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Poespoprodjo JR, Douglas NM, Ansong D, Kho S, Anstey NM. Malaria. Lancet 2023; 402:2328-2345. [PMID: 37924827 DOI: 10.1016/s0140-6736(23)01249-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 05/22/2023] [Accepted: 06/16/2023] [Indexed: 11/06/2023]
Abstract
Malaria is resurging in many African and South American countries, exacerbated by COVID-19-related health service disruption. In 2021, there were an estimated 247 million malaria cases and 619 000 deaths in 84 endemic countries. Plasmodium falciparum strains partly resistant to artemisinins are entrenched in the Greater Mekong region and have emerged in Africa, while Anopheles mosquito vectors continue to evolve physiological and behavioural resistance to insecticides. Elimination of Plasmodium vivax malaria is hindered by impractical and potentially toxic antirelapse regimens. Parasitological diagnosis and treatment with oral or parenteral artemisinin-based therapy is the mainstay of patient management. Timely blood transfusion, renal replacement therapy, and restrictive fluid therapy can improve survival in severe malaria. Rigorous use of intermittent preventive treatment in pregnancy and infancy and seasonal chemoprevention, potentially combined with pre-erythrocytic vaccines endorsed by WHO in 2021 and 2023, can substantially reduce malaria morbidity. Improved surveillance, better access to effective treatment, more labour-efficient vector control, continued drug development, targeted mass drug administration, and sustained political commitment are required to achieve targets for malaria reduction by the end of this decade.
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Affiliation(s)
- Jeanne Rini Poespoprodjo
- Centre for Child Health and Department of Child Health, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia; Timika Malaria Research Facility, Papuan Health and Community Development Foundation, Timika, Indonesia; Mimika District Hospital and District Health Authority, Timika, Indonesia; Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia.
| | - Nicholas M Douglas
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia; Department of Infectious Diseases, Christchurch Hospital, Te Whatu Ora Waitaha, Christchurch, New Zealand; Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Daniel Ansong
- School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Steven Kho
- Timika Malaria Research Facility, Papuan Health and Community Development Foundation, Timika, Indonesia; Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia
| | - Nicholas M Anstey
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia; Department of Infectious Diseases, Royal Darwin Hospital, Darwin, NT, Australia
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Saito M, Phyo AP, Chu C, Proux S, Rijken MJ, Beau C, Win HH, Archasuksan L, Wiladphaingern J, Phu NH, Hien TT, Day NP, Dondorp AM, White NJ, Nosten F, McGready R. Severe falciparum malaria in pregnancy in Southeast Asia: a multi-centre retrospective cohort study. BMC Med 2023; 21:320. [PMID: 37620809 PMCID: PMC10464355 DOI: 10.1186/s12916-023-02991-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Accepted: 07/20/2023] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND Severe malaria in pregnancy causes maternal mortality, morbidity, and adverse foetal outcomes. The factors contributing to adverse maternal and foetal outcomes are not well defined. We aimed to identify the factors predicting higher maternal mortality and to describe the foetal mortality and morbidity associated with severe falciparum malaria in pregnancy. METHODS A retrospective cohort study was conducted of severe falciparum malaria in pregnancy, as defined by the World Health Organization severe malaria criteria. The patients were managed prospectively by the Shoklo Malaria Research Unit (SMRU) on the Thailand-Myanmar border or were included in hospital-based clinical trials in six Southeast Asian countries. Fixed-effects multivariable penalised logistic regression was used for analysing maternal mortality. RESULTS We included 213 (123 SMRU and 90 hospital-based) episodes of severe falciparum malaria in pregnancy managed between 1980 and 2020. The mean maternal age was 25.7 (SD 6.8) years, and the mean gestational age was 25.6 (SD 8.9) weeks. The overall maternal mortality was 12.2% (26/213). Coma (adjusted odds ratio [aOR], 7.18, 95% CI 2.01-25.57, p = 0.0002), hypotension (aOR 11.21, 95%CI 1.27-98.92, p = 0.03) and respiratory failure (aOR 4.98, 95%CI 1.13-22.01, p = 0.03) were associated with maternal mortality. Pregnant women with one or more of these three criteria had a mortality of 29.1% (25/86) (95%CI 19.5 to 38.7%) whereas there were no deaths in 88 pregnant women with hyperparasitaemia (> 10% parasitised erythrocytes) only or severe anaemia (haematocrit < 20%) only. In the SMRU prospective cohort, in which the pregnant women were followed up until delivery, the risks of foetal loss (23.3% by Kaplan-Meier estimator, 25/117) and small-for-gestational-age (38.3%, 23/60) after severe malaria were high. Maternal death, foetal loss and preterm birth occurred commonly within a week of diagnosis of severe malaria. CONCLUSIONS Vital organ dysfunction in pregnant women with severe malaria was associated with a very high maternal and foetal mortality whereas severe anaemia or hyperparasitaemia alone were not associated with poor prognosis, which may explain the variation of reported mortality from severe malaria in pregnancy. Access to antenatal care must be promoted to reduce barriers to early diagnosis and treatment of both malaria and anaemia.
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Affiliation(s)
- Makoto Saito
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand.
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
- Division of Infectious Diseases, Advanced Clinical Research Center, Institute of Medical Science, University of Tokyo, Tokyo, Japan.
| | - Aung Pyae Phyo
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Cindy Chu
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Stephane Proux
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Marcus J Rijken
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Department of Obstetrics and Gynecology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Candy Beau
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Htun Htun Win
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Laypaw Archasuksan
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Jacher Wiladphaingern
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Nguyen H Phu
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Tran T Hien
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Nick P Day
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Arjen M Dondorp
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Nicholas J White
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - François Nosten
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Rose McGready
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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Borgstein A, Zhang B, Lam C, Gushu MB, Liomba AW, Malenga A, Pensulo P, Tebulo A, Small DS, Taylor T, Seydel K. Delayed presentation to hospital care is associated with sequelae but not mortality in children with cerebral malaria in Malawi. Malar J 2022; 21:60. [PMID: 35193585 PMCID: PMC8864854 DOI: 10.1186/s12936-022-04080-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Accepted: 02/06/2022] [Indexed: 11/10/2022] Open
Abstract
Background Cerebral malaria is still a major cause of death in children in sub-Saharan Africa. Among survivors, debilitating neurological sequelae can leave children with permanent cognitive impairments and societal stigma, resulting in taxing repercussions for their families. This study investigated the effect of delay in presentation to medical care on outcome in children with cerebral malaria in Malawi. Methods This retrospective study included participants enrolled in a longstanding study of cerebral malaria between 2001 and 2021 and considered coma duration prior to arrival at hospital (with or without anti-malarial treatment), HIV status, blood lactate levels at admission and age as factors that could affect clinical outcome. Outcomes were categorized as full recovery, sequelae at the time of discharge, or death. A multinomial regression was fit and run controlling for coma duration, HIV status, lactate levels and age, to determine the association between each explanatory variable and outcome. Results A total of 1663 children with cerebral malaria, aged 6 months to 14 years were included. Longer coma duration (in hours) was associated with greater odds of developing sequelae (OR = 1.023, 95% CI 1.007–1.039, p = 0.006) but not death (OR = 1.00, 95% CI 0.986–1.015, p = 0.961). Younger age (in months) was also correlated with higher rates of sequelae, (OR = 0.990, 95% CI 0.983–0.997, p = 0.004) but not with increased mortality (OR = 0.998, 95% CI 0.993–1.003, p = 0.335). Blood lactate levels on admission were correlated with mortality (OR = 1.125, 95% CI 1.090–1.161, p < 0.001) but not associated with increased rates of sequelae (OR = 1.016, 95% CI 0.973–1.060, p = 0.475). Positive HIV status and treatment with an anti-malarial (artemisinin or non-artemisinin-based) prior to arrival at the hospital were not significantly associated with either adverse outcome. Conclusions In Malawian children with cerebral malaria, higher rates of sequelae were significantly associated with extended coma duration prior to admission and younger age. Mortality rates were correlated with increased lactate levels on admission. The differential effects of variables on clinical outcomes suggest that there may be different pathogenic pathways leading to sequelae and death. Actions taken by parents and health care professionals are critical in defining when patients arrive at hospital and determining their ultimate outcome. Supplementary Information The online version contains supplementary material available at 10.1186/s12936-022-04080-2.
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Affiliation(s)
- Arabella Borgstein
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Private Bag 360, Blantyre, Malawi.,St. George's University of London/University of Nicosia Medical School, Nicosia, Cyprus
| | - Bo Zhang
- Department of Statistics and Data Science, The Wharton School, University of Pennsylvania, Philadelphia, USA
| | - Colin Lam
- Bronx High School of Science, Bronx, NY, USA
| | - Montfort Bernard Gushu
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Private Bag 360, Blantyre, Malawi
| | - Alice Wangui Liomba
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Private Bag 360, Blantyre, Malawi
| | - Albert Malenga
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Private Bag 360, Blantyre, Malawi
| | - Paul Pensulo
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Private Bag 360, Blantyre, Malawi
| | - Andrew Tebulo
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Private Bag 360, Blantyre, Malawi
| | - Dylan S Small
- Department of Statistics and Data Science, The Wharton School, University of Pennsylvania, Philadelphia, USA
| | - Terrie Taylor
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Private Bag 360, Blantyre, Malawi.,Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, MI, USA
| | - Karl Seydel
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Private Bag 360, Blantyre, Malawi. .,Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, MI, USA. .,Malawi-Liverpool-Wellcome Trust Research Programme, Kamuzu University of Health Sciences, Blantyre, Malawi.
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Factors Associated with Prolonged Hospital Length of Stay in Adults with Imported Falciparum Malaria-An Observational Study from a Tertiary Care University Hospital in Berlin, Germany. Microorganisms 2021; 9:microorganisms9091941. [PMID: 34576836 PMCID: PMC8466442 DOI: 10.3390/microorganisms9091941] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 08/22/2021] [Accepted: 09/06/2021] [Indexed: 12/20/2022] Open
Abstract
Outcome of falciparum malaria is largely influenced by the standard of care provided, which in turn depends on the available medical resources. Worldwide, the COVID-19 pandemic has had a major impact on the availability of these resources, even in resource-rich healthcare systems such as Germany's. The present study aimed to determine the under-explored factors associated with hospital length of stay (LOS) in imported falciparum malaria to identify potential targets for improving management. This retrospective observational study used multivariate Cox proportional hazard regression with time to discharge as an endpoint for adults hospitalized between 2001 and 2015 with imported falciparum malaria in the Charité University Hospital, Berlin. The median LOS of the 535 cases enrolled was 3 days (inter-quartile range, IQR, 3-4 days). The likelihood of being discharged by day 3 strongly decreased with severe malaria (hazard ratio, HR, 0.274; 95% Confidence interval, 95%CI: 0.190-0.396) and by 40% with each additional presenting complication (HR, 0.595; 95%CI: 0.510-0.694). The 55 (10.3%) severe cases required a median LOS of 7 days (IQR, 5-12 days). In multivariate analysis, occurrence of shock (adjusted HR, aHR, 0.438; 95%CI 0.220-0.873), acute pulmonary oedema or acute respiratory distress syndrome (aHR, 0.450; 95%CI: 0.223-0.874), and the need for renal replacement therapy (aHR, 0.170; 95%CI: 0.063-0.461) were independently associated with LOS. All patients survived to discharge. This study illustrates that favourable outcomes can be achieved with high-standard care in imported falciparum malaria. Early recognition of disease severity together with targeted supportive care can lead to avoidance of manifest organ failure, thereby potentially decreasing LOS and alleviating pressure on bed capacities.
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Hoffmeister B, Aguilar Valdez AD. 'Run them dry': a retrospective experience with a restrictive fluid management strategy in severe imported falciparum malaria from a tertiary care university hospital in Berlin, Germany. Trans R Soc Trop Med Hyg 2021; 115:520-530. [PMID: 33681989 DOI: 10.1093/trstmh/trab027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 02/08/2021] [Accepted: 02/13/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Due to the unique pathophysiology with progressive mircocirculatory obstruction and simultaneously increased vascular permeability, overhydration can be rapidly harmful in patients with falciparum malaria. The outcome in all 558 cases hospitalised during 2001-2015 in the Charité University Hospital, Berlin, was favourable, independent of the antimalarial used. Here, the fluid management strategy in the most severely affected subgroup is examined. METHODS All fluids in 32 patients requiring treatment on intensive care units (ICUs) for >48 h were retrospectively quantified. All malaria-specific complications were followed up over the whole ICU stay. RESULTS Strong linear relationships between fluid intake and positive balances reflecting dehydration and increased vascular permeability were evident over the whole stay. With 2.2 (range: 0.7-6.9), 1.8 (0.6-6.1) and 1.3 (0.3-5.0) mL/kg/h on day 1, day 2 and over the remaining ICU stay, respectively, median fluid volumes remained below the actual WHO recommendations. No evidence for deterioration of any malaria-specific complication under such restrictive fluid management was found. The key prognostic parameter metabolic acidosis improved significantly over 48 h (p=0.02). All patients survived to discharge. CONCLUSIONS These results suggest that in the face of markedly increased vascular permeability, a restrictive fluid management strategy is clinically safe in adults with severe imported falciparum malaria.
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Affiliation(s)
- Bodo Hoffmeister
- D epartment of Respiratory Medicine , Clinic-Group Ernst von Bergmann, Potsdam and Bad Belzig, 14806 Bad Belzig, Germany
| | - Abner D Aguilar Valdez
- Department of Endocrinology, Clinic-Group Ernst von Bergmann, Potsdam and Bad Belzig, 14806 Bad Belzig, Germany
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Aung NM, Nyein PP, Kyi MM, Hanson J. Bacterial Coinfection in Adults With Severe Malaria. Clin Infect Dis 2021; 72:535-536. [PMID: 33527124 DOI: 10.1093/cid/ciaa732] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Ne Myo Aung
- Department of Medicine, Insein General Hospital, Insein Township, Yangon, Myanmar
| | - Phyo Pyae Nyein
- Department of Medicine, Specialist Hospital Mingaladon, Mingaladon Township, Yangon, Myanmar
| | - Mar Mar Kyi
- Department of Medicine, Insein General Hospital, Insein Township, Yangon, Myanmar
| | - Josh Hanson
- Director's Unit, Kirby Institute, University of New South Wales, Sydney, Australia
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Bekele SK, Ayele MB, Mihiret AG, Dinegde NG, Mekonen H, Yesera GE. Treatment Outcome of Severe Malaria and Associated Factors among Adults Admitted in Arba Minch General Hospital, Southern Nation Nationality and People's Region, Ethiopia. J Parasitol Res 2021; 2021:6664070. [PMID: 33936805 PMCID: PMC8055393 DOI: 10.1155/2021/6664070] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 03/26/2021] [Accepted: 04/02/2021] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION Malaria is a protozoan disease transmitted by the bite of infected female Anopheles mosquitoes. Progression to severe and fatal disease is largely but not entirely confined to Plasmodium falciparum infections. Malaria is a major public health problem in Ethiopia despite relatively low malaria prevalence compared to most other malaria-endemic countries in Africa. In Ethiopia, a nationwide report during 2015 showed that the total number of deaths associated with malaria was 1561. METHODS A retrospective cross-sectional study was conducted in Arba Minch General Hospital on February 2019. Data were collected from a patient record who was admitted with severe malaria in the past four years from Sept. 2015 to Aug. 2018. RESULTS This study included a total of 387 patients with severe malaria. The mortality rate associated with severe malaria in the year between 2015 and 2018 at Arba Minch General Hospital was 5.7%. Comorbidity, impaired consciousness, and acidosis were significantly associated with mortality, at significant level of P < 0.05. CONCLUSIONS Comorbidity, impaired consciousness, and acidosis were found to be poor prognostic indicators for patients with severe malaria.
