Coinfections and antimicrobial treatment in a cohort of falciparum malaria in a non-endemic country: a 10-year experience

Abstract

Introduction Falciparum malaria remains one of the deadliest infectious diseases worldwide. In Germany, it is mainly an imported infection among travellers. Rates of coinfection are often unknown, and a clinical rationale for the beneficial use of calculated antibiotic therapy in patients with malaria and suspected coinfection is lacking. Methods We conducted an analysis of all in-patients treated with falciparum malaria at a German infectious diseases centre in vicinity to one of Europe’s major airports for 2010–2019. Logistic regression and time-to-event analysis were used to evaluate predictors for bacterial coinfection, the use of antibacterial substances, as well as their influence on clinical course. Results In total, 264 patients were included. Of those, 64% received an additional antibacterial therapy (n = 169). Twenty-nine patients (11.0%) were found to have suffered from a relevant bacterial coinfection, while only a small fraction had relevant bacteremia (n = 3, 1.4%). However, patients with severe malaria did not suffer from coinfections more frequently (p = 0.283). CRP levels were not a reliable predictor for a bacterial coinfection (OR 0.99, 95% CI 0.94–1.06, p = 0.850), while another clinical focus of infection was positively associated (OR 3.86, 95% CI 1.45–11.55, p = 0.010). Conclusion Although bacterial coinfections were rare in patients with malaria at our centre, the risk does not seem negligible. These data point rather towards individual risk assessment in respective patients than to general empiric antibiotic use.

Identification and management of co-infections in people with malaria

“…Large observational studies suggest the prevalence of bacteraemic co-infection is lower in those who do not reside in high malaria transmission settings. Bacteraemia was present in 1% (95% CI 0.4% to 1.8%) of Vietnamese adults with severe malaria,141.4% (3/219) of adult patients with imported malaria at a German university hospital,8 and 0.3% (2/417) of imported malaria cases in Sweden 15. Overall rates of bacterial co-infection (including non-bacteraemic infections) were 4.3% (12/291) in Sweden15 and 11% (29/264) in adults in Germany 8.…”

“…Bacteraemia was present in 1% (95% CI 0.4% to 1.8%) of Vietnamese adults with severe malaria,141.4% (3/219) of adult patients with imported malaria at a German university hospital,8 and 0.3% (2/417) of imported malaria cases in Sweden 15. Overall rates of bacterial co-infection (including non-bacteraemic infections) were 4.3% (12/291) in Sweden15 and 11% (29/264) in adults in Germany 8. Higher rates of bacterial co-infection have been reported in patients with imported severe malaria: 20% (10/49) in German adults8 and 14% (13/91) in a French intensive care unit 16…”

“…A postmortem study of Malawian children who met diagnostic criteria for cerebral malaria at time of death found an alternative infectious cause of death in at least 19% (6/31) 6. Among imported malaria patients at specialist university hospitals in Italy and Germany, co-infection rates were 13% (9/70) and 16% (41/264), respectively 78…”

“…Overall rates of bacterial co-infection (including non-bacteraemic infections) were 4.3% (12/291) in Sweden15 and 11% (29/264) in adults in Germany 8. Higher rates of bacterial co-infection have been reported in patients with imported severe malaria: 20% (10/49) in German adults8 and 14% (13/91) in a French intensive care unit 16…”

“…In Malawian children with a clinical diagnosis of cerebral malaria, 35% (27/78) also had a central nervous system viral infection 17. Conversely, only 5% (14/264) of adults with imported malaria at a German university hospital were found to have a viral co-infection 8…”