Etiologies of Illness Among Patients Meeting Integrated Management of Adolescent and Adult Illness District Clinician Manual Criteria for Severe Infections in Northern Tanzania: Implications for Empiric Antimicrobial Therapy

Abstract

Abstract. We describe the laboratory-confirmed etiologies of illness among participants in a hospital-based febrile illness cohort study in northern Tanzania who retrospectively met Integrated Management of Adolescent and Adult Illness District Clinician Manual (IMAI) criteria for septic shock, severe respiratory distress without shock, and severe pneumonia, and compare these etiologies against commonly used antimicrobials, including IMAI recommendations for emergency antibacterials (ceftriaxone or ampicillin plus gentamicin) and IMAI first-line recommendations for severe pneumonia (ceftriaxone and a macrolide). Among 423 participants hospitalized with febrile illness, there were 25 septic shock, 37 severe respiratory distress without shock, and 109 severe pneumonia cases. Ceftriaxone had the highest potential utility of all antimicrobials assessed, with responsive etiologies in 12 (48%) septic shock, 5 (14%) severe respiratory distress without shock, and 19 (17%) severe pneumonia illnesses. For each syndrome 17-27% of participants had etiologic diagnoses that would be non-responsive to ceftriaxone, but responsive to other available antimicrobial regimens including amphotericin for cryptococcosis and histoplasmosis; anti-tuberculosis therapy for bacteremic disseminated tuberculosis; or tetracycline therapy for rickettsioses and Q fever. We conclude that although empiric ceftriaxone is appropriate in our setting, etiologies not explicitly addressed in IMAI guidance for these syndromes, such as cryptococcosis, histoplasmosis, and tetracyclineresponsive bacterial infections, were common.

Reducing Uncertainty for Acute Febrile Illness in Resource-Limited Settings: The Current Diagnostic Landscape

“…World Health Organization (WHO) syndrome-based guidelines often advise antimicrobials that prove ineffective for patients with acute febrile illness, even when effective ones are widely available in resource-limited settings if the correct diagnosis can be determined. 14 Reliance on such guidelines also results in over-prescription of antimicrobials to patients who do not need them. 15 Despite concerns of worsening antimicrobial resistance, more patients perish worldwide from lack of access to antimicrobials than die of antimicrobial resistance.…”

Acute care for the three leading causes of mortality in lower-middle-income countries: A systematic review

“…Other diseases (cryptococcosis, histoplasmosis, Q fever, Rickettsial diseases) were common and need their specific treatment. [ 73 ] A cohort of patients with CAP in France were significantly older with more comorbidities than in Conakry, while those in Conakry were more likely to have initial shock and herpes. Mortality (6% vs. 8%) and clinical recovery (88% vs. 85%) were similar in both settings despite penicillin along being used in the majority of cases in Conakry and multiple or second-line antibiotics being often used in France.…”

Zoonotic causes of febrile illness in malaria endemic countries: a systematic review

“…These would benefit from treatment with tetracyclines, which are not currently included in the Integrated Management of Adolescent and Adult Illness (IMAI) algorithms for septic shock and severe respiratory distress without shock. 45 In light of the extensive contribution of tetracycline-responsive infections to fever in malaria-endemic countries, revisions to clinical guidelines may be warranted to suggest the empirical use of tetracyclines in addition to betalactams in scenarios where the infection with tetracycline-responsive pathogens cannot be excluded. The findings of this review show that one or more zoonotic causes of fever are likely to present a threat to health in all of the countries included in this review.…”