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Affiliation(s)
- Solomon K. Bekele
- Arba Minch University College of Medicine and Health Science, Ethiopia
| | - Muluken B. Ayele
- Arba Minch University College of Medicine and Health Science, Ethiopia
| | - Asmare G. Mihiret
- Arba Minch University College of Medicine and Health Science, Ethiopia
| | | | - Hussen Mekonen
- Addis Ababa University College of Health Sciences, Ethiopia
| | - Gesila E. Yesera
- Arba Minch University College of Medicine and Health Science, Ethiopia
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Bhutani A, Kaushik RM, Kaushik R. A study on multi-organ dysfunction syndrome in malaria using sequential organ failure assessment score. Trop Parasitol 2021; 10:86-94. [PMID: 33747874 PMCID: PMC7951073 DOI: 10.4103/tp.tp_12_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 12/23/2019] [Accepted: 05/30/2020] [Indexed: 11/12/2022] Open
Abstract
Purpose: The purpose of this study is to examine the prevalence, clinical spectrum, prognostic factors, and outcome of multi-organ dysfunction syndrome (MODS) in patients with malaria. Materials and Methods: One hundred and twenty-four patients with malaria, diagnosed by a positive peripheral blood film and rapid malaria test, were studied for MODS using the sequential organ failure assessment (SOFA) score. The severity of malaria was assessed by the WHO criteria. Results: Severe malaria was present in 54 (43.54%) patients. MODS was detected in 108 (87.09%) patients with malaria (Plasmodium falciparum - 57 [85.07%], Plasmodium vivax - 46 [88.46%] and mixed P. falciparum and P. vivax malaria - 5 [100%] cases). SOFA scores of MODS-and non-MODS-patients differed significantly (P < 0.001). No significant association was seen between MODS and type of malaria (P = 0.894). Mortality among malaria patients with MODS was 5.55% (6/108) (P. falciparum 8.77% [5/57] and P. vivax 2.17% [1/46]). The outcome of MODS was associated significantly with the severity of the SOFA score at admission (P = 0.011) but not with the type of malaria, malaria parasite index, and the number of organs involved (P > 0.05 each). The SOFA score at admission correlated significantly with the duration of hospitalization (P < 0.0001). Conclusions: MODS occurs with high frequency in malaria and is not dependent on the type of malaria. The outcome of MODS and recovery time depends on the severity of MODS. The SOFA score is useful in detecting MODS and ascertaining its severity and prognosis in malaria.
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Affiliation(s)
- Amish Bhutani
- Department of Medicine, Himalayan Institute of Medical Sciences, Swami Rama Himalayan University, Dehradun, Uttarakhand, India
| | - Rajeev Mohan Kaushik
- Department of Medicine, Himalayan Institute of Medical Sciences, Swami Rama Himalayan University, Dehradun, Uttarakhand, India
| | - Reshma Kaushik
- Department of Medicine, Himalayan Institute of Medical Sciences, Swami Rama Himalayan University, Dehradun, Uttarakhand, India
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Mar Minn M, Aung NM, Kyaw DZ, Zaw TT, Chann PN, Khine HE, McLoughlin S, Kelleher AD, Tun NL, Oo TZC, Myint NPST, Law M, Mar Kyi M, Hanson J. The comparative ability of commonly used disease severity scores to predict death or a requirement for ICU care in patients hospitalised with possible sepsis in Yangon, Myanmar. Int J Infect Dis 2021; 104:543-550. [PMID: 33493689 DOI: 10.1016/j.ijid.2021.01.047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 01/17/2021] [Accepted: 01/19/2021] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES To determine the comparative prognostic utility of commonly used disease prediction scores in adults with presumed community-acquired sepsis in a resource-limited tropical setting. METHODS This prospective, observational study was performed on the medical ward of a tertiary-referral hospital in Yangon, Myanmar. The ability of the National Early Warning Score 2 (NEWS2), quick NEWS (qNEWS), quick Sequential Organ Failure Assessment (qSOFA) score, Universal Vital Assessment (UVA) and Sequential Organ Failure Assessment (SOFA) scores to predict a complicated inpatient course (death or requirement for intensive care unit (ICU) support) in patients with two or more systemic inflammatory response syndrome criteria was determined. RESULTS Among the 509 patients, 30 (6%) were HIV-seropositive. The most commonly confirmed diagnoses were tuberculosis (30/509, 5.9%) and measles (26/509, 5.1%). Overall, 75/509 (14.7%) died or required ICU support. All the scores except the qSOFA score, which was inferior, had a similar ability to predict a complicated inpatient course. CONCLUSIONS In this resource-limited tropical setting, disease severity scores calculated at presentation using only vital signs-such as the NEWS2 score-identified high-risk sepsis patient as well as the SOFA score, which is calculated at 24 h and which also requires laboratory data. Use of these simple clinical scores can be used to facilitate recognition of the high-risk patient and to optimise the use of finite resources.
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Affiliation(s)
- Mar Mar Minn
- Insein General Hospital, Insein Township, Yangon, Myanmar
| | - Ne Myo Aung
- Insein General Hospital, Insein Township, Yangon, Myanmar; University of Medicine 2, North Okkalapa Township, Yangon, Myanmar; Myanmar Australia Research Collaboration for Health (MARCH), Yangon, Myanmar
| | - De Zin Kyaw
- Myanmar Australia Research Collaboration for Health (MARCH), Yangon, Myanmar
| | - Thet Tun Zaw
- Myanmar Australia Research Collaboration for Health (MARCH), Yangon, Myanmar
| | - Pyae Nyein Chann
- Myanmar Australia Research Collaboration for Health (MARCH), Yangon, Myanmar
| | - Hnin Ei Khine
- Myanmar Australia Research Collaboration for Health (MARCH), Yangon, Myanmar
| | | | | | - Ne Lin Tun
- Insein General Hospital, Insein Township, Yangon, Myanmar; University of Medicine 2, North Okkalapa Township, Yangon, Myanmar; Myanmar Australia Research Collaboration for Health (MARCH), Yangon, Myanmar
| | - Thin Zar Cho Oo
- Insein General Hospital, Insein Township, Yangon, Myanmar; University of Medicine 2, North Okkalapa Township, Yangon, Myanmar; Myanmar Australia Research Collaboration for Health (MARCH), Yangon, Myanmar
| | - Nan Phyu Sin Toe Myint
- Insein General Hospital, Insein Township, Yangon, Myanmar; University of Medicine 2, North Okkalapa Township, Yangon, Myanmar; Myanmar Australia Research Collaboration for Health (MARCH), Yangon, Myanmar
| | - Matthew Law
- The Kirby Institute, University of New South Wales, Sydney, Australia
| | - Mar Mar Kyi
- Insein General Hospital, Insein Township, Yangon, Myanmar; University of Medicine 2, North Okkalapa Township, Yangon, Myanmar; Myanmar Australia Research Collaboration for Health (MARCH), Yangon, Myanmar
| | - Josh Hanson
- University of Medicine 2, North Okkalapa Township, Yangon, Myanmar; Myanmar Australia Research Collaboration for Health (MARCH), Yangon, Myanmar; The Kirby Institute, University of New South Wales, Sydney, Australia.
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Abstract
Lactic acidosis and hyperlactatemia are common metabolic disturbances in patients with severe malaria. Lactic acidosis causes physiological adverse effects, which can aggravate the outcome of malaria. Despite its clear association with mortality in malaria patients, the etiology of lactic acidosis is not completely understood. In this review, the possible contributors to lactic acidosis and hyperlactatemia in patients with malaria are discussed. Both increased lactate production and impaired lactate clearance may play a role in the pathogenesis of lactic acidosis. The increased lactate production is caused by several factors, including the metabolism of intraerythrocytic Plasmodium parasites, aerobic glycolysis by activated immune cells, and an increase in anaerobic glycolysis in hypoxic cells and tissues as a consequence of parasite sequestration and anemia. Impaired hepatic and renal lactate clearance, caused by underlying liver and kidney disease, might further aggravate hyperlactatemia. Multiple factors thus participate in the etiology of lactic acidosis in malaria, and further investigations are required to fully understand their relative contributions and the consequences of this major metabolic disturbance.
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Affiliation(s)
- Hendrik Possemiers
- Laboratory of Immunoparasitology, Department of Microbiology and Immunology, Rega Institute for Medical Research, KU Leuven, University of Leuven, Belgium
| | - Leen Vandermosten
- Laboratory of Immunoparasitology, Department of Microbiology and Immunology, Rega Institute for Medical Research, KU Leuven, University of Leuven, Belgium
| | - Philippe E. Van den Steen
- Laboratory of Immunoparasitology, Department of Microbiology and Immunology, Rega Institute for Medical Research, KU Leuven, University of Leuven, Belgium
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Hanson J, Nyein PP, Aung NM, Kyi MM. Time for pragmatic, prospective clinical trials to determine the role of empirical antibacterial therapy in critically ill adults hospitalized with malaria. Int J Infect Dis 2020; 102:28-31. [PMID: 33017698 DOI: 10.1016/j.ijid.2020.09.1472] [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: 08/24/2020] [Revised: 09/25/2020] [Accepted: 09/25/2020] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Children with severe falciparum malaria in malaria-endemic regions are predisposed to developing life-threatening bacterial co-infection. International guidelines therefore recommend empirical broad-spectrum antibacterial therapy in these children. Few studies have examined co-infection in adults, although it has been believed to be relatively rare; antibacterial therapy is therefore not routinely recommended in adults with falciparum malaria. DISCUSSION However, the fundamental pathophysiology of falciparum malaria in adults and children is the same; it is therefore unclear why adults would not also be predisposed to bacterial infection. Indeed, recent studies have identified bacteraemia in >10% of adults hospitalized with malaria. Some have suggested that these adults probably had bacterial sepsis, with the parasitaemia an incidental finding. However, it is usually impossible in resource-limited settings to determine-at presentation-whether critically ill, parasitaemic adults have severe malaria, bacterial sepsis, or both. Given the significant case-fatality rates of severe malaria and bacterial sepsis, the pragmatic initial approach would be to cover both possibilities. CONCLUSIONS Life-threatening bacterial co-infection may be more common in critically ill adults with malaria than previously believed. While further prospective data are awaited to confirm these findings, it might be more appropriate to provide empirical aantibacterial cover in these patients than current guidelines suggest.
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Affiliation(s)
- Josh Hanson
- The Kirby Institute, University of New South Wales, Sydney, Australia; University of Medicine 2, North Okkalapa Township, Yangon, Myanmar; Myanmar Australia Research Collaboration for Health (MARCH), Yangon, Myanmar.
| | - Phyo Pyae Nyein
- Myanmar Australia Research Collaboration for Health (MARCH), Yangon, Myanmar; Mingaladon Specialist Hospital, Mingaladon Township, Yangon, Myanmar
| | - Ne Myo Aung
- University of Medicine 2, North Okkalapa Township, Yangon, Myanmar; Myanmar Australia Research Collaboration for Health (MARCH), Yangon, Myanmar; Insein General Hospital, Insein Township, Yangon, Myanmar
| | - Mar Mar Kyi
- University of Medicine 2, North Okkalapa Township, Yangon, Myanmar; Myanmar Australia Research Collaboration for Health (MARCH), Yangon, Myanmar; Insein General Hospital, Insein Township, Yangon, Myanmar
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12
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Watson JA, Holmes CC. Graphing and reporting heterogeneous treatment effects through reference classes. Trials 2020; 21:386. [PMID: 32381030 PMCID: PMC7204233 DOI: 10.1186/s13063-020-04306-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Accepted: 04/02/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Exploration and modelling of heterogeneous treatment effects as a function of baseline covariates is an important aspect of precision medicine in randomised controlled trials (RCTs). Randomisation generally guarantees the internal validity of an RCT, but heterogeneity in treatment effect can reduce external validity. Estimation of heterogeneous treatment effects is usually done via a predictive model for individual outcomes, where one searches for interactions between treatment allocation and important patient baseline covariates. However, such models are prone to overfitting and multiple testing and typically demand a transformation of the outcome measurement, for example, from the absolute risk in the original RCT to log-odds of risk in the predictive model. METHODS We show how reference classes derived from baseline covariates can be used to explore heterogeneous treatment effects via a two-stage approach. We first estimate a risk score which captures on a single dimension some of the heterogeneity in outcomes of the trial population. Heterogeneity in the treatment effect can then be explored via reweighting schemes along this axis of variation. This two-stage approach bypasses the search for interactions with multiple covariates, thus protecting against multiple testing. It also allows for exploration of heterogeneous treatment effects on the original outcome scale of the RCT. This approach would typically be applied to multivariable models of baseline risk to assess the stability of average treatment effects with respect to the distribution of risk in the population studied. CASE STUDY We illustrate this approach using the single largest randomised treatment trial in severe falciparum malaria and demonstrate how the estimated treatment effect in terms of absolute mortality risk reduction increases considerably in higher risk strata. CONCLUSIONS 'Local' and 'tilting' reweighting schemes based on ranking patients by baseline risk can be used as a general approach for exploring, graphing and reporting heterogeneity of treatment effect in RCTs. TRIAL REGISTRATION ISRCTN clinical trials registry: ISRCTN50258054. Prospectively registered on 22 July 2005.
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Affiliation(s)
- James A Watson
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, 10400, Thailand.
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | - Chris C Holmes
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
- Department of Statistics, University of Oxford, Oxford, UK.
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Severe malaria. Current concepts and practical overview: What every intensivist should know. Intensive Care Med 2020; 46:907-918. [PMID: 32347322 DOI: 10.1007/s00134-020-06019-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 03/19/2020] [Indexed: 10/24/2022]
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14
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Watson JA, Holmes CC. Machine learning analysis plans for randomised controlled trials: detecting treatment effect heterogeneity with strict control of type I error. Trials 2020; 21:156. [PMID: 32041653 PMCID: PMC7011561 DOI: 10.1186/s13063-020-4076-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 01/15/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Retrospective exploratory analyses of randomised controlled trials (RCTs) seeking to identify treatment effect heterogeneity (TEH) are prone to bias and false positives. Yet the desire to learn all we can from exhaustive data measurements on trial participants motivates the inclusion of such analyses within RCTs. Moreover, widespread advances in machine learning (ML) methods hold potential to utilise such data to identify subjects exhibiting heterogeneous treatment response. METHODS We present a novel analysis strategy for detecting TEH in randomised data using ML methods, whilst ensuring proper control of the false positive discovery rate. Our approach uses random data partitioning with statistical or ML-based prediction on held-out data. This method can test for both crossover TEH (switch in optimal treatment) and non-crossover TEH (systematic variation in benefit across patients). The former is done via a two-sample hypothesis test measuring overall predictive performance. The latter is done via 'stacking' the ML predictors alongside a classical statistical model to formally test the added benefit of the ML algorithm. An adaptation of recent statistical theory allows for the construction of a valid aggregate p value. This testing strategy is independent of the choice of ML method. RESULTS We demonstrate our approach with a re-analysis of the SEAQUAMAT trial, which compared quinine to artesunate for the treatment of severe malaria in Asian adults. We find no evidence for any subgroup who would benefit from a change in treatment from the current standard of care, artesunate, but strong evidence for significant TEH within the artesunate treatment group. In particular, we find that artesunate provides a differential benefit to patients with high numbers of circulating ring stage parasites. CONCLUSIONS ML analysis plans using computational notebooks (documents linked to a programming language that capture the model parameter settings, data processing choices, and evaluation criteria) along with version control can improve the robustness and transparency of RCT exploratory analyses. A data-partitioning algorithm allows researchers to apply the latest ML techniques safe in the knowledge that any declared associations are statistically significant at a user-defined level.
