Diarrhea is a Major killer of Children with Severe Acute Malnutrition Admitted to Inpatient Set-up in Lusaka, Zambia

<p>Abstract</p> <p>Introduction</p> <p>Mortality of children with Severe Acute Malnutrition (SAM) in inpatient set-ups in sub-Saharan Africa still remains unacceptably high. We investigated the prevalence and effect of diarrhea and HIV infection on inpatient treatment outcome of children with complicated SAM receiving treatment in inpatient units.</p> <p>Method</p> <p>A cohort of 430 children aged 6-59 months old with complicated SAM admitted to Zambia University Teaching Hospital's stabilization centre from August to December 2009 were followed. Data on nutritional status, socio-demographic factors, and admission medical conditions were collected up on enrollment. T-test and chi-square tests were used to compare difference in mean or percentage values. Logistic regression was used to assess risk of mortality by admission characteristics.</p> <p>Results</p> <p>Majority, 55.3% (238/430) were boys. The median age of the cohort was 17 months (inter-quartile range, IQR 12-22). Among the children, 68.9% (295/428) had edema at admission. The majority of the children, 67.3% (261/388), presented with diarrhea; 38.9% (162/420) tested HIV positive; and 40.5% (174/430) of the children died. The median Length of stay of the cohort was 9 days (IQR, 5-14 days); 30.6% (53/173) of the death occurred within 48 hours of admission. Children with diarrhea on admission had two and half times higher odds of mortality than those without diarrhea; Adjusted OR = 2.5 (95% CI 1.50-4.09, P < 0.001). The odds of mortality for children with HIV infection was higher than children without HIV infection; Adjusted OR = 1.6 (95% CI 0.99-2.48 P = 0.5).</p> <p>Conclusion</p> <p>Diarrhea is a major cause of complication in children with severe acute malnutrition. Under the current standard management approach, diarrhea in children with SAM was found to increase their odds of death substantially irrespective of other factors.</p

Effect of Bacteraemia and HIV infection on treatment outcome in children with severe acute malnutrition admitted to the University Teaching Hospital Malnutrition Ward, Lusaka, Zambia

Background:Severe malnutrition remains a major cause of mortality in children less than 5 years at the University Teaching Hospital, with rates ranging between 30-40 % among patients admitted in the malnutrition ward. The effects of bacteraemia and HIV infection on outcome to treatment remain unknown. Objective:To establish the magnitude of bacteraemia and HIV infection in children with severe acute malnutrition (SAM) admitted to the Zambian University Teaching Hospital (UTH) malnutrition ward, describe the types of bacteria and antimicrobial sensitivity, and effect on treatment outcome. Method: Children admitted to the malnutrition ward at the UTH from August to December of 2009 were included in the study after acquiring informed consent. Data on nutritional status, social demographic factors and admission medical conditions were collected. In addition blood sample was collected from every child. Identification of positive culture yielding pathogenic bacterial strains were done using BACTEC machine, and completed with morphologic and biochemical tests. Antibiotic susceptibility tests were performed using Kirby-Bauer susceptibility testing method. Results: Data were collected from 441 children aged six to 59 months old, 55.3% (244/441) of whom were boys. Median age of the cohort was 17 months (inter quartile range, IQR 12-22). 68.9% (295/428) had edema at admission; 57.4% (247/430) had weight for height Z score < -3SD at admission. The majority, 67.3% (261/388) of the children presented with diarrhea. 38.9 % (162/420) tested HIV-positive; 21.4% (91/425) of the children had one or more bacteria isolated from their blood samples; 40.5% (174/430) of the children died. The predominant organisms isolated were Coagulase negative Staphylococcus (20.7%), E. coli (15.5%), Staphylococcus aureus (15.5%), Salmonella (12.1%,), Pseudomonas (8.6%), Diphteriods (6.9%) and Klebsiella pneumonia (6.9%). Crystalline Penicillin had 85.7% (12/14) resistance; ranging from 66.7% to S.Aureus to 100% to E.coli and klebsiella. Gentamycine had 23.6% (5/19) resistance; ranging from 0% to E.coli to 100% to Klebsiella; Ciprofloxacin had 27.9% (13/43); ranging from 0% to Salmonella, Klebsiella and Psuedomonas to 55.6% to E.Coli. HIV positive children had increased odds of mortality, adjusted 0R= 1.70 (95% CI 1.04-2.83, P=0.04). Children with bacteremia had increased odds of mortality compared to those with no bacteremia, adjusted OR=1.90 (95% CI 1.04-3.40, P=0.04). There was no interaction between bacteremia and HIV infection on outcome (P=0.77). Conclusion: SAM children admitted in UTH suffer from high prevalence of bacteremia on admission. This has increased their odds of death by almost two folds regardless of their admission nutritional status, diarrhea, age, sex, and HIV status. The baseline mortality and HIV prevalence in the malnutrition ward was higher than other similar studies. The drug resistance, to first line antibiotics mainly to penicillin, calls for an in-depth review of drug management

