Elsevier

The Lancet

Volume 355, Issue 9211, 8 April 2000, Pages 1225-1230
The Lancet

Articles
Aetiology, outcome, and risk factors for mortality among adults with acute pneumonia in Kenya

https://doi.org/10.1016/S0140-6736(00)02089-4Get rights and content

Summary

Background

Despite a substantial disease burden, there is little descriptive epidemiology of acute pneumonia in sub-Saharan Africa. We did this study to define the aetiology of acute pneumonia, to estimate mortality at convalescence, and to analyse mortality risk-factors.

Methods

We studied 281 Kenyan adults who presented to two public hospitals (one urban and one rural) with acute radiologically confirmed pneumonia during 1994–96. We did blood and lung-aspirate cultures, mycobacterial cultures, serotype-specific pneumococcal antigen detection, and serology for viral and atypical agents.

Findings

Aetiology was defined in 182 (65%) patients. Streptococcus pneumoniae was the most common causative agent, being found in 129 (46%) cases; Mycobacterium tuberculosis was found in 26 (9%). Of 255 patients followed up for at least 3 weeks, 25 (10%) died at a median age of 33 years. In multivariate analyses, risk or protective factors for mortality were age (odds ratio 1·51 per decade [95% Cl 1·04–2·19]), unemployment (4·42 [1·21–16·1]), visiting a traditional healer (5·26 [1·67–16·5]), visiting a pharmacy (0·30 [0·10–0·91]), heart rate (1·64 per 10 beats [1·24–2·16]), and herpes labialis (15·4 [2·22–107]). HIV-1 seropositivity, found in 52%, was not associated with mortality. Death or failure to recover after 3 weeks was more common in patients with pneumococci of intermediate resistance to benzylpenicillin, which comprised 28% of pneumococcal isolates, than in those infected with susceptible pneumococci (5·60 [1·33–23·6]).

Interpretation

We suggest that tuberculosis is a sufficiently common cause of acute pneumonia in Kenyan adults to justify routine sputum culture, and that treatment with benzylpenicillin remains appropriate for clinical failure due to M tuberculosis, intermediate-resistant pneumococci, and other bacterial pathogens. However, interventions restricted to hospital management will fail to decrease mortality associated with socioeconomic, educational, and behavioural factors.

Introduction

There are no community-based incidence data on acute adult pneumonia in sub-Saharan Africa, but this disease ranks consistently highly as a cause of admission in hospital-based series.1, 2 Management guidelines were established 15–20 years ago, since when demography, urbanisation, HIV seroprevalence, and access to pharmaceutical products have changed substantially.3, 4 The aim of this prospective study was to provide an accurate description of the aetiology and outcome of acute pneumonia in a rural and an urban population, and to analyse the risk factors for mortality.

Section snippets

Study population

The study population comprised consecutive adults (≥15 years old) with acute pneumonia who had lived for longer than 3 months in the Coast Province of Kenya. The cases presented between March, 1994, and May, 1996, to Coast Province General Hospital (which serves an urban population in Mombasa), or Kilifi District Hospital (which serves a rural population 60 km away). A case was defined by an illness of 14 days' duration or less that consisted of at least two respiratory symptoms (cough, sputum,

Patients' characteristics

We examined 281 clinical episodes of acute pneumonia. Seven patients were admitted to the study twice and one patient three times; these episodes were analysed independently. 63% of patients were male, 40% were aged 25–34 years, and 52% were HIV-1 seropositive (table 1). Mean body-mass index was 18·6 kg/m2 and mean haemoglobin concentration was 12·4 g/dL in men and 9·0 g/dL in women.

Of the 233 patients who presented to the urban hospital, a significantly greater number were male, HIV positive,

Discussion

In studies of pneumonia, the proportion of patients in whom a cause is identified varies from 16·5% to 98%.9, 10, 11, 12 This variation is attributable more to diagnostic specificity than to the populations studied.10, 12 If each of the 14 assays undertaken here had a specificity of 0·95, more than half the patients would have had at least one false positive diagnosis and 15% would have had at least two. To keep this problem to a minimum, we selected assays of high specificity—ie, blood and

References (30)

  • RA Drobniewski et al.

    Mycobacterial speciation

  • JAG Scott et al.

    Diagnosis of pneumococcal pneumonia in epidemiological studies: evaluation of Kenyan adults of a serotype-specific urine latex agglutination assay

    Clin Infect Dis

    (1999)
  • Community-acquired pneumonia in adults in British hospitals in 1982–1983: a survey of aetiology, mortality, prognostic factors and outcome

    Q J M

    (1987)
  • GD Fang et al.

    New and emerging etiologies for community-acquired pneumonia with implications for therapy: a prospective multicenter study of 359 cases

    Medicine (Baltimore)

    (1990)
  • BJ Marston et al.

    Incidence of community-acquired pneumonia requiring hospitalization: results of a populationbased active surveillance Study in Ohio. The Community-Based Pneumonia Incidence Study Group

    Arch Intern Med

    (1997)
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