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Affiliation(s)
- James A Watson
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Rajvithi Road, Bangkok, 10400, Thailand. .,Nuffield Department of Medicine, University of Oxford, Oxford, OX3 7LF, UK.
| | - Chris C Holmes
- Nuffield Department of Medicine, University of Oxford, Oxford, OX3 7LF, UK.,Department of Statistics, University of Oxford, 29 Saint Giles', Oxford, OX1 3LB, UK
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15
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Malaria. HIGHLY INFECTIOUS DISEASES IN CRITICAL CARE 2020. [PMCID: PMC7120402 DOI: 10.1007/978-3-030-33803-9_13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Malaria is a significant cause of morbidity and mortality throughout the world, and environmental changes are likely to increase its importance in the coming years. Diagnosing this disease is difficult and requires a high index of suspicion, especially in non-endemic countries. Critical care providers play a major role in treating severe malaria and its complications, which has management particularities that might not be readily apparent. Fluid resuscitation should be carefully tailored to avoid complications, and dysperfusion seems more related to degree of parasitemia than hypovolemia. Antimalarial agents are effective, but resistance is growing. Complications can be found in nearly every organ, including cerebral malaria, acute respiratory distress syndrome, and acute kidney injury. As such, a critical care unit is frequently required for organ support when they appear. Superimposed infections are not infrequent. Despite all of this, mortality is encouragingly low with a timely diagnosis and access to appropriate treatment.
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16
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Abstract
OBJECTIVE Malaria infection could result in severe disease with high mortality. Prognostic models and scores predicting severity of infection, complications and mortality could help clinicians prioritise patients. We conducted a systematic review to assess the various models that have been produced to predict disease severity and mortality in patients infected with malaria. DESIGN A systematic review. DATA SOURCES Medline, Global health and CINAHL were searched up to 4 September 2019. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Published articles on models which used at least two points (or variables) of patient data to predict disease severity; potential development of complications (including coma or cerebral malaria; shock; acidosis; severe anaemia; acute kidney injury; hypoglycaemia; respiratory failure and sepsis) and mortality in patients with malaria infection. DATA EXTRACTION AND SYNTHESIS Two independent reviewers extracted the data and assessed risk of bias using the Prediction model Risk Of Bias Assessment Tool. RESULTS A total of 564 articles were screened and 24 articles were retained which described 27 models/scores of interests. Two of the articles described models predicting complications of malaria (severe anaemia in children and development of sepsis); 15 articles described original models predicting mortality in severe malaria; 3 articles described models predicting mortality in different contexts but adapted and validated to predict mortality in malaria; and 4 articles described models predicting severity of the disease. For the models predicting mortality, all the models had neurological dysfunction as a predictor; in children, half of the models contained hypoglycaemia and respiratory failure as a predictor meanwhile, six out of the nine models in adults had respiratory failure as a clinical predictor. Acidosis, renal failure and shock were also common predictors of mortality. Eighteen of the articles described models that could be applicable in real-life settings and all the articles had a high risk of bias due to lack of use of consistent and up-to-date methods of internal validation. CONCLUSION Evidence is lacking on the generalisability of most of these models due lack of external validation. Emphasis should be placed on external validation of existing models and publication of the findings of their use in clinical settings to guide clinicians on management options depending on the priorities of their patients. PROSPERO REGISTRATION NUMBER CRD42019130673.
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Affiliation(s)
- Tsi Njim
- Surgical Department, Regional Hospital Bamenda, Buea, Cameroon
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17
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D’Abramo A, Lepore L, Iannetta M, Gebremeskel Tekle S, Corpolongo A, Scorzolini L, Bevilacqua N, Mariano A, Giancola ML, Vulcano A, Maritti M, Agresta A, Antonini M, D’Alessandro U, Nicastri E. Imported severe malaria and risk factors for intensive care: A single-centre retrospective analysis. PLoS One 2019; 14:e0225135. [PMID: 31725774 PMCID: PMC6855647 DOI: 10.1371/journal.pone.0225135] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 10/29/2019] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES This study aims to identify the risk factors for intensive care (IC) in severe malaria patients admitted to the "Lazzaro Spallanzani" National Institute for Infectious Diseases, Rome, Italy. METHODS All patients with confirmed severe malaria and hospitalized between 2007 and 2015 were included in the analysis and stratified into two groups: those requiring IC and those who did not. Five prognostic malaria scores were estimated; clinical severity at IC unit admission was assessed using the Sequential Organ Failure Assessment and the quick-Sequential Organ Failure Assessment scores. Univariate and multivariate analysis were performed to assess factors independently associated to IC. RESULTS A total of 98 severe malaria patients were included; 10 of them required IC. There were no deaths or sequelae. Patients requiring IC had higher severity scores. At the multivariate analysis, only the number of World Health Organization criteria and the aspartate aminotransferase value were independently associated with the need of IC. CONCLUSIONS An early and accurate assessment of the severity score is essential for the management of severe malaria patients.
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Affiliation(s)
- Alessandra D’Abramo
- National Institute for Infectious Diseases, IRCCS, Lazzaro Spallanzani, Rome, Italy
| | - Luciana Lepore
- National Institute for Infectious Diseases, IRCCS, Lazzaro Spallanzani, Rome, Italy
| | - Marco Iannetta
- National Institute for Infectious Diseases, IRCCS, Lazzaro Spallanzani, Rome, Italy
| | | | - Angela Corpolongo
- National Institute for Infectious Diseases, IRCCS, Lazzaro Spallanzani, Rome, Italy
| | - Laura Scorzolini
- National Institute for Infectious Diseases, IRCCS, Lazzaro Spallanzani, Rome, Italy
| | - Nazario Bevilacqua
- National Institute for Infectious Diseases, IRCCS, Lazzaro Spallanzani, Rome, Italy
| | - Andrea Mariano
- National Institute for Infectious Diseases, IRCCS, Lazzaro Spallanzani, Rome, Italy
| | | | - Antonella Vulcano
- National Institute for Infectious Diseases, IRCCS, Lazzaro Spallanzani, Rome, Italy
| | - Micaela Maritti
- National Institute for Infectious Diseases, IRCCS, Lazzaro Spallanzani, Rome, Italy
| | - Alessandro Agresta
- National Institute for Infectious Diseases, IRCCS, Lazzaro Spallanzani, Rome, Italy
| | - Mario Antonini
- National Institute for Infectious Diseases, IRCCS, Lazzaro Spallanzani, Rome, Italy
| | - Umberto D’Alessandro
- MRC Unit The Gambia at the London School of Hygiene and Tropical Medicine, Atlantic Boulevard, Fajara, The Gambia
| | - Emanuele Nicastri
- National Institute for Infectious Diseases, IRCCS, Lazzaro Spallanzani, Rome, Italy
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18
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Teparrukkul P, Hantrakun V, Imwong M, Teerawattanasook N, Wongsuvan G, Day NPJ, Dondorp AM, West TE, Limmathurotsakul D. Utility of qSOFA and modified SOFA in severe malaria presenting as sepsis. PLoS One 2019; 14:e0223457. [PMID: 31596907 PMCID: PMC6785116 DOI: 10.1371/journal.pone.0223457] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 09/20/2019] [Indexed: 12/22/2022] Open
Abstract
Sepsis can be caused by malaria infection, but little is known about the utility of the quick Sequential (Sepsis-Related) Organ Failure Assessment (qSOFA) and SOFA score in malaria. We conducted a prospective observational study from March 2013 to February 2017 to examine adults admitted with community-acquired infection in a tertiary-care hospital in Ubon Ratchathani, Northeast Thailand (Ubon-sepsis). Subjects were classified as having sepsis if they had a modified SOFA score ≥2 within 24 hours of admission. Serum was stored and later tested for malaria parasites using a nested PCR assay. Presence of severe malaria was defined using modified World Health Organization criteria. Of 4,989 patients enrolled, 153 patients (3%) were PCR positive for either Plasmodium falciparum (74 [48%]), P. vivax (69 [45%]), or both organisms (10 [7%]). Of 153 malaria patients, 80 were severe malaria patients presenting with sepsis, 70 were non-severe malaria patients presenting with sepsis, and three were non-severe malaria patients presenting without sepsis. The modified SOFA score (median 5; IQR 4–6; range 1–18) was strongly correlated with malaria severity determined by the number of World Health Organization severity criteria satisfied by the patient (Spearman’s rho = 0.61, p<0.001). Of 80 severe malaria patients, 2 (2.5%), 11 (14%), 62 (77.5%) and 5 (6%), presented with qSOFA scores of 0, 1, 2 and 3, respectively. Twenty eight-day mortality was 1.3% (2/153). In conclusion, qSOFA and SOFA can serve as markers of disease severity in adults with malarial sepsis. Patients presenting with a qSOFA score of 1 may also require careful evaluation for sepsis; including diagnosis of cause of infection, initiation of medical intervention, and consideration for referral as appropriate.
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Affiliation(s)
- Prapit Teparrukkul
- Medical Department, Sunpasitthiprasong Hospital, Ubon Ratchthani, Thailand
| | - Viriya Hantrakun
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Mallika Imwong
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Department of Molecular Tropical Medicine and Genetics, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | | | - Gumphol Wongsuvan
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Nicholas PJ. Day
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | - Arjen M. Dondorp
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | - T. Eoin West
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington, Seattle, Washington, United States of America
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Direk Limmathurotsakul
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
- Department of Tropical Hygiene, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- * E-mail:
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19
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Joynt GM, Gopalan PD, Argent A, Chetty S, Wise R, Lai VKW, Hodgson E, Lee A, Joubert I, Mokgokong S, Tshukutsoane S, Richards GA, Menezes C, Mathivha LR, Espen B, Levy B, Asante K, Paruk F. The Critical Care Society of Southern Africa Consensus Statement on ICU Triage and Rationing (ConICTri). SOUTHERN AFRICAN JOURNAL OF CRITICAL CARE 2019; 35:10.7196/SAJCC.2019.v35.i1b.383. [PMID: 37719327 PMCID: PMC10503494 DOI: 10.7196/sajcc.2019.v35.i1b.383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/01/2019] [Indexed: 09/19/2023] Open
Abstract
Background In South Africa (SA), intensive care is faced with the challenge of resource scarcity as well as an increasing demand for intensive care unit (ICU) services. ICU services are expensive, and practitioners in low- to middle-income countries experience daily the consequences of limited resources. Critically limited resources necessitate that rationing and triage (prioritisation) decisions are frequently necessary in SA, particularly in the publicly funded health sector. Purpose The purpose of this consensus statement is to examine key questions that arise when considering the status of ICU resources in SA, and more specifically ICU admission, rationing and triage decisions. The accompanying guideline in this issue is intended to guide frontline triage policy and ensure the best utilisation of intensive care in SA, while maintaining a fair distribution of available resources. Fair and efficient triage is important to ensure the ongoing provision of high-quality care to adult patients referred for intensive care. Recommendations In response to 14 key questions developed using a modified Delphi technique, 29 recommendations were formulated and graded using an adapted GRADE score. The 14 key questions addressed the status of the provision of ICU services in SA, the degree of resource restriction, the efficiency of resource management, the need for triage, and how triage could be most justly implemented. Important recommendations included the need to formally recognise and accurately quantify the provision of ICU services in SA by national audit; actively seek additional resources from governmental bodies; consider methods to maximise the efficiency of ICU care; evaluate lower level of care alternatives; develop a triage guideline to assist policy-makers and frontline practitioners to implement triage decisions in an efficient and fair way; measure and audit the consequence of triage; and promote research to improve the accuracy and consistency of triage decisions. The consensus document and guideline should be reviewed and revised appropriately within 5 years. Conclusion In recognition of the absolute need to limit patient access to ICU because of the lack of sufficient intensive care resources in public hospitals, recommendations and a guideline have been developed to guide policy-making and assist frontline triage decision-making in SA. These documents are not a complete plan for quality practice but rather the beginning of a long-term initiative to engage clinicians, the public and administrators in appropriate triage decision-making, and promote systems that will ultimately maximise the efficient and fair use of available ICU resources.
