Aetiology, susceptibility and outcomes of fever in patients receiving chemotherapy in Malawi: a prospective study

Objectives: To evaluate causes of fever, including resistance patterns, in patients undergoing cancer treatment in Malawi.

Methods: In this prospective cohort study, enrolled patients undergoing chemotherapy at Kamuzu Central Hospital in Lilongwe, Malawi were given a thermometer. If a temperature of ≥38°C was recorded, they were instructed to return for hospitalization, standardized fever workup, and antibiotics. All patients were followed through 90 days post-fever event or completion of chemotherapy.

Results: One hundred and five patients were screened and 50 were enrolled. Of the enrollees, 26 (52%) were men and 26 (52%) were HIV positive, with a mean ART duration of 7 years and CD4 count of 293 cells/µL. The most common diagnoses were aggressive non-Hodgkin lymphoma (40%) and Hodgkin lymphoma (22%). Twenty-three febrile events were recorded from 15 patients. Of the 23 events, a causative agent was isolated in 13 cases: Escherichia coli (6), Plasmodium falciparum (3), Streptococcus pneumoniae (2), Pseudomonas aeruginosa (1) and Citrobacter freundii (1). Of the six E. coli isolates, all were found to be resistant to fluoroquinolones and 4/6 (66%) were resistant to cephalosporins. All patients but one survived; the death was attributed to Pseudomonas bacteraemia.

Conclusions: This study describes laboratory-confirmed causes of neutropenic fever (NF) in cancer patients in Malawi. Gram-negative rods, followed by malaria, were the most common source of infection. Gram-negative rods were associated with high rates of antimicrobial resistance. Malaria and resistant bacterial infections should be considered for NF treatment and prevention in sub-Saharan Africa.