Pneumococcal disease in HIV-infected Malawian adults: acute mortality and long-term survival.
OBJECTIVE
HIV-infected patients in Africa are vulnerable to severe recurrent infection with Streptococcus pneumoniae, but no effective preventive strategy has been developed. We set out to determine which factors influence in-hospital mortality and long-term survival of Malawians with invasive pneumococcal disease.


METHODS
Acute clinical features, inpatient mortality and long-term survival were described among consecutively admitted hospital patients with S. pneumoniae in the blood or cerebrospinal fluid. Factors associated with inpatient mortality were determined, and patients surviving to discharge were followed to determine their long-term outcome.


RESULTS
A total of 217 patients with pneumococcal disease were studied over an 18-month period. Among these, 158 out of 167 consenting to testing (95%) were HIV positive. Inpatient mortality was 65% for pneumococcal meningitis (n = 64), 20% for pneumococcaemic pneumonia (n = 92), 26% for patients with pneumococcaemia without localizing signs (n = 43), and 76% in patients with probable meningitis (n = 17). Lowered consciousness level, hypotension, and age exceeding 55 years at presentation were associated with inpatient death, but not long-term outcome in survivors. Hospital survivors were followed for a median of 414 days; 39% died in the community during the study period. Outpatient death was associated with multilobar chest signs, oral candidiasis, and severe anaemia as an inpatient.


CONCLUSIONS
Most patients with pneumococcal disease in Malawi have HIV co-infection. They have severe disease with a high mortality rate. At discharge, all HIV-infected adults have a poor prognosis but patients with multilobar chest signs or anaemia are at particular risk.
Malawi-Liverpool Wellcome Trust Clinical Research Programme, University of Malawi. sgordon@mlw.medcol.mw
Stephen B
SB
Gordon
Mas
M
Chaponda
Amanda L
AL
Walsh
Christopher J M
CJ
Whitty
Melita A
MA
Gordon
C Edward
CE
Machili
Charles F
CF
Gilks
Martin J
MJ
Boeree
Sam
S
Kampondeni
Robert C
RC
Read
Malcolm E
ME
Molyneux
D000367:Age Factors; D000740:Anemia / Q000150:complications; D002180:Candidiasis, Oral / Q000150:complications; D015331:Cohort Studies; D005260:Female; D015658:HIV Infections / Q000150:complications* / Q000453:epidemiology / Q000401:mortality; D006760:Hospitalization; D006801:Humans; D008295:Malawi / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D011008:Pneumococcal Infections / Q000150:complications* / Q000382:microbiology / Q000401:mortality; D011379:Prognosis; D012307:Risk Factors; D013296:Streptococcus pneumoniae / Q000302:isolation & purification; D016019:Survival Analysis