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Affiliation(s)
- G M Joynt
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong
| | - P D Gopalan
- Department of Anaesthesiology and Critical Care, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - A Argent
- Department of Paediatrics and Child Health, University of Cape Town, South Africa
| | - S Chetty
- Department of Anaesthesiology and Critical Care, Stellenbosch University, Cape Town, South Africa
| | - R Wise
- Department of Anaesthesiology and Critical Care, School of Clinical Medicine, University of KwaZulu-Natal, Durban, and Edendale Hospital,
Pietermaritzburg, South Africa
| | - V K W Lai
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong
| | - E Hodgson
- Department of Anaesthesiology and Critical Care, School of Clinical Medicine, University of KwaZulu-Natal, Durban, and Inkosi Albert Luthuli
Central Hospital, Durban, South Africa
| | - A Lee
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong
| | - I Joubert
- Department of Anaesthesia and Peri-operative Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - S Mokgokong
- Department of Neurosurgery, University of Pretoria, South Africa
| | - S Tshukutsoane
- Chris Hani Baragwanath Academic Hospital, Soweto, Johannesburg, South Africa
| | - G A Richards
- Department of Critical Care, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - C Menezes
- Chris Hani Baragwanath Academic Hospital, Soweto, Johannesburg, South Africa
- Department of Critical Care, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - L R Mathivha
- Department of Critical Care, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - B Espen
- Centre for Health Professions Education, Stellenbosch University, Cape Town, South Africa
| | - B Levy
- Netcare Rosebank Hospital, Johannesburg, South Africa
| | - K Asante
- African Organization for Research and Training in Cancer, Cape Town, South Africa
| | - F Paruk
- Department of Critical Care, University of Pretoria, South Africa
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20
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Kingston HW, Ghose A, Rungpradubvong V, Herdman MT, Plewes K, Ishioka H, Leopold SJ, Maude RJ, Intharabut B, Mohanty S, Day NPJ, White NJ, Hossain MA, Anstey NM, Dondorp AM. Does reduced oxygen delivery cause lactic acidosis in falciparum malaria? An observational study. Malar J 2019; 18:97. [PMID: 30909915 PMCID: PMC6434797 DOI: 10.1186/s12936-019-2733-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 03/18/2019] [Indexed: 12/18/2022] Open
Abstract
Background Lactic acidosis with an elevated lactate–pyruvate ratio suggesting anoxia is a common feature of severe falciparum malaria. High lactate levels are associated with parasitized erythrocyte sequestration in the microcirculation. To assess if there is an additional contribution to hyperlactataemia from relatively inadequate total oxygen delivery, oxygen consumption and delivery were investigated in patients with malaria. Methods Adult Bangladeshi and Indian patients with uncomplicated (N = 50) or severe (N = 46) falciparum malaria or suspected bacterial sepsis (N = 27) and healthy participants as controls (N = 26) were recruited at Chittagong Medical College Hospital, Chittagong, Bangladesh and Ispat General Hospital, Rourkela, India. Oxygen delivery (DO2I) was estimated from pulse oximetry, echocardiographic estimates of cardiac index and haematocrit. Oxygen consumption (VO2I) was estimated by expired gas collection. Results VO2I was elevated in uncomplicated median (IQR) 185.1 ml/min/m2 (135–215.9) and severe malaria 192 ml/min/m2 (140.7–227.9) relative to healthy persons 107.9 ml/min/m2 (69.9–138.1) (both p < 0.001). Median DO2I was similar in uncomplicated 515 ml/min/m2 (432–612) and severe 487 ml/min/m2 (382–601) malaria and healthy persons 503 ml/min/m2 (447–517) (p = 0.27 and 0.89, respectively). The VO2/DO2 ratio was, therefore, increased by similar amounts in both uncomplicated 0.35 (0.28–0.44) and severe malaria 0.38 (0.29–0.48) relative to healthy participants 0.23 (0.17–0.28) (both p < 0.001). VO2I, DO2I and VO2/DO2 did not correlate with plasma lactate concentrations in severe malaria. Conclusions Reduced total oxygen delivery is not a major contributor to lactic acidosis in severe falciparum malaria. Electronic supplementary material The online version of this article (10.1186/s12936-019-2733-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Hugh W Kingston
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, 10400, Thailand. .,Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, NT, 0909, Australia. .,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, Churchill Hospital, Oxford, OX3 7LJ, UK.
| | | | - Voravut Rungpradubvong
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Cardiac Center, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - M Trent Herdman
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, 10400, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, Churchill Hospital, Oxford, OX3 7LJ, UK
| | - Katherine Plewes
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, 10400, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, Churchill Hospital, Oxford, OX3 7LJ, UK
| | - Haruhiko Ishioka
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, 10400, Thailand.,Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, 10400, Thailand
| | - Stije J Leopold
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, 10400, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, Churchill Hospital, Oxford, OX3 7LJ, UK
| | - Richard J Maude
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, 10400, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, Churchill Hospital, Oxford, OX3 7LJ, UK
| | - Benjamas Intharabut
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, 10400, Thailand
| | | | - Nicholas P J Day
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, 10400, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, Churchill Hospital, Oxford, OX3 7LJ, UK
| | - Nicholas J White
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, 10400, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, Churchill Hospital, Oxford, OX3 7LJ, UK
| | | | - Nicholas M Anstey
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, NT, 0909, Australia
| | - Arjen M Dondorp
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, 10400, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, Churchill Hospital, Oxford, OX3 7LJ, UK
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21
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Joshi V, Wigdahl J, Nemeth S, Manda C, Lewallen S, Taylor T, MacCormick I, Harding S, Soliz P. Automated Detection of Malarial Retinopathy in Retinal Fundus Images obtained in Clinical Settings. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2018; 2018:5950-5953. [PMID: 30441691 DOI: 10.1109/embc.2018.8513603] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Cerebral malaria (CM) is a life-threatening clinical syndrome associated with 5-10% of malarial infection cases, most prevalent in Africa. About 23% of cerebral malaria cases are misdiagnosed as false positives, leading to inappropriate treatment and loss of lives. Malarial retinopathy (MR) is a retinal manifestation of CM that presents with a highly specific set of lesions. The detection of MR can reduce the false positive diagnosis of CM and alert physicians to investigate for other possible causes of the clinical symptoms and apply a more appropriate clinical intervention of underlying diseases. In order to facilitate easily accessible and affordable means of MR detection, we have developed an automated software system that detects the retinal lesions specific to MR, whitening and hemorrhages, using retinal color fundus images. The individual lesion detection algorithms were combined into an MR detection model using partial least square classifier. The classifier model was trained and tested on retinal image dataset obtained from 64 patients presenting with clinical signs of CM (44 with MR, 20 without MR). The MR detection model yielded specificity of 92% and sensitivity of 68%, with an AUC of 0.82. The proposed MR detection system demonstrates potential for broad screening of MR and can be integrated with a low-cost and portable retinal camera, to provide a bed-side tool for confirming CM diagnosis.
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22
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Bruneel F, Raffetin A, Corne P, Llitjos JF, Mourvillier B, Argaud L, Wolff M, Laurent V, Jauréguiberry S. Management of severe imported malaria in adults. Med Mal Infect 2018; 50:213-225. [PMID: 30266432 DOI: 10.1016/j.medmal.2018.08.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 08/30/2018] [Indexed: 11/28/2022]
Abstract
Severe malaria accounts for approximately 10% of all cases of imported malaria in France; cases are mainly due to Plasmodium falciparum, while other Plasmodium species are possible but uncommon (P. vivax, P. knowlesi, P. malariae, and P. ovale). On the basis of WHO criteria for endemic areas, the French criteria defining severe imported malaria in adults have been progressively adapted to the European healthcare level. Management of severe imported malaria is a diagnostic and treatment emergency and must be initially conducted in the intensive care unit. Anti-infective treatment is now based on intravenous artesunate, which must be available in every hospital of the country likely to receive severe imported malaria patients. Intravenous quinine is thus used as a second-line treatment and is restricted to limited indications. Critical care management of organ failure is essential, particularly in patients presenting with very severe malaria. To date, no adjunctive therapy (including exchange transfusion) has demonstrated clear beneficial effects.
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Affiliation(s)
- F Bruneel
- Réanimation médico-chirurgicale, hôpital Mignot, centre hospitalier de Versailles, 177, rue de Versailles, 78150 Le Chesnay, France.
| | - A Raffetin
- Médecine interne, maladies infectieuses et tropicales, CHI Villeneuve-Saint-Georges, 94190 Villeneuve-Saint-Georges, France
| | - P Corne
- Réanimation médicale, CHU de Montpellier, 34000 Montpellier, France
| | - J F Llitjos
- Réanimation médicale, CHU Cochin, 75014 Paris, France
| | - B Mourvillier
- Réanimation médicale et infectieuse, CHU Bichat-Claude-Bernard, 75018 Paris, France
| | - L Argaud
- Réanimation médicale, CHU Edouard-Herriot, 69000 Lyon, France
| | - M Wolff
- Réanimation médicale et infectieuse, CHU Bichat-Claude-Bernard, 75018 Paris, France
| | - V Laurent
- Réanimation médico-chirurgicale, hôpital Mignot, centre hospitalier de Versailles, 177, rue de Versailles, 78150 Le Chesnay, France
| | - S Jauréguiberry
- Maladies infectieuses et tropicales, CHU Pitié-Salpêtrière, 75013 Paris, France
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23
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Njim T, Dondorp A, Mukaka M, Ohuma EO. Identifying risk factors for the development of sepsis during adult severe malaria. Malar J 2018; 17:278. [PMID: 30064433 PMCID: PMC6066934 DOI: 10.1186/s12936-018-2430-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Accepted: 07/26/2018] [Indexed: 11/23/2022] Open
Abstract
Background Severe falciparum malaria can be compounded by bacterial sepsis, necessitating antibiotics in addition to anti-malarial treatment. The objective of this analysis was to develop a prognostic model to identify patients admitted with severe malaria at higher risk
of developing bacterial sepsis. Methods A retrospective data analysis using trial data from the South East Asian Quinine Artesunate Malaria Trial. Variables correlating with development of clinically defined sepsis were identified by univariable analysis, and subsequently included into a multivariable logistic regression model. Internal validation was performed by bootstrapping. Discrimination and goodness-of-fit were assessed using the area under the curve (AUC) and a calibration plot, respectively. Results Of the 1187 adults with severe malaria, 86 (7.3%) developed clinical sepsis during admission. Predictors for developing sepsis were: female sex, high blood urea nitrogen, high plasma anion gap, respiratory distress, shock on admission, high parasitaemia, coma and jaundice. The AUC of the model was 0.789, signifying modest differentiation for identifying patients developing sepsis. The model was well-calibrated (Hosmer–Lemeshow Chi squared = 1.02). The 25th percentile of the distribution of risk scores among those who developed sepsis could identify a high-risk group with a sensitivity and specificity of 70.0 and 69.4%, respectively. Conclusions The proposed model identifies patients with severe malaria at risk of developing clinical sepsis, potentially benefiting from antibiotic treatment in addition to anti-malarials. The model will need further evaluation with more strictly defined bacterial sepsis as outcome measure. Electronic supplementary material The online version of this article (10.1186/s12936-018-2430-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Tsi Njim
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Old Road Campus, Oxford, OX3 7BN, UK. .,Health and Human Development Research Group, Douala, Cameroon.
| | - Arjen Dondorp
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Old Road Campus, Oxford, OX3 7BN, UK.,Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, 3/F, 60th Anniversary Chalermprakiat Building, 420/6 Rajvithi Road, Bangkok, 10400, Thailand
| | - Mavuto Mukaka
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Old Road Campus, Oxford, OX3 7BN, UK.,Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, 3/F, 60th Anniversary Chalermprakiat Building, 420/6 Rajvithi Road, Bangkok, 10400, Thailand
| | - Eric O Ohuma
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Old Road Campus, Oxford, OX3 7BN, UK.,Centre for Statistics in Medicine, Botnar Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Windmill Road, Oxford, OX3 7LD, UK
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24
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Aung NM, Nyein PP, Htut TY, Htet ZW, Kyi TT, Anstey NM, Kyi MM, Hanson J. Antibiotic Therapy in Adults with Malaria (ANTHEM): High Rate of Clinically Significant Bacteremia in Hospitalized Adults Diagnosed with Falciparum Malaria. Am J Trop Med Hyg 2018; 99:688-696. [PMID: 30014826 DOI: 10.4269/ajtmh.18-0378] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
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.
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Affiliation(s)
- Ne Myo Aung
- University of Medicine 2, Yangon, Myanmar.,Insein General Hospital, Yangon, Myanmar
| | | | | | | | - Tint Tint Kyi
- Department of Medical Care, Ministry of Health and Sports, Nay Pyi Taw, Myanmar
| | - Nicholas M Anstey
- Menzies School of Health Research, Charles Darwin University, Darwin, Australia
| | - Mar Mar Kyi
- University of Medicine 2, Yangon, Myanmar.,Insein General Hospital, Yangon, Myanmar
| | - Josh Hanson
- Menzies School of Health Research, Charles Darwin University, Darwin, Australia.,Kirby Institute, University of New South Wales, Sydney, Australia.,University of Medicine 2, Yangon, Myanmar
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25
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Abstract
In the mosquito-human life cycle, the six species of malaria parasites infecting humans (Plasmodium falciparum, Plasmodium vivax, Plasmodium ovale wallickeri, Plasmodium ovale curtisi, Plasmodium malariae, and Plasmodium knowlesi) undergo 10 or more morphological states, replicate from single to 10,000+ cells, and vary in total population from one to many more than 106 organisms. In the human host, only a small number of these morphological stages lead to clinical disease and the vast majority of all malaria-infected patients in the world produce few (if any) symptoms in the human. Human clinical disease (e.g., fever, anemia, coma) is the result of the parasite preprogrammed biology in concert with the human pathophysiological response. Caveats and corollaries that add variation to this host-parasite interaction include parasite genetic diversity of key proteins, coinfections, comorbidities, delays in treatment, human polymorphisms, and environmental determinants.
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Affiliation(s)
- Danny A Milner
- Harvard T.H. Chan School of Public Health, American Society for Clinical Pathology, Center for Global Health, Chicago, Illinois 60603
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26
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Anghan H, Sethi P, Soneja M, Mahajan S, Wig N. Clinical and Laboratory Features Associated with Acute Kidney Injury in Severe Malaria. Indian J Crit Care Med 2018; 22:718-722. [PMID: 30405282 PMCID: PMC6201649 DOI: 10.4103/ijccm.ijccm_468_17] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Introduction: Critically ill severe malaria constitutes one of the major hospital admissions in Indian setting. Clinical studies identifying the factors associated with acute kidney injury (AKI) in malaria are lacking. This study aimed to identify these factors. Methods: This prospective observational study was conducted in a tertiary care center of North India. All adult patients with severe malaria were studied during 2012–2014. Results: The study included 79 patients and AKI was observed in 36 patients. Of these 79 patients, 52.7% were Plasmodium falciparum positive and 47.2% were Plasmodium vivax positive. In AKI patients, thrombocytopenia and jaundice were the most common other complications seen. Among P. vivax malarial patients, 17 (36%) patients had AKI. Features associated with AKI among patients admitted with P. vivax malaria were as follows: tachycardia (adjusted relative risk [RR]: 3.9; 95% confidence interval [CI]: 1.1–13.7), direct hyperbilirubinemia (adjusted RR: 4.7; 95% CI: 1.4–15.2), anemia (adjusted RR: 6; 95% CI: 1.7–22.4), and sepsis (adjusted RR: 3.3; 95% CI: 1.1–13.7). The presence of tachycardia, acidosis, cerebral malaria, acute respiratory distress syndrome/acute lung injury, hypotensive shock, and poor Glasgow Coma Scale were associated with higher mortality in patients with AKI. Patients who required mechanical ventilation and/or vasopressor support had higher mortality. Conclusion: P. vivax is an important cause of severe malaria with AKI in our setting. Various other clinical features are associated with AKI and related mortality.
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Affiliation(s)
- Hiren Anghan
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Prayas Sethi
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Manish Soneja
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Sandeep Mahajan
- Department of Nephrology, All India Institute of Medical Sciences, New Delhi, India
| | - Naveet Wig
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
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27
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Antinori S, Corona A, Castelli A, Rech R, Borghi B, Giannotti C, Colombo R, Fossali T, Ballone E, Minari C, Perotti A, Bergomi P, Galimberti L, Milazzo L, Ricaboni D, Scorza D, Grande R, Genderini F, Ieri M, Raimondi F, Catena E, Galli M, Corbellino M. Severe Plasmodium falciparum malaria in the intensive care unit: A 6-year experience in Milano, Italy. Travel Med Infect Dis 2017; 17:43-49. [PMID: 28554853 DOI: 10.1016/j.tmaid.2017.05.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Revised: 05/02/2017] [Accepted: 05/23/2017] [Indexed: 12/29/2022]
Abstract
BACKGROUND Severe imported Plasmodium falciparum malaria is a potentially life-threatening disease with a reported mortality rate of 5-10% when patients are admitted to the Intensive Care Unit. METHODS To retrospectively review the clinical aspects, the value of severity predictive scores and the management of patients with severe P. falciparum malaria admitted to an ICU in Milano, Italy between January 2010 and December 2015. RESULTS Twelve patients were included: seven were male and five female with a median age of 43 years. All were initially treated with intravenous quinine. Median parasitaemia upon admission was 14,5% (range 1-20%). At the time of ICU admission, 3 patients (25%) had 5 or more World Health Organization criteria for severe malaria while another 6 of them developed one or more of the latter during their stay in ICU. Five required mechanical ventilation because of respiratory failure due to ARDS. Four patients required renal replacement therapy. Three patients underwent blood exchange transfusion. All patients survived. CONCLUSIONS Our retrospective evaluation of adults patients admitted to the ICU with severe imported P. falciparum malaria demonstrated a favourable outcome. Severity predictive scores currently in use probably overestimate the risk of malaria mortality in patients treated in health care systems of high income countries.
