title: A reduction in adult blood stream infection and case fatality at a large African hospital following antiretroviral therapy roll-out.
abstract: BACKGROUND
  Blood-stream infection (BSI) is one of the principle determinants of the morbidity and mortality associated with advanced HIV infection, especially in sub-Saharan Africa. Over the last 10 years, there has been rapid roll-out of anti-retroviral therapy (ART) and cotrimoxazole prophylactic therapy (CPT) in many high HIV prevalence African countries.
  
  
  METHODS
  A prospective cohort of adults with suspected BSI presenting to Queen's Hospital, Malawi was recruited between 2009 and 2010 to describe causes of and outcomes from BSI. Comparison was made with a cohort pre-dating ART roll-out to investigate whether and how ART and CPT have affected BSI. Malawian census and Ministry of Health ART data were used to estimate minimum incidence of BSI in Blantyre district.
  
  
  RESULTS
  2,007 patients were recruited, 90% were HIV infected. Since 1997/8, culture-confirmed BSI has fallen from 16% of suspected cases to 10% (p<0.001) and case fatality rate from confirmed BSI has fallen from 40% to 14% (p<0.001). Minimum incidence of BSI was estimated at 0.03/1000 years in HIV uninfected vs. 2.16/1000 years in HIV infected adults. Compared to HIV seronegative patients, the estimated incidence rate-ratio for BSI was 80 (95% CI:46-139) in HIV-infected/untreated adults, 568 (95% CI:302-1069) during the first 3 months of ART and 30 (95% CI:16-59) after 3 months of ART.
  
  
  CONCLUSIONS
  Following ART roll-out, the incidence of BSI has fallen and clinical outcomes have improved markedly. Nonetheless, BSI incidence remains high in the first 3 months of ART despite CPT. Further interventions to reduce BSI-associated mortality in the first 3 months of ART require urgent evaluation.
authors.affiliation: Malawi Liverpool Wellcome Trust Clinical Research Programme (MLW), University of Malawi College of Medicine, Blantyre, Malawi; Department of Medicine, University of Malawi College of Medicine, Blantyre, Malawi; Liverpool School of Tropical Medicine, Liverpool, United Kingdom.
authors.forename: Nicholas A
authors.initials: NA
authors.lastname: Feasey
authors.affiliation: Department of Medicine, University of Malawi College of Medicine, Blantyre, Malawi.
authors.forename: Angela
authors.initials: A
authors.lastname: Houston
authors.affiliation: Malawi Liverpool Wellcome Trust Clinical Research Programme (MLW), University of Malawi College of Medicine, Blantyre, Malawi.
authors.forename: Mavuto
authors.initials: M
authors.lastname: Mukaka
authors.affiliation: Department of Medicine, University of Malawi College of Medicine, Blantyre, Malawi.
authors.forename: Dan
authors.initials: D
authors.lastname: Komrower
authors.affiliation: Malawi Liverpool Wellcome Trust Clinical Research Programme (MLW), University of Malawi College of Medicine, Blantyre, Malawi; Department of Medicine, University of Malawi College of Medicine, Blantyre, Malawi.
authors.forename: Thandie
authors.initials: T
authors.lastname: Mwalukomo
authors.affiliation: Department of HIV and AIDS, Ministry of Health, Lilongwe, Malawi; I-TECH Lilongwe, Malawi.
authors.forename: Lyson
authors.initials: L
authors.lastname: Tenthani
authors.affiliation: Department of HIV and AIDS, Ministry of Health, Lilongwe, Malawi; I-TECH, Department for Global Health, University of Washington, Seattle, Washington, United States of America.
authors.forename: Andreas
authors.initials: A
authors.lastname: Jahn
authors.affiliation: Malawi Liverpool Wellcome Trust Clinical Research Programme (MLW), University of Malawi College of Medicine, Blantyre, Malawi; Liverpool School of Tropical Medicine, Liverpool, United Kingdom.
authors.forename: Mike
authors.initials: M
authors.lastname: Moore
authors.affiliation: Anova Health Institute, Johannesburg and Tzaneen, South Africa.
authors.forename: Remco P H
authors.initials: RP
authors.lastname: Peters
authors.affiliation: Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom.
authors.forename: Melita A
authors.initials: MA
authors.lastname: Gordon
authors.affiliation: Malawi Liverpool Wellcome Trust Clinical Research Programme (MLW), University of Malawi College of Medicine, Blantyre, Malawi; Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom.
authors.forename: Dean B
authors.initials: DB
authors.lastname: Everett
authors.affiliation: Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom.
authors.forename: Neil
authors.initials: N
authors.lastname: French
authors.affiliation: Malawi Liverpool Wellcome Trust Clinical Research Programme (MLW), University of Malawi College of Medicine, Blantyre, Malawi; Dignitas International, Zomba, Blantyre, Malawi.
authors.forename: Joep J
authors.initials: JJ
authors.lastname: van Oosterhout
authors.affiliation: Department of Medicine, University of Malawi College of Medicine, Blantyre, Malawi.
authors.forename: Theresa J
authors.initials: TJ
authors.lastname: Allain
authors.affiliation: Malawi Liverpool Wellcome Trust Clinical Research Programme (MLW), University of Malawi College of Medicine, Blantyre, Malawi; Department of Medicine, University of Malawi College of Medicine, Blantyre, Malawi; Liverpool School of Tropical Medicine, Liverpool, United Kingdom.
authors.forename: Robert S
authors.initials: RS
authors.lastname: Heyderman
mesh_terms: D000328:Adult; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D016470:Bacteremia / Q000401:mortality* / Q000517:prevention & control; D060085:Coinfection / Q000401:mortality* / Q000517:prevention & control; D005260:Female; D015658:HIV Infections / Q000188:drug therapy / Q000401:mortality*; D006773:Hospitals, Municipal; D006801:Humans; D015994:Incidence; D008295:Malawi / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012307:Risk Factors; D012480:Salmonella Infections / Q000401:mortality* / Q000517:prevention & control; D017678:Sex Distribution; D013290:Streptococcal Infections / Q000401:mortality* / Q000517:prevention & control; D015662:Trimethoprim, Sulfamethoxazole Drug Combination / Q000627:therapeutic use; D055815:Young Adult
chemical_list: D019380:Anti-HIV Agents; D015662:Trimethoprim, Sulfamethoxazole Drug Combination