title: Increased risk of death in human immunodeficiency virus-infected children with pneumococcal meningitis in South Africa, 2003-2005.
abstract: BACKGROUND
  Pneumococcal disease is a major global cause of morbidity and mortality. This study evaluated risk factors for mortality in children with pneumococcal meningitis and other invasive pneumococcal diseases (IPD).
  
  
  METHODS
  The study population included patients <15 years of age with laboratory-confirmed IPD and available outcome data between January 1, 2003 and December 31, 2005 as reported to a national laboratory-based surveillance program. Meningitis was defined by having pneumococcus identified from cerebrospinal fluid culture, while other IPD included patients with pneumococci identified from other normally sterile site specimens. Risk factors for mortality were evaluated using multivariable logistic regression.
  
  
  RESULTS
  A total of 2251 patients with IPD were reported from sentinel sites: 581 with laboratory-confirmed meningitis and 1670 with other IPD. The case-fatality ratio was 35% (205/581) among meningitis cases and 18% (300/1670) among other IPD cases (P < 0.001). Among individuals with available human immunodeficiency virus (HIV) status data, HIV coinfection was less likely among patients with meningitis compared with other IPD (74% [244/328] vs. 82% [880/1067] P < 0.001). On multivariable analysis, HIV-infected status (odds ratio [OR]: 5.34, 95% confidence interval [CI]: 2.32-12.29), Pitt bacteremia score ≥4 (OR: 3.08, 95% CI: 1.21-7.83) and age group <1 year (OR: 2.58, 95% CI: 1.21-5.51) were independent predictors of death among patients with meningitis. Among children with other IPD, malnutrition was an independent predictor of death while HIV infection was not independently associated with increased risk of death.
  
  
  CONCLUSIONS
  Pneumococcal meningitis is associated with a high case-fatality ratio among South African children and this is increased by HIV coinfection. Increasing access to antiretroviral therapy and a catch-up program for pneumococcal conjugate vaccine among HIV-infected and malnourished children could reduce this excess mortality.
authors.affiliation: School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa. peter.nyasulu@wits.ac.za
authors.forename: Peter
authors.initials: P
authors.lastname: Nyasulu
authors.forename: Cheryl
authors.initials: C
authors.lastname: Cohen
authors.forename: Linda
authors.initials: L
authors.lastname: De Gouveia
authors.forename: Charles
authors.initials: C
authors.lastname: Feldman
authors.forename: Keith P
authors.initials: KP
authors.lastname: Klugman
authors.forename: Anne
authors.initials: A
authors.lastname: von Gottberg
mesh_terms: D000293:Adolescent; D000704:Analysis of Variance; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D002648:Child; D002675:Child, Preschool; D005260:Female; D015658:HIV Infections / Q000188:drug therapy / Q000382:microbiology* / Q000401:mortality*; D006801:Humans; D007223:Infant; D008297:Male; D008586:Meningitis, Pneumococcal / Q000188:drug therapy / Q000401:mortality* / Q000821:virology*; D012307:Risk Factors; D013019:South Africa / Q000453:epidemiology
chemical_list: D000900:Anti-Bacterial Agents