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Affiliation(s)
- Spinello Antinori
- Department of Clinical and Biomedical Sciences Luigi Sacco, University of Milano, Italy; III Division of Infectious Diseases, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, Milano, Italy.
| | - Alberto Corona
- Intensive Care Unit 1, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, Milano, Italy
| | - Antonio Castelli
- Intensive Care Unit 1, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, Milano, Italy
| | - Roberto Rech
- Intensive Care Unit 1, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, Milano, Italy
| | - Beatrice Borghi
- Intensive Care Unit 1, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, Milano, Italy
| | - Claudia Giannotti
- Intensive Care Unit 1, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, Milano, Italy
| | - Riccardo Colombo
- Intensive Care Unit 1, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, Milano, Italy
| | - Tommaso Fossali
- Intensive Care Unit 1, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, Milano, Italy
| | - Elisabetta Ballone
- Intensive Care Unit 1, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, Milano, Italy
| | - Caterina Minari
- Intensive Care Unit 1, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, Milano, Italy
| | - Andrea Perotti
- Intensive Care Unit 1, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, Milano, Italy
| | - Paola Bergomi
- Intensive Care Unit 1, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, Milano, Italy
| | - Laura Galimberti
- III Division of Infectious Diseases, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, Milano, Italy
| | - Laura Milazzo
- III Division of Infectious Diseases, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, Milano, Italy
| | - Davide Ricaboni
- III Division of Infectious Diseases, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, Milano, Italy
| | - Daniele Scorza
- Nephrology and Dialysis Unit, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, Milano, Italy
| | - Romualdo Grande
- Department of Diagnostic Services, Clinical Microbiology, Virology and Bioemergence Diagnostics, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, Milano, Italy
| | - Francesco Genderini
- III Division of Infectious Diseases, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, Milano, Italy
| | - Marco Ieri
- Hematology and Transfusion Medicine, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, Milano, Italy
| | - Ferdinando Raimondi
- Intensive Care Unit 1, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, Milano, Italy
| | - Emanuele Catena
- Intensive Care Unit 1, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, Milano, Italy
| | - Massimo Galli
- Department of Clinical and Biomedical Sciences Luigi Sacco, University of Milano, Italy; III Division of Infectious Diseases, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, Milano, Italy
| | - Mario Corbellino
- III Division of Infectious Diseases, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, Milano, Italy
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28
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Aggarwal HK, Jain D, Rao A, Kalra R. Role of Coma Acidosis Malaria Score in Patients with Severe Malaria among Indian Population: a Tertiary Care Center Experience. Eurasian J Med 2017; 49:30-35. [PMID: 28416929 DOI: 10.5152/eurasianjmed.2017.16069] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
OBJECTIVE Malaria is a prime public health threat in developing countries like India. There is an unmet need of a simplified methodology for the purpose of triage and provision of intensive care to the severely infected patients in these areas. MATERIALS AND METHODS We did a prospective study in patients (n=60) admitted with severe malaria in a single tertiary care center in the state of Haryana, India. We assessed the role of coma acidosis malaria (CAM) score in these patients when predicting mortality and morbidity events. Stepwise logistic regression analysis was applied to identify patients requiring intensive care based on the CAM score, and the prediction value of the scoring system was assessed among these patients. RESULTS Cerebral malaria (measured using the Glasgow coma scale) and acidosis (base deficit) were the major determinants of the CAM score. Serum bicarbonate levels and respiratory rates were assessed as the proxy markers of the base deficit as it is not always available. Morbidity increased steadily as the CAM scores increased. Sensitivity and negative predictive value of 100% depicted that the scoring system was able to identify patients who needed intensive care and accurately exclude the patients who could be conservatively managed in the ward. Positive predictive values of 73.9%, 68%, and 80.9% indicated that CAM, bicarbonate-based CAM (BCAM), and respiratory rate-based CAM (RCAM) scores, respectively, could precisely predict the morbidity and mortality events among patients with CAM scores ≥2. CONCLUSION CAM scores have precise predictive values in assessing patients with severe malaria. The scoring system helps in accurate and systemic triage of patients, irrespective of species, and directs the treating physicians toward vigilant treatment and emergency care.
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Affiliation(s)
- Hari Krishan Aggarwal
- Department of Medicine, Pt B.D. Sharma University of Health Sciences, Haryana, India
| | - Deepak Jain
- Department of Medicine, Pt B.D. Sharma University of Health Sciences, Haryana, India
| | - Avinash Rao
- Department of Medicine, Pt B.D. Sharma University of Health Sciences, Haryana, India
| | - Rajinish Kalra
- Department of Pathology, Pt B.D. Sharma University of Health Sciences, Haryana, India
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29
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Jeeyapant A, Kingston HW, Plewes K, Maude RJ, Hanson J, Herdman MT, Leopold SJ, Ngernseng T, Charunwatthana P, Phu NH, Ghose A, Hasan MMU, Fanello CI, Faiz MA, Hien TT, Day NPJ, White NJ, Dondorp AM. Defining Surrogate Endpoints for Clinical Trials in Severe Falciparum Malaria. PLoS One 2017; 12:e0169307. [PMID: 28052109 PMCID: PMC5215574 DOI: 10.1371/journal.pone.0169307] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Accepted: 12/14/2016] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Clinical trials in severe falciparum malaria require a large sample size to detect clinically meaningful differences in mortality. This means few interventions can be evaluated at any time. Using a validated surrogate endpoint for mortality would provide a useful alternative allowing a smaller sample size. Here we evaluate changes in coma score and plasma lactate as surrogate endpoints for mortality in severe falciparum malaria. METHODS Three datasets of clinical studies in severe malaria were re-evaluated: studies from Chittagong, Bangladesh (adults), the African 'AQUAMAT' trial comparing artesunate and quinine (children), and the Vietnamese 'AQ' study (adults) comparing artemether with quinine. The absolute change, relative change, slope of the normalization over time, and time to normalization were derived from sequential measurements of plasma lactate and coma score, and validated for their use as surrogate endpoint, including the proportion of treatment effect on mortality explained (PTE) by these surrogate measures. RESULTS Improvements in lactate concentration or coma scores over the first 24 hours of admission, were strongly prognostic for survival in all datasets. In hyperlactataemic patients in the AQ study (n = 173), lower mortality with artemether compared to quinine closely correlated with faster reduction in plasma lactate concentration, with a high PTE of the relative change in plasma lactate at 8 and 12 hours of 0.81 and 0.75, respectively. In paediatric patients enrolled in the 'AQUAMAT' study with cerebral malaria (n = 785), mortality was lower with artesunate compared to quinine, but this was not associated with faster coma recovery. CONCLUSIONS The relative changes in plasma lactate concentration assessed at 8 or 12 hours after admission are valid surrogate endpoints for severe malaria studies on antimalarial drugs or adjuvant treatments aiming at improving the microcirculation. Measures of coma recovery are not valid surrogate endpoints for mortality.
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Affiliation(s)
- Atthanee Jeeyapant
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Hugh W. Kingston
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Charles Darwin University, Darwin, Northern Territory, Australia
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Katherine Plewes
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Richard J. Maude
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Josh Hanson
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Global Health Division, Menzies School of Health Research, Darwin, Australia
| | - M. Trent Herdman
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- University College, Oxford, United Kingdom
| | - Stije J. Leopold
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Thatsanun Ngernseng
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Prakaykaew Charunwatthana
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol Unversity,Bangkok,Thailand
| | - Nguyen Hoan Phu
- Oxford University Clinical Research Unit. Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Aniruddha Ghose
- Department of Medicine, Chittagong Medical College Hospital, Chittagong, Bangladesh
| | | | - Caterina I. Fanello
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Kinshasa School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Md Abul Faiz
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Malaria Research Group, Dev Care Foundation, Dhaka, Bangladesh
| | - Tran Tinh Hien
- Oxford University Clinical Research Unit. Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Nicholas P. J. Day
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Nicholas J. White
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Arjen M. Dondorp
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
- * E-mail:
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30
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Chery L, Maki JN, Mascarenhas A, Walke JT, Gawas P, Almeida A, Fernandes M, Vaz M, Ramanan R, Shirodkar D, Bernabeu M, Manoharan SK, Pereira L, Dash R, Sharma A, Shaik RB, Chakrabarti R, Babar P, White J, Mudeppa DG, Kumar S, Zuo W, Skillman KM, Kanjee U, Lim C, Shaw-Saliba K, Kumar A, Valecha N, Jindal VN, Khandeparkar A, Naik P, Amonkar S, Duraisingh MT, Tuljapurkar S, Smith JD, Dubhashi N, Pinto RGW, Silveria M, Gomes E, Rathod PK. Demographic and clinical profiles of Plasmodium falciparum and Plasmodium vivax patients at a tertiary care centre in southwestern India. Malar J 2016; 15:569. [PMID: 27884146 PMCID: PMC5123287 DOI: 10.1186/s12936-016-1619-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Accepted: 11/15/2016] [Indexed: 01/11/2023] Open
Abstract
Background Malaria remains an important cause of morbidity and mortality in India. Though many comprehensive studies have been carried out in Africa and Southeast Asia to characterize and examine determinants of Plasmodium falciparum and Plasmodium vivax malaria pathogenesis, fewer have been conducted in India. Methods A prospective study of malaria-positive individuals was conducted at Goa Medical College and Hospital (GMC) from 2012 to 2015 to identify demographic, diagnostic and clinical indicators associated with P. falciparum and P. vivax infection on univariate analysis. Results Between 2012 and 2015, 74,571 febrile individuals, 6287 (8.4%) of whom were malaria positive, presented to GMC. The total number of malaria cases at GMC increased more than two-fold over four years, with both P. vivax and P. falciparum cases present year-round. Some 1116 malaria-positive individuals (mean age = 27, 91% male), 88.2% of whom were born outside of Goa and 51% of whom were construction workers, were enroled in the study. Of 1088 confirmed malaria-positive patients, 77.0% had P. vivax, 21.0% had P. falciparum and 2.0% had mixed malaria. Patients over 40 years of age and with P. falciparum infection were significantly (p < 0.001) more likely to be hospitalised than younger and P. vivax patients, respectively. While approximately equal percentages of hospitalised P. falciparum (76.6%) and P. vivax (78.9%) cases presented with at least one WHO severity indicator, a greater percentage of P. falciparum inpatients presented with at least two (43.9%, p < 0.05) and at least three (29.9%, p < 0.01) severity features. There were six deaths among the 182 hospitalised malaria positive patients, all of whom had P. falciparum. Conclusion During the four year study period at GMC, the number of malaria cases increased substantially and the greatest burden of severe disease was contributed by P. falciparum.
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Affiliation(s)
- Laura Chery
- Departments of Chemistry and Global Health, University of Washington, Seattle, WA, 98195, USA
| | - Jennifer N Maki
- Departments of Chemistry and Global Health, University of Washington, Seattle, WA, 98195, USA
| | - Anjali Mascarenhas
- Departments of Chemistry and Global Health, University of Washington, Seattle, WA, 98195, USA.,Goa Medical College and Hospital, Bambolim, Goa, 403202, India
| | - Jayashri T Walke
- Departments of Chemistry and Global Health, University of Washington, Seattle, WA, 98195, USA.,Goa Medical College and Hospital, Bambolim, Goa, 403202, India
| | - Pooja Gawas
- Departments of Chemistry and Global Health, University of Washington, Seattle, WA, 98195, USA.,Goa Medical College and Hospital, Bambolim, Goa, 403202, India
| | - Anvily Almeida
- Departments of Chemistry and Global Health, University of Washington, Seattle, WA, 98195, USA.,Goa Medical College and Hospital, Bambolim, Goa, 403202, India
| | - Mezia Fernandes
- Departments of Chemistry and Global Health, University of Washington, Seattle, WA, 98195, USA.,Goa Medical College and Hospital, Bambolim, Goa, 403202, India
| | - Marina Vaz
- Goa Medical College and Hospital, Bambolim, Goa, 403202, India
| | - Rakesh Ramanan
- Goa Medical College and Hospital, Bambolim, Goa, 403202, India
| | | | - Maria Bernabeu
- Center for Infectious Disease Research (CIDR), Seattle, WA, 98109, USA
| | - Suresh Kumar Manoharan
- Departments of Chemistry and Global Health, University of Washington, Seattle, WA, 98195, USA.,Goa Medical College and Hospital, Bambolim, Goa, 403202, India
| | - Ligia Pereira
- Departments of Chemistry and Global Health, University of Washington, Seattle, WA, 98195, USA.,Goa Medical College and Hospital, Bambolim, Goa, 403202, India
| | - Rashmi Dash
- Departments of Chemistry and Global Health, University of Washington, Seattle, WA, 98195, USA.,Goa Medical College and Hospital, Bambolim, Goa, 403202, India
| | - Ambika Sharma
- Departments of Chemistry and Global Health, University of Washington, Seattle, WA, 98195, USA.,Goa Medical College and Hospital, Bambolim, Goa, 403202, India
| | - Riaz Basha Shaik
- Departments of Chemistry and Global Health, University of Washington, Seattle, WA, 98195, USA.,Goa Medical College and Hospital, Bambolim, Goa, 403202, India
| | - Rimi Chakrabarti
- Departments of Chemistry and Global Health, University of Washington, Seattle, WA, 98195, USA.,Goa Medical College and Hospital, Bambolim, Goa, 403202, India
| | - Prasad Babar
- Departments of Chemistry and Global Health, University of Washington, Seattle, WA, 98195, USA.,Goa Medical College and Hospital, Bambolim, Goa, 403202, India
| | - John White
- Departments of Chemistry and Global Health, University of Washington, Seattle, WA, 98195, USA
| | - Devaraja G Mudeppa
- Departments of Chemistry and Global Health, University of Washington, Seattle, WA, 98195, USA
| | - Shiva Kumar
- Departments of Chemistry and Global Health, University of Washington, Seattle, WA, 98195, USA
| | - Wenyun Zuo
- Department of Biology, Stanford University, Stanford, CA, 94305, USA
| | - Kristen M Skillman
- Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, Boston, MA, 02115, USA
| | - Usheer Kanjee
- Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, Boston, MA, 02115, USA
| | - Caeul Lim
- Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, Boston, MA, 02115, USA
| | - Kathryn Shaw-Saliba
- Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, Boston, MA, 02115, USA
| | - Ashwani Kumar
- National Institute of Malaria Research, Field Unit, Campal, Goa, 403001, India
| | - Neena Valecha
- National Institute of Malaria Research (ICMR), Sector 8, Dwarka, New Delhi, 110077, India
| | - V N Jindal
- Goa Medical College and Hospital, Bambolim, Goa, 403202, India
| | | | - Pradeep Naik
- Goa Medical College and Hospital, Bambolim, Goa, 403202, India
| | - Sunanda Amonkar
- Goa Medical College and Hospital, Bambolim, Goa, 403202, India
| | - Manoj T Duraisingh
- Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, Boston, MA, 02115, USA
| | | | - Joseph D Smith
- Center for Infectious Disease Research (CIDR), Seattle, WA, 98109, USA
| | - Nagesh Dubhashi
- Goa Medical College and Hospital, Bambolim, Goa, 403202, India
| | - Roque G W Pinto
- Goa Medical College and Hospital, Bambolim, Goa, 403202, India
| | - Maria Silveria
- Goa Medical College and Hospital, Bambolim, Goa, 403202, India
| | - Edwin Gomes
- Goa Medical College and Hospital, Bambolim, Goa, 403202, India
| | - Pradipsinh K Rathod
- Departments of Chemistry and Global Health, University of Washington, Seattle, WA, 98195, USA.
