Malaria Coinfections in Febrile Pediatric Inpatients: A Hospital-Based Study From Ghana

Abstract

Background: The epidemiology of pediatric febrile illness is shifting in sub-Saharan Africa, but malaria remains a major cause of childhood morbidity and mortality. The present study describes causes of febrile illness in hospitalized children in Ghana and aims to determine the burden of malaria coinfections and their association with parasite densities.

Methods: In a prospective study, children (aged ≥30 days and ≤15 years) with fever ≥38.0°C were recruited after admission to the pediatric ward of a primary hospital in Ghana. Malaria parasitemia was determined and blood, stool, urine, respiratory, and cerebrospinal fluid specimens were screened for parasitic, bacterial, and viral pathogens. Associations of Plasmodium densities with other pathogens were calculated.

Results: From November 2013 to April 2015, 1238 children were enrolled from 4169 admissions. A clinical/microbiological diagnosis could be made in 1109/1238 (90%) patients, with Plasmodium parasitemia (n = 728/1238 [59%]) being predominant. This was followed by lower respiratory tract infections/pneumonia (n = 411/1238 [34%]; among detected pathogens most frequently Streptococcus pneumoniae, n = 192/299 [64%]), urinary tract infections (n = 218/1238 [18%]; Escherichia coli, n = 21/32 [66%]), gastrointestinal infections (n = 210 [17%]; rotavirus, n = 32/97 [33%]), and invasive bloodstream infections (n = 62 [5%]; Salmonella species, n = 47 [76%]). In Plasmodium-infected children the frequency of lower respiratory tract, gastrointestinal, and bloodstream infections increased with decreasing parasite densities.

Conclusions: In a hospital setting, the likelihood of comorbidity with a nonmalarial disease is inversely correlated with increasing blood levels of malaria parasites. Hence, parasite densities provide important information as an indicator for the probability of coinfection, in particular to guide antimicrobial medication.

Figure 1.

Study profile.

Figure 2.

Age distribution of malaria parasitemia and 6 most common diagnoses with and without pathogen detection in febrile inpatient children from Ghana. Malaria parasitemia and bloodstream infection diagnoses were defined by the presence of a pathogen. Abbreviations: CNS, central nervous system; LRTI, lower respiratory tract infection.

Figure 3.

Proportion of the most common diagnoses in febrile inpatient children from Ghana, without the presence of malaria parasites and in association with 3 different parasitemia groups over increasing parasite counts. Abbreviations: CNS, central nervous system; LRTI, lower respiratory tract infection.

Figure 4.

Cumulative proportions of parasitemic children along increasing parasite counts for fever-free control group, children with both parasitemia and an alternative diagnosis (coinfection), and those with parasitemia only (monoinfection). In children with Plasmodium coinfection, 17% (n = 60/356) and, in those with Plasmodium monoinfection, only 12% (n = 45/372) had a parasite count <10000/µL. At the parasite level of 100000/µL, 100% of the fever-free controls, 64% (n = 226/356) of the coinfected patients, and 54% (n = 192/372) of the monoinfected children had a parasitemia below that value.