title: Clinical indicators for bacterial co-infection in Ghanaian children with P. falciparum infection.
abstract: Differentiation of infectious causes in severely ill children is essential but challenging in sub- Saharan Africa. The aim of the study was to determine clinical indicators that are able to identify bacterial co-infections in P. falciparum infected children in rural Ghana. In total, 1,915 severely ill children below the age of 15 years were recruited at Agogo Presbyterian Hospital in Ghana between May 2007 and February 2011. In 771 (40%) of the children malaria parasites were detected. This group was analyzed for indicators of bacterial co-infections using bivariate and multivariate regression analyses with 24 socio-economic variables, 16 terms describing medical history and anthropometrical information and 68 variables describing clinical symptoms. The variables were tested for sensitivity, specificity, positive predictive value and negative predictive value. In 46 (6.0%) of the children with malaria infection, bacterial co-infection was detected. The most frequent pathogens were non-typhoid salmonellae (45.7%), followed by Streptococcus spp. (13.0%). Coughing, dehydration, splenomegaly, severe anemia and leukocytosis were positively associated with bacteremia. Domestic hygiene and exclusive breastfeeding is negatively associated with bacteremia. In cases of high parasitemia (>10,000/μl), a significant association with bacteremia was found for splenomegaly (OR 8.8; CI 1.6-48.9), dehydration (OR 18.2; CI 2.0-166.0) and coughing (OR 9.0; CI 0.7-118.6). In children with low parasitemia, associations with bacteremia were found for vomiting (OR 4.7; CI 1.4-15.8), severe anemia (OR 3.3; CI 1.0-11.1) and leukocytosis (OR 6.8 CI 1.9-24.2). Clinical signs of impaired microcirculation were negatively associated with bacteremia. Ceftriaxone achieved best coverage of isolated pathogens. The results demonstrate the limitation of clinical symptoms to determine bacterial co-infections in P. falciparum infected children. Best clinical indicators are dependent on the parasitemia level. Even with a moderate sensitivity of >60%, only low positive predictive values can be obtained due to low prevalence of bacteremia. Rapid testing for distinguishing parasitemia and bacteremia is essential.
authors: Bernhard Nocht Institute for Tropical Medicine, Infectious Disease Epidemiology, Hamburg, Germany.
authors: Maja Verena
authors: MV
authors: Nielsen
authors: Kumasi Centre for Collaborative Research in Tropical Medicine, Kumasi, Ghana.
authors: Solomon
authors: S
authors: Amemasor
authors: Kumasi Centre for Collaborative Research in Tropical Medicine, Kumasi, Ghana.
authors: Alex
authors: A
authors: Agyekum
authors: Bernhard Nocht Institute for Tropical Medicine, Infectious Disease Epidemiology, Hamburg, Germany; Kumasi Centre for Collaborative Research in Tropical Medicine, Kumasi, Ghana.
authors: Wibke
authors: W
authors: Loag
authors: International Vaccine Institute, Seoul, South Korea.
authors: Florian
authors: F
authors: Marks
authors: Kumasi Centre for Collaborative Research in Tropical Medicine, Kumasi, Ghana; German Center for Infection Research (DZIF), partner site Hamburg-Borstel-Lübeck, Hamburg, Germany.
authors: Nimako
authors: N
authors: Sarpong
authors: Bernhard Nocht Institute for Tropical Medicine, Infectious Disease Epidemiology, Hamburg, Germany.
authors: Denise
authors: D
authors: Dekker
authors: Kwame Nkrumah University of Science and Technology, School of Medical Sciences, Kumasi, Ghana.
authors: Yaw
authors: Y
authors: Adu-Sarkodie
authors: Bernhard Nocht Institute for Tropical Medicine, Infectious Disease Epidemiology, Hamburg, Germany; German Center for Infection Research (DZIF), partner site Hamburg-Borstel-Lübeck, Hamburg, Germany.
authors: Jürgen
authors: J
authors: May
mesh_terms: D000293:Adolescent; D000886:Anthropometry; D016470:Bacteremia / Q000453:epidemiology* / Q000473:pathology; D002648:Child; D002675:Child, Preschool; D060085:Coinfection / Q000453:epidemiology* / Q000382:microbiology; D003371:Cough / Q000473:pathology; D003681:Dehydration / Q000473:pathology; D005869:Ghana; D006801:Humans; D016778:Malaria, Falciparum / Q000453:epidemiology* / Q000382:microbiology*; D016017:Odds Ratio; D011237:Predictive Value of Tests; D015995:Prevalence; D012044:Regression Analysis; D012424:Rural Population; D012480:Salmonella Infections / Q000453:epidemiology* / Q000473:pathology; D012680:Sensitivity and Specificity; D012959:Socioeconomic Factors; D013163:Splenomegaly / Q000473:pathology; D013290:Streptococcal Infections / Q000453:epidemiology* / Q000473:pathology