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Nyein PP, Aung NM, Kyi TT, Htet ZW, Anstey NM, Kyi MM, Hanson J. High Frequency of Clinically Significant Bacteremia in Adults Hospitalized With Falciparum Malaria. Open Forum Infect Dis 2016; 3:ofw028. [PMID: 26989752 PMCID: PMC4794945 DOI: 10.1093/ofid/ofw028] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Accepted: 02/05/2016] [Indexed: 11/14/2022] Open
Abstract
Background. African children with severe falciparum malaria commonly have concomitant Gram-negative bacteremia, but co-infection has been thought to be relatively rare in adult malaria. Methods. Adults with a diagnosis of falciparum malaria hospitalized at 4 tertiary referral hospitals in Myanmar had blood cultures collected at admission. The frequency of concomitant bacteremia and the clinical characteristics of the patients, with and without bacteremia, were explored. Results. Of 67 adults hospitalized with falciparum malaria, 9 (13% [95% confidence interval, 5.3%-21.6%]) were also bacteremic on admission, 7 (78%) with Gram-negative enteric organisms (Escherichia coli [n = 3], typhoidal Salmonella species [n = 3], nontyphoidal Salmonella [n = 1]). Bacteremic adults had more severe disease (median Respiratory Coma Acidosis Malaria [RCAM] score 3; interquartile range [IQR], 1-4) than those without bacteremia (median RCAM score 1; IQR, 1-2) and had a higher frequency of acute kidney injury (50% vs 16%, P = .03). Although 35 (52%) were at high risk of death (RCAM score ≥2), all 67 patients in the study survived, 51 (76%) of whom received empirical antibiotics on admission. Conclusions. Bacteremia was relatively frequent in adults hospitalized with falciparum malaria in Myanmar. Like children in high transmission settings, bacteremic adults in this low transmission setting were sicker than nonbacteremic adults, and were often difficult to identify at presentation. Empirical antibiotics may also be appropriate in adults hospitalized with falciparum malaria in low transmission settings, until bacterial infection is excluded.
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Affiliation(s)
| | | | | | | | - Nicholas M Anstey
- Menzies School of Health Research, Charles Darwin University , Darwin , Australia
| | | | - Josh Hanson
- Menzies School of Health Research, Charles Darwin University , Darwin , Australia
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Aung NM, Kaung M, Kyi TT, Kyaw MP, Min M, Htet ZW, Anstey NM, Kyi MM, Hanson J. The Safety of a Conservative Fluid Replacement Strategy in Adults Hospitalised with Malaria. PLoS One 2015; 10:e0143062. [PMID: 26581060 PMCID: PMC4651424 DOI: 10.1371/journal.pone.0143062] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Accepted: 10/22/2015] [Indexed: 12/29/2022] Open
Abstract
Background A conservative approach to fluid resuscitation improves survival in children with severe malaria; however, this strategy has not been formally evaluated in adults with the disease. Methods Adults hospitalised with malaria at two tertiary referral hospitals in Myanmar received intravenous fluid replacement with isotonic saline, administered at a maintenance rate using a simple weight-based algorithm. Clinical and biochemical indices were followed sequentially. Results Of 61 adults enrolled, 34 (56%) had Plasmodium falciparum mono-infection, 17 (28%) Plasmodium vivax mono-infection and 10 (16%) mixed infection; 27 (44%) patients were at high risk of death (P. falciparum infection and RCAM score ≥ 2). In the first six hours of hospitalisation patients received a mean 1.7 ml/kg/hour (range: 1.3–2.2) of intravenous fluid and were able to drink a mean of 0.8 ml/kg/hour (range: 0–3). Intravenous fluid administration and oral intake were similar for the remainder of the first 48 hours of hospitalisation. All 61 patients survived to discharge. No patient developed Adult Respiratory Distress Syndrome, a requirement for renal replacement therapy or hypotension (mean arterial pressure < 60mmHg). Plasma lactate was elevated (> 2 mmol/L) on enrolment in 26 (43%) patients but had declined by 6 hours in 25 (96%) and was declining at 24 hours in the other patient. Plasma creatinine was elevated (> 120 μmol/L) on enrolment in 17 (28%) patients, but was normal or falling in 16 (94%) at 48 hours and declining in the other patient by 72 hours. There was no clinically meaningful increase in plasma lactate or creatinine in any patient with a normal value on enrolment. Patients receiving fluid replacement with the conservative fluid replacement algorithm were more likely to survive than historical controls in the same hospitals who had received fluid replacement guided by clinical judgement in the year prior to the study (p = 0.03), despite having more severe disease (p < 0.001). Conclusions A conservative fluid resuscitation strategy appears safe in adults hospitalised with malaria.
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Affiliation(s)
| | - Myat Kaung
- Hpa-an Hospital, Hpa-an, Kayin State, Myanmar
| | | | - Myat Phone Kyaw
- Department of Medical Research (Lower Myanmar), Yangon, Myanmar
| | - Myo Min
- Myanmar Medical Association, Yangon, Myanmar
| | | | - Nicholas M. Anstey
- Menzies School of Health Research, Charles Darwin University, Darwin, Australia
| | | | - Josh Hanson
- Menzies School of Health Research, Charles Darwin University, Darwin, Australia
- * E-mail:
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Ampawong S, Chaisri U, Viriyavejakul P, Prapansilp P, Grau GE, Turner GDH, Pongponratn E. A potential role for interleukin-33 and γ-epithelium sodium channel in the pathogenesis of human malaria associated lung injury. Malar J 2015; 14:389. [PMID: 26437894 PMCID: PMC4595310 DOI: 10.1186/s12936-015-0922-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Accepted: 09/27/2015] [Indexed: 01/05/2023] Open
Abstract
Background The pathogenesis of pulmonary oedema (PE) in patients with severe malaria is still unclear. It has been hypothesized that lung injury depends, in addition to microvascular obstruction, on an increased pulmonary capillary pressure and altered alveolar-capillary membrane permeability, causing pulmonary fluid accumulation. Methods This study compared the histopathological features of lung injury in Southeast Asian patients (n = 43) who died from severe Plasmodium falciparum malaria, and correlated these with clinical history in groups with or without PE. To investigate the expression of mediators that may influence fluid accumulation in PE, immunohistochemistry and image analysis were performed on controls and sub-sets of patient with or without PE. Results The expression of leukocyte sub-set antigens, bronchial interleukin (IL)-33, γ-epithelium sodium channel (ENaC), aquaporin (AQP)-1 and -5, and control cytokeratin staining was quantified in the lung tissue of severe malaria patients. Bronchial IL-33 expression was significantly increased in severe malaria patients with PE. Malaria patients with shock showed significantly increased bronchial IL-33 compare to other clinical manifestations. Bronchial IL-33 levels were positively correlated with CD68+ monocyte and elastase + neutrophil, septal congestion and hyaline membrane formation. Moreover, the expression of both vascular smooth muscle cell (VSMC) and bronchial γ-ENaC significantly decreased in severe malaria patients with PE. Both VSMC and bronchial γ-ENaC were negatively correlated with the degree of parasitized erythrocyte sequestration, alveolar thickness, alveolar expansion score, septal congestion score, and malarial pigment score. In contrast AQP-1 and -5 and pan cytokeratin levels were similar between groups. Conclusions The results suggest that IL-33 may play a role in lung injury during severe malaria and lead to PE. Both VSMC and bronchial γ-ENaC downregulation may explain pulmonary fluid disturbances and participate in PE pathogenesis in severe malaria patients.
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Affiliation(s)
- Sumate Ampawong
- Department of Tropical Pathology, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.
| | - Urai Chaisri
- Department of Tropical Pathology, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.
| | - Parnpen Viriyavejakul
- Department of Tropical Pathology, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.
| | - Panote Prapansilp
- Department of Tropical Pathology, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.
| | - Georges E Grau
- Vascular Immunology Unit, Department of Pathology, Sydney Medical School, The University of Sydney, Parramatta Road, Camperdown, NSW, Australia.
| | - Gareth D H Turner
- Department of Tropical Pathology, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. .,Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. .,Nuffield Department of Clinical Medicine, Centre for Tropical Medicine and Global Health, Oxford University, Oxford, UK.
| | - Emsri Pongponratn
- Department of Tropical Pathology, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.
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The role of previously unmeasured organic acids in the pathogenesis of severe malaria. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:317. [PMID: 26343146 PMCID: PMC4561438 DOI: 10.1186/s13054-015-1023-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/30/2015] [Accepted: 08/11/2015] [Indexed: 12/16/2022]
Abstract
Introduction Severe falciparum malaria is commonly complicated by metabolic acidosis. Together with lactic acid (LA), other previously unmeasured acids have been implicated in the pathogenesis of falciparum malaria. Methods In this prospective study, we characterised organic acids in adults with severe falciparum malaria in India and Bangladesh. Liquid chromatography-mass spectrometry was used to measure organic acids in plasma and urine. Patients were followed until recovery or death. Results Patients with severe malaria (n=138), uncomplicated malaria (n=102), sepsis (n=32) and febrile encephalopathy (n=35) were included. Strong ion gap (mean±SD) was elevated in severe malaria (8.2 mEq/L±4.5) and severe sepsis (8.6 mEq/L±7.7) compared with uncomplicated malaria (6.0 mEq/L±5.1) and encephalopathy (6.6 mEq/L±4.7). Compared with uncomplicated malaria, severe malaria was characterised by elevated plasma LA, hydroxyphenyllactic acid (HPLA), α-hydroxybutyric acid and β-hydroxybutyric acid (all P<0.05). In urine, concentrations of methylmalonic, ethylmalonic and α-ketoglutaric acids were also elevated. Multivariate logistic regression showed that plasma HPLA was a strong independent predictor of death (odds ratio [OR] 3.5, 95 % confidence interval [CI] 1.6–7.5, P=0.001), comparable to LA (OR 3.5, 95 % CI 1.5–7.8, P=0.003) (combined area under the receiver operating characteristic curve 0.81). Conclusions Newly identified acids, in addition to LA, are elevated in patients with severe malaria and are highly predictive of fatal outcome. Further characterisation of their sources and metabolic pathways is now needed. Electronic supplementary material The online version of this article (doi:10.1186/s13054-015-1023-5) contains supplementary material, which is available to authorized users.
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35
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Hanson J, Phu NH, Hasan MU, Charunwatthana P, Plewes K, Maude RJ, Prapansilp P, Kingston HWF, Mishra SK, Mohanty S, Price RN, Faiz MA, Dondorp AM, White NJ, Hien TT, Day NPJ. The clinical implications of thrombocytopenia in adults with severe falciparum malaria: a retrospective analysis. BMC Med 2015; 13:97. [PMID: 25907925 PMCID: PMC4408603 DOI: 10.1186/s12916-015-0324-5] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Accepted: 03/13/2015] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Thrombocytopenia is a common finding in adults with severe falciparum malaria, but its clinical and prognostic utility is incompletely defined. METHODS Clinical and laboratory data from 647 adults with severe falciparum malaria were analysed retrospectively to determine the relationship between a patient's platelet count on admission to hospital and their subsequent clinical course. RESULTS On admission, 614 patients (94.9%) were thrombocytopenic (platelet count <150 × 10(9)/L) and 328 (50.7%) had a platelet count <50 × 10(9)/L. The admission platelet count was inversely correlated with parasite biomass (estimated from plasma PfHRP2 concentrations, rs = -0.28, P = 0.003), the degree of microvascular sequestration (measured with orthogonal polarizing spectral imaging, rs = -0.31, P = 0.001) and disease severity (the number of World Health Organization severity criteria satisfied by the patient, rs = -0.21, P <0.001). Platelet counts were lower on admission in the patients who died (median: 30 (interquartile range 22 to 52) × 10(9)/L versus 50 (34 to 78) × 10(9)/L in survivors; P <0.001), but did not predict outcome independently from other established laboratory and clinical prognostic indices. The 39 patients (6%) with profound thrombocytopenia (platelet count <20 × 10(9)/L) were more likely to die (odds ratio: 5.00, 95% confidence interval: 2.56 to 9.75) than patients with higher platelet counts, but these high-risk patients could be identified more rapidly with simple bedside clinical assessment. The admission platelet count did not reliably identify the 50 patients (7.7%) with major bleeding during the study. CONCLUSIONS Thrombocytopenia is a marker of disease severity in adults with falciparum malaria, but has limited utility in prognostication, triage and management.
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Affiliation(s)
- Josh Hanson
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. .,Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, NT, Australia.
| | - Nguyen Hoan Phu
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam.
| | | | - Prakaykaew Charunwatthana
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.
| | - Katherine Plewes
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.
| | - Richard J Maude
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. .,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | - Panote Prapansilp
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. .,Department of Laboratory Medicine, Faculty of Medicine, Chulalongkorn University, Chulalongkorn, Thailand.
| | - Hugh W F Kingston
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.
| | | | | | - Ric N Price
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, NT, Australia. .,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | - M Abul Faiz
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. .,Dev Care Foundation, Dhaka, Bangladesh.
| | - Arjen M Dondorp
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. .,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | - Nicholas J White
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. .,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | - Tran Tinh Hien
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam.
| | - Nicholas P J Day
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. .,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
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Kaung M, Kyi TT, Aung NM, Kyaw MP, Min M, Htet ZW, Anstey NM, Kyi MM, Hanson J. The prognostic utility of bedside assessment of adults hospitalized with malaria in Myanmar: a retrospective analysis. Malar J 2015; 14:63. [PMID: 25881290 PMCID: PMC4323221 DOI: 10.1186/s12936-015-0549-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Accepted: 01/06/2015] [Indexed: 01/03/2023] Open
Abstract
Background Data collected in clinical trials have been used to develop scoring systems that identify adults with malaria at greatest risk of death. One of these, the RCAM score, can be simply determined by measuring a patient’s Glasgow Coma Score and respiratory rate on admission to hospital. However the safety of using the RCAM score to define high-risk patients has not been assessed outside of the clinical trial setting. Methods A retrospective audit of medical records of all adults admitted with a diagnosis of malaria to two tertiary referral hospitals in Lower Myanmar in 2013 was undertaken. An RCAM score was calculated in all patients and related to their subsequent clinical course. Results The recent decline in malaria hospitalizations at both sites continued in 2013. During the year 90 adults were hospitalized with malaria; 62 (69%) had Plasmodium falciparum mono-infection, 11 (12%) had Plasmodium vivax mono-infection, 17 (19%) had mixed infection. All seven (7.7%) deaths occurred in patients infected with P. falciparum. An admission RCAM score <2 identified all the patients that would survive to discharge (positive predictive value (95% confidence interval (CI)) 100% (94.9-100%) and also predicted a requirement for less supportive care: 9/70 (13%) patients with an admission RCAM score <2 required supportive care (blood transfusion, vasopressor support or oxygen supplementation) during their hospitalization compared with 12/20 (60%) patients with an admission RCAM score ≥2 (p < 0.0001). No patient with P. vivax mono-infection required supportive care during their hospitalization. Patients with an oxygen saturation ≤95% on room air on admission were more likely to die before discharge (odds ratio 17.3 (95% CI: 2.9-101.2) than patients with a higher oxygen saturation (p = 0.002). Conclusions Even outside a clinical trial setting the RCAM score reliably identifies adults with malaria who are at greatest risk of death and can be safely used in the initial triage and management of these patients.