Development of tuberculosis treatment decision algorithms in children below 5 years hospitalised with severe acute malnutrition in Zambia and Uganda: a prospective diagnostic cohort studyResearch in context

Summary: Background: In children with severe acute malnutrition (SAM) tuberculosis is common, challenging to diagnose, and often fatal. We developed tuberculosis treatment decision algorithms (TDAs) for children under the age of 5 years with SAM. Methods: In this prospective diagnostic study, we enrolled and followed up children aged <60 months hospitalised with SAM at three tertiary hospitals in Zambia and Uganda from 4 November 2019 to 20 June 2022. We included children aged 2–59 months with SAM as defined by WHO and hospitalised following the WHO clinical criteria. We excluded children with current or history of antituberculosis treatment within the preceding 3 months. They underwent tuberculosis symptom screening, clinical assessment, chest X-ray, abdominal ultrasound, Xpert MTB/RIF Ultra (Ultra) and culture on respiratory and stool samples with 6 months follow-up. Tuberculosis was retrospectively defined using the 2015 standard case definition for childhood tuberculosis. We used logistic regression to develop diagnostic prediction models for a one-step diagnosis and a two-step screening and diagnostic approaches. We derived scores from models using WHO-recommended thresholds for sensitivity and proposed TDAs. This study is registered with ClinicalTrials.gov, NCT04240990. Findings: Of 1906 children hospitalised with SAM during the study period, 1230 were screened, 1152 were eligible and 603 were enrolled. Of the 603 children enrolled–median age 15 (inter-quartile range (IQR): 11–20) months and 65 (11.0%) living with HIV–114 (18.9%) were diagnosed with tuberculosis, including 51 (8.5%) with microbiological confirmation and 104 (17.2%) initiated treatment at a median of 6(IQR: 2–10) days after inclusion. 108 children were retrospectively classified as having tuberculosis resulting in a prevalence of 17.9% (95% confidence intervals (CI): 15.1; 21.2). 75 (69.4%) children with tuberculosis reported cough of any duration, 32 (29.6%) cough ≥2 weeks and 11 (10.2%) tuberculosis contact history. 535 children had complete data and were included in the diagnostic prediction model. The one-step diagnostic model had 15 predictors, including Ultra, clinical, radiographic, and abdominal features, an area under the receiving operating curve (AUROC) of 0.910, and derived TDA sensitivity of 86.14% (95% CI: 78.07–91.56) and specificity of 80.88% (95% CI: 76.91–84.30). The two-step model had AUROCs of 0.750 and 0.912 for screening and diagnosis, respectively, and derived combined TDA sensitivity of 79.21% (95% CI: 70.30–85.98) and a specificity of 83.64% (95% CI: 79.87–86.82). Interpretation: Tuberculosis prevalence was high among hospitalised children with SAM, with atypical clinical features. TDAs achieved satisfactory diagnostic accuracy and could be used to improve diagnosis in this vulnerable group. Funding: Unitaid