. In multivariable analysis, immunosuppression (odds ratio (OR) (95% confidence interval (CI)): (2.76 (1.21-6.27), p = 0.02), a wet season presentation (2.27 (1.44-3.59), p < 0.0001) and male sex (1.69 (1.08-2.63), p = 0.02), increased the likelihood of bacteraemia. Patients with a skin or soft tissue infection (0.32 (0.19-0.57), p < 0.0001) or without predisposing factors for melioidosis (0.53 (0.30-0.93), p = 0.03) were less likely to be bacteraemic. Bacteraemia was associated with intensive care unit admission (OR (95%CI): 4.27 (2.35-7.76), p < 0.0001), and death (2.12 (1.04-4.33), p = 0.04). The median (interquartile range) time to blood culture positivity was 31 (26-39) hours. Patients with positive blood cultures within 24 h were more likely to die than patients whose blood culture flagged positive after this time (OR (95%CI): 11.05 (3.96-30.83), p < 0.0001). Bacteraemia portends a worse outcome in patients with melioidosis. Its presence or absence might be used to help predict outcomes in cases of melioidosis and to inform optimal clinical management.
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Affiliation(s)
- Carmen Prinsloo
- College of Medicine and Dentistry, James Cook University, Cairns Hospital, Cairns, QLD 4870, Australia
| | - Simon Smith
- Department of Medicine, Cairns Hospital, Cairns, QLD 4870, Australia;
| | - Matthew Law
- The Kirby Institute, University of New South Wales, Sydney, NSW 2042, Australia;
| | - Josh Hanson
- Department of Medicine, Cairns Hospital, Cairns, QLD 4870, Australia;
- The Kirby Institute, University of New South Wales, Sydney, NSW 2042, Australia;
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT 0811, Australia
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Adegbite BR, Edoa JR, Ndzebe Ndoumba WF, Dimessa Mbadinga LB, Mombo-Ngoma G, Jacob ST, Rylance J, Hänscheid T, Adegnika AA, Grobusch MP. A comparison of different scores for diagnosis and mortality prediction of adults with sepsis in Low-and-Middle -Income Countries: a systematic review and meta-analysis. EClinicalMedicine 2021; 42:101184. [PMID: 34765956 PMCID: PMC8569629 DOI: 10.1016/j.eclinm.2021.101184] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Revised: 10/11/2021] [Accepted: 10/19/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Clinical scores for sepsis have been primarily developed for, and applied in High-Income Countries. This systematic review and meta-analysis examined the performance of the quick Sequential Organ Failure Assessment (qSOFA), Systemic Inflammatory Response Syndrome (SIRS), Modified Early Warning Score (MEWS), and Universal Vital Assessment (UVA) scores for diagnosis and prediction of mortality in patients with suspected infection in Low-and-Middle-Income Countries. METHODS PubMed, Science Direct, Web of Science, and the Cochrane Central Register of Controlled Trials databases were searched until May 18, 2021. Studies reporting the performance of at least one of the above-mentioned scores for predicting mortality in patients of 15 years of age and older with suspected infection or sepsis were eligible. The Quality Assessment of Diagnostic Accuracy Studies tool was used for risk-of-bias assessment. PRISMA guidelines were followed (PROSPERO registration: CRD42020153906). The bivariate random-effects regression model was used to pool the individual sensitivities, specificities and areas-under-the-curve (AUC). FINDINGS Twenty-four articles (of 5669 identified) with 27,237 patients were eligible for inclusion. qSOFA pooled sensitivity was 0·70 (95% confidence interval [CI] 0·60-0·78), specificity 0·73 (95% CI 0·67-0·79), and AUC 0·77 (95% CI 0·72-0·82). SIRS pooled sensitivity, specificity and AUC were 0·88 (95% CI 0·79 -0·93), 0·34 (95% CI 0·25-0·44), and 0·69 (95% CI 0·50-0·83), respectively. MEWS pooled sensitivity, specificity and AUC were 0·70 (95% CI 0·57 -0·81), 0·61 (95% CI 0·42-0·77), and 0·72 (95% CI 0·64-0·77), respectively. UVA pooled sensitivity, specificity and AUC were 0·49 (95% CI 0·33 -0·65), 0·91(95% CI 0·84-0·96), and 0·76 (95% CI 0·44-0·93), respectively. Significant heterogeneity was observed in the pooled analysis. INTERPRETATION Individual score performances ranged from poor to acceptable. Future studies should combine selected or modified elements of different scores. FUNDING Partially funded by the UK National Institute for Health Research (NIHR) (17/63/42).
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Affiliation(s)
- Bayode R Adegbite
- Centre de Recherches Médicales de Lambaréné and African Partner Institution, German Center for Infection Research (CERMEL), Lambaréné, Gabon
- Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Amsterdam University Medical Centers, location AMC, Amsterdam Infection & Immunity, Amsterdam Public Health, University of Amsterdam, Amsterdam, The Netherlands
- Institut für Tropenmedizin, Universität Tübingen and German Center for Infection Research, Tübingen, Germany
| | - Jean R Edoa
- Centre de Recherches Médicales de Lambaréné and African Partner Institution, German Center for Infection Research (CERMEL), Lambaréné, Gabon
- Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Amsterdam University Medical Centers, location AMC, Amsterdam Infection & Immunity, Amsterdam Public Health, University of Amsterdam, Amsterdam, The Netherlands
- Institut für Tropenmedizin, Universität Tübingen and German Center for Infection Research, Tübingen, Germany
| | - Wilfrid F Ndzebe Ndoumba
- Centre de Recherches Médicales de Lambaréné and African Partner Institution, German Center for Infection Research (CERMEL), Lambaréné, Gabon
| | - Lia B Dimessa Mbadinga
- Centre de Recherches Médicales de Lambaréné and African Partner Institution, German Center for Infection Research (CERMEL), Lambaréné, Gabon
| | - Ghyslain Mombo-Ngoma
- Centre de Recherches Médicales de Lambaréné and African Partner Institution, German Center for Infection Research (CERMEL), Lambaréné, Gabon
- Institut für Tropenmedizin, Universität Tübingen and German Center for Infection Research, Tübingen, Germany
- Department of Tropical Medicine, Bernhard Nocht Institute for Tropical Medicine & I Department of Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Shevin T Jacob
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool
- Walimu, Kampala, Uganda
| | - Jamie Rylance
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool
- Malawi-Liverpool-Wellcome Trust, Chichiri, Blantyre, Malawi
| | - Thomas Hänscheid
- Instituto de Microbiologica, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
| | - Ayola A Adegnika
- Centre de Recherches Médicales de Lambaréné and African Partner Institution, German Center for Infection Research (CERMEL), Lambaréné, Gabon
- Institut für Tropenmedizin, Universität Tübingen and German Center for Infection Research, Tübingen, Germany
- Department of Parasitology, Leiden University Medical Center, Leiden, The Netherlands
| | - Martin P Grobusch
- Centre de Recherches Médicales de Lambaréné and African Partner Institution, German Center for Infection Research (CERMEL), Lambaréné, Gabon
- Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Amsterdam University Medical Centers, location AMC, Amsterdam Infection & Immunity, Amsterdam Public Health, University of Amsterdam, Amsterdam, The Netherlands
- Institut für Tropenmedizin, Universität Tübingen and German Center for Infection Research, Tübingen, Germany
- MasangaMedical Research Unit, Masanga, Sierra Leone
- Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Correspondence: Prof. Martin P. Grobusch, Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Amsterdam University Medical Centers, location AMC, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands, Phone: +31 6 566 4380
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