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Affiliation(s)
- Myat Kaung
- Hpa-an Hospital, Hpa-an, Kayin State, Myanmar.
| | | | - Ne Myo Aung
- Insein Hospital, Insein Township, Yangon, Myanmar.
| | - Myat Phone Kyaw
- Department of Medical Research (Lower Myanmar), Yangon, Myanmar.
| | - Myo Min
- Myanmar Medical Association, Yangon, Myanmar.
| | - Zaw Win Htet
- Insein Hospital, Insein Township, Yangon, Myanmar.
| | - Nicholas M Anstey
- Menzies School of Health Research, Charles Darwin University, Darwin, Australia.
| | - Mar Mar Kyi
- Insein Hospital, Insein Township, Yangon, Myanmar.
| | - Josh Hanson
- Menzies School of Health Research, Charles Darwin University, Darwin, Australia.
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Färnert A, Wyss K, Dashti S, Naucler P. Duration of residency in a non-endemic area and risk of severe malaria in African immigrants. Clin Microbiol Infect 2014; 21:494-501. [PMID: 25656623 DOI: 10.1016/j.cmi.2014.12.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Revised: 12/06/2014] [Accepted: 12/14/2014] [Indexed: 11/26/2022]
Abstract
In malaria-endemic areas, adults very rarely succumb to severe malaria, suggesting that immunity to severe disease is life-long under conditions of repeated exposure. To what extent this protection persists in the absence of exposure remains to be established. The aim of this study was to assess whether duration of residency in a malaria-free country affects the risk for severe malaria in immigrants originating from sub-Saharan Africa. We conducted a retrospective chart review of 948 cases of malaria diagnosed in Stockholm, Sweden in 1995-2013. Among 501 adult patients with Plasmodium falciparum (315 of endemic origin and 186 of non-endemic origin, mainly Sweden), 41 (8.2%) had severe malaria according to WHO criteria (including 5% with parasitaemia), 22 (4.4%) had factors prognostic of poor outcome, and 35 (7.0%) were admitted to intensive care. Overall, patient origin did not affect the odds of severe malaria, according to any of these definitions. However, when the immigrants were stratified with regard to their duration of residency in Sweden, the risk of factors prognostic for poor outcome was associated with duration of prior residency in a malaria-free country among patients of endemic origin (p 0.02), and immigrants who had lived for ≥ 15 years in Sweden had a similar risk as non-immune travellers. The results of this explorative study suggest that, although immunity to severe malaria is maintained for several years in African adults, this protection might be lost with time without repeated re-exposure. A larger study, preferably including multiple centres, will be needed to confirm our findings.
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Affiliation(s)
- A Färnert
- Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden; Infectious Diseases Unit, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.
| | - K Wyss
- Infectious Diseases Unit, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden; Department of Emergency Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - S Dashti
- Infectious Diseases Unit, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - P Naucler
- Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden; Infectious Diseases Unit, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
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Jain V, Basak S, Bhandari S, Bharti PK, Thomas T, Singh MP, Singh N. Burden of complicated malaria in a densely forested Bastar region of Chhattisgarh State (Central India). PLoS One 2014; 9:e115266. [PMID: 25531373 PMCID: PMC4274025 DOI: 10.1371/journal.pone.0115266] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2014] [Accepted: 11/20/2014] [Indexed: 11/21/2022] Open
Abstract
Background A prospective study on severe and complicated malaria was undertaken in the tribal dominated area of Bastar division, Chhattisgarh (CG), Central India, with an objective to understand the clinical epidemiology of complicated malaria in patients attending at a referral hospital. Methods Blood smears, collected from the general medicine and pediatric wards of a government tertiary health care facility located in Jagdalpur, CG, were microscopically examined for malaria parasite from July 2010 to December 2013. The Plasmodium falciparum positive malaria cases who met enrollment criteria and provided written informed consent were enrolled under different malaria categories following WHO guidelines. PCR was performed to reconfirm the presence of P.falciparum mono infection among enrolled cases. Univariate and multivariate logistic regression analysis was done to identify different risk factors using STATA 11.0. Results A total of 40,924 cases were screened for malaria. The prevalence of malaria and P.falciparum associated complicated malaria (severe and cerebral both) in the hospital was 6% and 0.81%, respectively. P.falciparum malaria prevalence, severity and associated mortality in this region peaked at the age of>4–5 years and declined with increasing age. P.falciparum malaria was significantly more prevalent in children than adults (P<0.00001). Among adults, males had significantly more P.falciparum malaria than females (P<0.00001). Case fatality rate due to cerebral malaria and severe malaria was, respectively, 32% and 9% among PCR confirmed mono P.falciparum cases. Coma was the only independent predictor of mortality in multivariate regression analysis. Mortality was significantly associated with multi-organ complication score (P = 0.0003). Conclusion This study has revealed that the pattern of morbidity and mortality in this part of India is very different from earlier reported studies from India. We find that the peak morbidity and mortality in younger children regardless of seasonality. This suggests that this age group needs special care for control and clinical management.
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Affiliation(s)
- Vidhan Jain
- Regional Medical Research Centre for Tribals (RMRCT), ICMR, Garha, Jabalpur, Madhya Pradesh, India
| | - Sanjay Basak
- District Malaria Office, Maharani Hospital and associated Medical College Jagdalpur, Chhattisgarh, India
| | - Sneha Bhandari
- Regional Medical Research Centre for Tribals (RMRCT), ICMR, Garha, Jabalpur, Madhya Pradesh, India
| | - Praveen K. Bharti
- Regional Medical Research Centre for Tribals (RMRCT), ICMR, Garha, Jabalpur, Madhya Pradesh, India
| | - Trilok Thomas
- Regional Medical Research Centre for Tribals (RMRCT), ICMR, Garha, Jabalpur, Madhya Pradesh, India
| | - Mrigendra P. Singh
- National Institute of Malaria Research, Field Unit, Jabalpur, Madhya Pradesh, India
| | - Neeru Singh
- Regional Medical Research Centre for Tribals (RMRCT), ICMR, Garha, Jabalpur, Madhya Pradesh, India
- * E-mail:
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Hanson J, Anstey NM, Bihari D, White NJ, Day NP, Dondorp AM. The fluid management of adults with severe malaria. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:642. [PMID: 25629462 PMCID: PMC4318383 DOI: 10.1186/s13054-014-0642-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Fluid resuscitation has long been considered a key intervention in the treatment of adults with severe falciparum malaria. Profound hypovolemia is common in these patients and has the potential to exacerbate the acidosis and acute kidney injury that are independent predictors of death. However, new microvascular imaging techniques have shown that disease severity correlates more strongly with obstruction of the microcirculation by parasitized erythrocytes - a process termed sequestration. Fluid loading has little effect on sequestration and increases the risk of complications, particularly pulmonary edema, a condition that can develop suddenly and unpredictably and that is frequently fatal in this population. Accordingly, even if a patient is clinically hypovolemic, if there is an adequate blood pressure and urine output, there may be little advantage in infusing intravenous fluid beyond a maintenance rate of 1 to 2 mL/kg per hour. The optimal agent for fluid resuscitation remains uncertain; significant anemia requires blood transfusion, but colloid solutions may be associated with harm and should be avoided. The preferred crystalloid is unclear, although the use of balanced solutions requires investigation. There are fewer data to guide the fluid management of severe vivax and knowlesi malaria, although a similar conservative strategy would appear prudent.
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Marks M, Gupta-Wright A, Doherty JF, Singer M, Walker D. Managing malaria in the intensive care unit. Br J Anaesth 2014; 113:910-21. [PMID: 24946778 PMCID: PMC4235570 DOI: 10.1093/bja/aeu157] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The number of people travelling to malaria-endemic countries continues to increase, and malaria remains the commonest cause of serious imported infection in non-endemic areas. Severe malaria, mostly caused by Plasmodium falciparum, often requires intensive care unit (ICU) admission and can be complicated by cerebral malaria, respiratory distress, acute kidney injury, bleeding complications, and co-infection. The mortality from imported malaria remains significant. This article reviews the manifestations, complications and principles of management of severe malaria as relevant to critical care clinicians, incorporating recent studies of anti-malarial and adjunctive treatment. Effective management of severe malaria includes prompt diagnosis and early institution of effective anti-malarial therapy, recognition of complications, and appropriate supportive management in an ICU. All cases should be discussed with a specialist unit and transfer of the patient considered.
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Affiliation(s)
- M Marks
- The Hospital for Tropical Diseases, Mortimer Market Centre, Capper Street, London, UK Department of Clinical Research, Faculty of Infectious and Tropical Diseases London School of Hygiene and Tropical Medicine, Keppel Street, London, UK
| | - A Gupta-Wright
- The Hospital for Tropical Diseases, Mortimer Market Centre, Capper Street, London, UK Department of Clinical Research, Faculty of Infectious and Tropical Diseases London School of Hygiene and Tropical Medicine, Keppel Street, London, UK
| | - J F Doherty
- The Hospital for Tropical Diseases, Mortimer Market Centre, Capper Street, London, UK
| | - M Singer
- Department of Critical Care, University College London Hospital NHS Foundation Trust, 3rd Floor, 235 Euston Road, London NW1 2BU, UK
| | - D Walker
- Department of Critical Care, University College London Hospital NHS Foundation Trust, 3rd Floor, 235 Euston Road, London NW1 2BU, UK
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Abstract
Although global morbidity and mortality have decreased substantially, malaria, a parasite infection of red blood cells, still kills roughly 2000 people per day, most of whom are children in Africa. Two factors largely account for these decreases; increased deployment of insecticide-treated bednets and increased availability of highly effective artemisinin combination treatments. In large trials, parenteral artesunate (an artemisinin derivative) reduced severe malaria mortality by 22·5% in Africa and 34·7% in Asia compared with quinine, whereas adjunctive interventions have been uniformly unsuccessful. Rapid tests have been an important addition to microscopy for malaria diagnosis. Chemopreventive strategies have been increasingly deployed in Africa, notably intermittent sulfadoxine-pyrimethamine treatment in pregnancy, and monthly amodiaquine-sulfadoxine-pyrimethamine during the rainy season months in children aged between 3 months and 5 years across the sub-Sahel. Enthusiasm for malaria elimination has resurfaced. This ambitious but laudable goal faces many challenges, including the worldwide economic downturn, difficulties in elimination of vivax malaria, development of pyrethroid resistance in some anopheline mosquitoes, and the emergence of artemisinin resistance in Plasmodium falciparum in southeast Asia. We review the epidemiology, clinical features, pathology, prevention, and treatment of malaria.
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Affiliation(s)
- Nicholas J White
- Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, Oxford, UK.
| | | | - Tran Tinh Hien
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - M Abul Faiz
- Department of Medicine, Dev Care Foundation, Dhaka, Bangladesh
| | | | - Arjen M Dondorp
- Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, Oxford, UK
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Experimental Models of Microvascular Immunopathology: The Example of Cerebral Malaria. JOURNAL OF NEUROINFECTIOUS DISEASES 2014; 5:134. [PMID: 26430675 PMCID: PMC4586166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Human cerebral malaria is a severe and often lethal complication of Plasmodium falciparum infection. Complex host and parasite interactions should the precise mechanisms involved in the onset of this neuropathology. Adhesion of parasitised red blood cells and host cells to endothelial cells lead to profound endothelial alterations that trigger immunopathological changes, varying degrees of brain oedema and can compromise cerebral blood flow, cause cranial nerve dysfunction and hypoxia. Study of the cerebral pathology in human patients is limited to clinical and genetic field studies in endemic areas, thus cerebral malaria (CM) research relies heavily on experimental models. The availability of malaria models allows study from the inoculation of Plasmodium to the onset of disease and permit invasive experiments. Here, we discuss some aspects of our current understanding of CM, the experimental models available and some important recent findings extrapolated from these models.
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Hanson J, Lee SJ, Mohanty S, Faiz MA, Anstey NM, Price RN, Charunwatthana P, Yunus EB, Mishra SK, Tjitra E, Rahman R, Nosten F, Htut Y, Maude RJ, Thi Hong Chau T, Phu NH, Hien TT, White NJ, Day NPJ, Dondorp AM. Rapid clinical assessment to facilitate the triage of adults with falciparum malaria, a retrospective analysis. PLoS One 2014; 9:e87020. [PMID: 24489828 PMCID: PMC3906099 DOI: 10.1371/journal.pone.0087020] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Accepted: 12/15/2013] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Most adults dying from falciparum malaria will die within 48 hours of their hospitalisation. An essential component of early supportive care is the rapid identification of patients at greatest risk. In resource-poor settings, where most patients with falciparum malaria are managed, decisions regarding patient care must frequently be made using clinical evaluation alone. METHODS We retrospectively analysed 4 studies of 1801 adults with severe falciparum malaria to determine whether the presence of simple clinical findings might assist patient triage. RESULTS If present on admission, shock, oligo-anuria, hypo- or hyperglycaemia, an increased respiratory rate, a decreased Glasgow Coma Score and an absence of fever were independently predictive of death. The variables were used to construct a simple clinical algorithm. When applied to the 1801 patients, this algorithm's positive predictive value for survival to 48 hours was 99.4 (95% confidence interval (CI) 97.8-99.9) and for survival to discharge 96.9% (95% CI 94.3-98.5). In the 712 patients receiving artesunate, the algorithm's positive predictive value for survival to 48 hours was 100% (95% CI 97.3-100) and to discharge was 98.5% (95% CI 94.8-99.8). CONCLUSIONS Simple clinical findings are closely linked to the pathophysiology of severe falciparum malaria in adults. A basic algorithm employing these indices can facilitate the triage of patients in settings where intensive care services are limited. Patients classified as low-risk by this algorithm can be safely managed initially on a general ward whilst awaiting senior clinical review and laboratory data.
