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Table 3 Quality assessment of studies describing children with severe malaria (SM) and concomitant invasive bacterial infection (IBI) with calculated case fractions and case fatality rates

From: Invasive bacterial co-infection in African children with Plasmodium falciparum malaria: a systematic review

Study

Study inclusion criteria for severe malaria compared to WHO definitiona

N with IBI data

% without IBI data

Overall mortality rate

n IBI

Case fraction (%) with IBI

Case fatality malaria with concomitant IBI (%)

Case fatality malaria without IBI (%)

Overall rating of study quality

Ranking

severe malaria (%)

co-infection

(95% CI)

Berkley [16]

IC or RD + parasitemia (one slide) Excludes SMA without IC or RD

643

18%

89/783 (11.4%)

42

6.53 (4.56-8.51)

14/42 (33%)

52/498 (10%)

High

YYY

Berkley [24]

IC or RD or SMA + parasitemia (any of three slides)

2,048

0.5%

76/861 (8.8%)

127

6.2 (5.12-7.73)

36/127 (28%)

137/1921 (7.1%)

High

YYY

Bronzan [38]

WHO plus asexual parasitemia (slide repeated six hrly). Clinical signs do not include RD

1,388

5.3%

235/1,388 (16.9%)

64

4.61 (3.48-5.74)

14/64 (22%)

211/1324 (16%)

High

YYY

Evans [24]

WHO definition plus asexual parasitemia (one slide)

182

0%

16/182 (8.8%)

23

12.64 (7.47-17.8)

2/23 (8.7%)

14/159 (8.8%)

High

YYY

Subtotal

 

4,261

 

416/3,224 (12.9)

256

6.01 (5.27-6.74)

    

Bassat [23]

WHO signs (incl glucose <2.2 mmol/L) + asexual parasitemia (one thick film)

1,404

12%

81/1,648 (4.9%)

76

5.41 (4.2-6.63)

13/59 (22%)

50/1244 (4.0%)

Moderate

YYN

Dondorp [2]

WHO definition plus RDT positive; requiring parenteral treatment

657

NR (88%) (BC data not available in all patients)

527/5,425 (9.7%)

65

9.89 (7.49-12.3)

NR

NR

Moderate

YNY

Enwere [39]

Cerebral malaria (BCS < =2) plus asexual parasitemia)

276

52% (BCx data not consecutive)

122/576 (21.1%)

14

5.07 (2.42-7.73)

1/14 (7.1%)

121/562 (22%)

Moderate

YNY

Subtotal

 

2,337

  

155

6.63 (5.59-7.68)

    

Angyo [39]

Clinical signs also include hypoglycemia; shock; DIC; acidosis; hemoglobinuria. Did not include confirmed parasitemia.

501

NR

16/501 (3.2%)

35

6.99 (4.67-9.30)

NR

NR

Low

YNN

Kremsner [42]

Clinical signs also include hyperparasitemia, glucose <2.2. Excludes children with Sickle Cell disease.

59

41% (BCx data not consecutive)

2/100 (2%)

7

11.86 (3.08-35.1)

1/7 (14%)

0/52 (0%)

Low

YNN

Prada [43]

Cerebral malaria only (not defined)

50

 

NR

8

16.0 (4.91-27.09)

NR

NR

Low

NYN

Subtotal

 

610

  

50

8.2 (5.92-24.26)

    

Overall total

 

7,208

  

461

6.40 (5.81-6.98)

81/336

585/5760

  

(24.1%)

(10.2%)

  1. aWHO Definition = clinical symptoms suggestive of SM according to WHO guidelines which includes children with the following symptoms or signs: 1) a Blantyre coma score (BCS) of two or less; 2) severe anemia with a hemoglobin level <5 g/dl or a hematocrit <15%; 3) severe respiratory distress, being marked in-drawing of the lower chest wall or deep (acidotic) breathing; and 4) prostration, being the inability to sit upright in a child able to do so, or to drink in the case of children too young to sit. Ranking is based on: 1) criteria for SM clearly defined; 2) bacterial species defined and contaminants excluded; and 3) mortality rate >7.4% (lowest CI in AQUAMAT) for SM cases. High = YYY, Moderate = YYN/YNY/NYY; Low = NNY/NYN/YNN for each of the criteria. BC, blood culture; NR, not reported; RDT, rapid (malaria) diagnostic test; Malaria definitions; IC, impaired consciousness; RD, respiratory distress; SMA, severe malaria anemia.