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Affiliation(s)
- Josh Hanson
- Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
- Global Health Division, Menzies School of Health Research, Darwin, Australia
- * E-mail:
| | - Sue J. Lee
- Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, Churchill Hospital, Oxford, United Kingdom
| | - Sanjib Mohanty
- Department of Medicine, Ispat Hospital, Rourkela, Orissa, India
| | - M. Abul Faiz
- Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
- Dev Care Foundation, Dhaka, Bangladesh
| | - Nicholas M. Anstey
- Global Health Division, Menzies School of Health Research, Darwin, Australia
| | - Ric N. Price
- Global Health Division, Menzies School of Health Research, Darwin, Australia
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, Churchill Hospital, Oxford, United Kingdom
| | | | | | - Saroj K. Mishra
- Department of Medicine, Ispat Hospital, Rourkela, Orissa, India
| | - Emiliana Tjitra
- National Institute of Health Research and Development, Ministry of Health, Jakarta, Indonesia
| | | | - Francois Nosten
- Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, Churchill Hospital, Oxford, United Kingdom
- Shoklo Malaria Research Unit, Mae Sot, Thailand
| | - Ye Htut
- Department of Medical Research, Lower Myanmar, Ministry of Health, Yangon, Myanmar
| | - Richard J. Maude
- Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, Churchill Hospital, Oxford, United Kingdom
| | - Tran Thi Hong Chau
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Nguyen Hoan Phu
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Tran Tinh Hien
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Nicholas J. White
- Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, Churchill Hospital, Oxford, United Kingdom
| | - Nicholas P. J. Day
- Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, Churchill Hospital, Oxford, United Kingdom
| | - Arjen M. Dondorp
- Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, Churchill Hospital, Oxford, United Kingdom
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Hanson J, Lam SWK, Alam S, Pattnaik R, Mahanta KC, Uddin Hasan M, Mohanty S, Mishra S, Cohen S, Day N, White N, Dondorp A. The reliability of the physical examination to guide fluid therapy in adults with severe falciparum malaria: an observational study. Malar J 2013; 12:348. [PMID: 24079262 PMCID: PMC3851438 DOI: 10.1186/1475-2875-12-348] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2013] [Accepted: 09/20/2013] [Indexed: 12/29/2022] Open
Abstract
Background Adults with severe malaria frequently require intravenous fluid therapy to restore their circulating volume. However, fluid must be delivered judiciously as both under- and over-hydration increase the risk of complications and, potentially, death. As most patients will be cared for in a resource-poor setting, management guidelines necessarily recommend that physical examination should guide fluid resuscitation. However, the reliability of this strategy is uncertain. Methods To determine the ability of physical examination to identify hypovolaemia, volume responsiveness, and pulmonary oedema, clinical signs and invasive measures of volume status were collected independently during an observational study of 28 adults with severe malaria. Results The physical examination defined volume status poorly. Jugular venous pressure (JVP) did not correlate with intravascular volume as determined by global end diastolic volume index (GEDVI; rs = 0.07, p = 0.19), neither did dry mucous membranes (p = 0.85), or dry axillae (p = 0.09). GEDVI was actually higher in patients with decreased tissue turgor (p < 0.001). Poor capillary return correlated with GEDVI, but was present infrequently (7% of observations) and, therefore, insensitive. Mean arterial pressure (MAP) correlated with GEDVI (rs = 0.16, p = 0.002), but even before resuscitation patients with a low GEDVI had a preserved MAP. Anuria on admission was unrelated to GEDVI and although liberal fluid resuscitation led to a median hourly urine output of 100 ml in 19 patients who were not anuric on admission, four (21%) developed clinical pulmonary oedema subsequently. MAP was unrelated to volume responsiveness (p = 0.71), while a low JVP, dry mucous membranes, dry axillae, increased tissue turgor, prolonged capillary refill, and tachycardia all had a positive predictive value for volume responsiveness of ≤50%. Extravascular lung water ≥11 ml/kg indicating pulmonary oedema was present on 99 of the 353 times that it was assessed during the study, but was identified on less than half these occasions by tachypnoea, chest auscultation, or an elevated JVP. A clear chest on auscultation and a respiratory rate <30 breaths/minute could exclude pulmonary oedema on 82% and 72% of occasions respectively. Conclusions Findings on physical examination correlate poorly with true volume status in adults with severe malaria and must be used with caution to guide fluid therapy. Trial registration Clinicaltrials.gov identifier: NCT00692627
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Affiliation(s)
- Josh Hanson
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.
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Abstract
Severe malaria is a medical emergency requiring early intervention to prevent death. This article highlights key aspects of the management of severe malaria syndromes in the intensive care unit, with a focus on individual case management of imported malaria. Key differences in the presentation, management, and outcomes of severe malaria by endemicity and by age group are emphasized. In all groups with severe malaria, intravenous artesunate is the antimalarial agent of choice. This article discusses specific antimalarial therapies, optimal supportive management strategies, differences from strategies for bacterial sepsis, and trials of adjunctive therapy for severe malaria in humans.
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Newton PN, Stepniewska K, Dondorp A, Silamut K, Chierakul W, Krishna S, Davis TME, Suputtamongkol Y, Angus B, Pukrittayakamee S, Ruangveerayuth R, Hanson J, Day NPJ, White NJ. Prognostic indicators in adults hospitalized with falciparum malaria in Western Thailand. Malar J 2013; 12:229. [PMID: 23829311 PMCID: PMC3711784 DOI: 10.1186/1475-2875-12-229] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2013] [Accepted: 06/23/2013] [Indexed: 11/17/2022] Open
Abstract
Background Severe malaria remains a major cause of death and morbidity amongst adults in the Asiatic tropics. Methods A retrospective analysis of the clinical and laboratory data of 988 adult patients, hospitalized with Plasmodium falciparum malaria and prospectively recruited to malaria studies in western Thailand between 1986 and 2002, was performed to assess the factors associated with a fatal outcome. Different severity scores and classifications for defining severe malaria were compared and, using multiple logistic regression, simple models for predicting mortality developed. Results The proportion of patients fulfilling the WHO 2000 definition of severe malaria was 78.1%, and their mortality was 10%. Mortality in patients given parenteral artesunate or artemether (16/317, 5%) was lower than in those given parenteral quinine (59/442, 13%) (P < 0.001). Models using parameter sets based on WHO 1990, 2000 and Adapted AQ criteria plus blood smear parasite-stage assessment gave the best mortality prediction. A malaria prognostic index (MPI), derived from the dataset using five clinical or laboratory variables gave similar prognostic accuracy. Conclusions The mortality of severe malaria in adults has fallen and the switch from quinine to artesunate has probably been an important contributor. Prognostic indices based on WHO 2000 definitions, and other simpler indices based on fewer variables, provide clinically useful predictions of outcome in Asian adults with severe malaria.
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Affiliation(s)
- Paul N Newton
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao PDR.
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Lon C, Timmermans A, Buathong N, Nou S, Se Y, Sitthy N, Chann S, Kraesub S, Wongstitwilairoong T, Walsh DS, Tyner S, Fukuda M, Callender D, Sherwood J, Koy L, Char M, Bethell D, Saunders D. Severe malaria in Battambang Referral Hospital, an area of multidrug resistance in Western-Cambodia: a retrospective analysis of cases from 2006-2009. Malar J 2013; 12:217. [PMID: 23802651 PMCID: PMC3699359 DOI: 10.1186/1475-2875-12-217] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Accepted: 06/23/2013] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Despite recent malaria containment and control efforts leading to reduced incidence, Cambodia remains endemic for both Plasmodium vivax and multidrug-resistant Plasmodium falciparum malaria. Little has been reported in the peer-reviewed literature regarding the burden of severe malaria (SM) in Cambodia. METHODS Medical records for all patients admitted to the Battambang Referral Hospital (BRH) with an admitting or discharge diagnosis of SM from 2006 to 2009 (suspected SM cases) were reviewed. Those meeting the case definition of SM according to retrospective chart review and investigator assessment of probable cases, based on published national guidelines available at the time, were analysed for trends in demographics, mortality and referral patterns. RESULTS Of the 537 suspected SM cases at BRH during the study period, 393 (73%) met published WHO criteria for SM infection. Despite limited diagnostic and treatment facilities, overall mortality was 14%, with 7% mortality in children 14 and under, but 19% in adults (60% of cases). Cerebral malaria with coma was relatively rare (17%), but mortality was disproportionately high at 35%. Mean time to hospital presentation was five days (range one to 30 days) after onset of symptoms. While patients with delays in presentation had worse outcomes, there was no excess mortality based on treatment referral times, distance travelled or residence in artemisinin-resistance containment (ARC) Zone 1 compared to Zone 2. CONCLUSIONS Despite limitations in diagnosis and treatment, and multiple confounding co-morbidities, mortality rates at BRH were similar to reports from other countries in the region. Interventions to improve access to early diagnosis and effective treatment, combined with modest improvements in intensive care, are likely to reduce mortality further. Patients referred from Zone 1 did not have excess mortality compared to Zone 2 ARC areas. A steep decrease in SM cases and deaths observed in the first half of 2009 has since continued, indicating some success from containment efforts despite the emergence of artemisinin resistance in this area.
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Affiliation(s)
- Chanthap Lon
- Department of Immunology & Medicine, Armed Forces Research Institute of Medical Sciences, 315/6 Rajvithi Road, Bangkok 10400, Thailand
| | - Ans Timmermans
- Department of Immunology & Medicine, Armed Forces Research Institute of Medical Sciences, 315/6 Rajvithi Road, Bangkok 10400, Thailand
| | - Nillawan Buathong
- Department of Immunology & Medicine, Armed Forces Research Institute of Medical Sciences, 315/6 Rajvithi Road, Bangkok 10400, Thailand
| | - Samon Nou
- Armed Forces Research Institute of Medical Sciences, Phnom Penh, Cambodia
| | - Youry Se
- Department of Immunology & Medicine, Armed Forces Research Institute of Medical Sciences, 315/6 Rajvithi Road, Bangkok 10400, Thailand
| | - Ngo Sitthy
- Battambang Referral Hospital, Cambodia, Dongkorteap village, Tuol Ta Ek Commune, Battambang District, Battambang Province, Cambodia
| | - Soklyda Chann
- Armed Forces Research Institute of Medical Sciences, Phnom Penh, Cambodia
| | - Somporn Kraesub
- Department of Immunology & Medicine, Armed Forces Research Institute of Medical Sciences, 315/6 Rajvithi Road, Bangkok 10400, Thailand
| | - Tippa Wongstitwilairoong
- Department of Immunology & Medicine, Armed Forces Research Institute of Medical Sciences, 315/6 Rajvithi Road, Bangkok 10400, Thailand
| | - Douglas S Walsh
- Department of Immunology & Medicine, Armed Forces Research Institute of Medical Sciences, 315/6 Rajvithi Road, Bangkok 10400, Thailand
| | - Stuart Tyner
- Department of Immunology & Medicine, Armed Forces Research Institute of Medical Sciences, 315/6 Rajvithi Road, Bangkok 10400, Thailand
| | - Mark Fukuda
- Armed Forces Health Surveillance Center, Silver Spring, MD, USA
| | | | | | - Lenin Koy
- Battambang Referral Hospital, Cambodia, Dongkorteap village, Tuol Ta Ek Commune, Battambang District, Battambang Province, Cambodia
| | - Mengchour Char
- National Center for Parasitology, Entomology and Malaria Control, #372 Blvd. Monivong, Phnom Penh, Cambodia
| | - Delia Bethell
- Department of Immunology & Medicine, Armed Forces Research Institute of Medical Sciences, 315/6 Rajvithi Road, Bangkok 10400, Thailand
| | - David Saunders
- Department of Immunology & Medicine, Armed Forces Research Institute of Medical Sciences, 315/6 Rajvithi Road, Bangkok 10400, Thailand
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Fluid resuscitation of adults with severe falciparum malaria: effects on Acid-base status, renal function, and extravascular lung water. Crit Care Med 2013; 41:972-81. [PMID: 23324951 DOI: 10.1097/ccm.0b013e31827466d2] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the efficacy and safety of liberal fluid resuscitation of adults with severe malaria. DESIGN, SETTING, PATIENTS, AND METHODS: Twenty-eight Bangladeshi and Indian adults with severe falciparum malaria received crystalloid resuscitation guided by transpulmonary thermodilution (PiCCO) in an intensive care setting. Systemic hemodynamics, microvascular indices and measures of acidosis, renal function, and pulmonary edema were followed prospectively. RESULTS All patients were hypovolemic (global end-diastolic volume index<680 mL/m) on enrollment. Patients received a median (range) 3230 mL (390-7300) of isotonic saline in the first 6 hours and 5450 mL (710-13,720) in the first 24 hours. With resuscitation, acid-base status deteriorated in 19 of 28 (68%), and there was no significant improvement in renal function. Extravascular lung water increased in 17 of 22 liberally resuscitated patients (77%); eight of these patients developed pulmonary edema, five of whom died. All other patients survived. All patients with pulmonary edema during the study were hypovolemic or euvolemic at the time pulmonary edema developed. Plasma lactate was lower in hypovolemic patients before (rs=0.38; p=0.05) and after (rs=0.49; p=0.01) resuscitation but was the strongest predictor of mortality before (chi-square=9.9; p=0.002) and after resuscitation (chi-square=11.1; p<0.001) and correlated with the degree of visualized microvascular sequestration of parasitized erythrocytes at both time points (rs=0.55; p=0.003 and rs=0.43; p=0.03, respectively). Persisting sequestration was evident in 7 of 15 patients (47%) 48 hours after enrollment. CONCLUSIONS Lactic acidosis--the strongest prognostic indicator in adults with severe falciparum malaria--results from sequestration of parasitized erythrocytes in the microcirculation, not from hypovolemia. Liberal fluid resuscitation has little effect on this sequestration and does not improve acid-base status or renal function. Pulmonary edema--secondary to increased pulmonary vascular permeability--is common, unpredictable, and exacerbated by fluid loading. Liberal fluid replacement of adults with severe malaria should be avoided.
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Cunnington AJ, Bretscher MT, Nogaro SI, Riley EM, Walther M. Comparison of parasite sequestration in uncomplicated and severe childhood Plasmodium falciparum malaria. J Infect 2013; 67:220-30. [PMID: 23623771 PMCID: PMC3744804 DOI: 10.1016/j.jinf.2013.04.013] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2013] [Revised: 04/13/2013] [Accepted: 04/15/2013] [Indexed: 12/31/2022]
Abstract
Objectives To determine whether sequestration of parasitized red blood cells differs between children with uncomplicated and severe Plasmodium falciparum malaria. Methods We quantified circulating-, total- and sequestered-parasite biomass, using a mathematical model based on plasma concentration of P. falciparum histidine rich protein 2, in Gambian children with severe (n = 127) and uncomplicated (n = 169) malaria. Results Circulating- and total-, but not sequestered-, parasite biomass estimates were significantly greater in children with severe malaria than in those with uncomplicated malaria. Sequestered biomass estimates in children with hyperlactataemia or prostration were similar to those in uncomplicated malaria, whereas sequestered biomass was higher in patients with severe anaemia, and showed a trend to higher values in cerebral malaria and fatal cases. Blood lactate concentration correlated with circulating- and total-, but not sequestered parasite biomass. These findings were robust after controlling for age, prior antimalarial treatment and clonality of infection, and over a realistic range of variation in model parameters. Conclusion Extensive sequestration is not a uniform requirement for severe paediatric malaria. The pathophysiology of hyperlactataemia and prostration appears to be unrelated to sequestered parasite biomass. Different mechanisms may underlie different severe malaria syndromes, and different therapeutic strategies may be required to improve survival.
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Affiliation(s)
- Aubrey J Cunnington
- Department of Immunology and Infection, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
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