There is a lack of quality clinical and laboratory data on co-infections among malaria patients despite several published systematic reviews of the literature

READERS’ FORUM- TROPICAL DOCTOR

Malarial co-infections are being increasingly recognized, but their diagnosis is still challenging, especially when presenting as an acute undifferentiated febrile illness identical to malaria. Our recent publication on concurrent infections among malaria cases described co-infections with dengue, chikungunya, typhoid, leptospira, tuberculosis, HIV, and bloodstream bacterial infections. ¹ The study provided clinical-laboratory features of co-infections compared to malaria mono-infection and subsequent approaches for diagnosis. Building upon this study, we decided to devise a working protocol for diagnosing concurrent infections among malaria cases.

We searched the PubMed database for systematic reviews and meta-analyses using the strategy (“Malaria"[Mesh] AND “Coinfection"[Mesh]). The date range was from inception to September 15, 2022. We retrieved a total of 35 results. Our search was not limited by language or year of publication. We reviewed each result and found co-infections of dengue, chikungunya, typhoidal & non-typhoidal salmonellosis, leptospirosis, scrub typhus, soil-transmitted helminths, trypanosomiasis, ebola, HIV/AIDS, Covid-19, visceral leishmaniasis and invasive bloodstream bacterial infections. These infections present as acute undifferentiated febrile illnesses except soil-transmitted helminthic infections. Therefore, co-infections with malaria have been reported, which might be shadowed or shadows the malaria infection.

We further screened each review for epidemiological, clinical, and laboratory data and found that all studies provided extensive epidemiological data, but promising clinical & laboratory data was missing. There were significant data on clinical features, laboratory findings, and outcomes in a review on Covid-19 co-infection. ² However, there were only some laboratory and complication-related data available for other co-infections.^3–5 Unfortunately, there were an overall paucity of clinical & laboratory data in these reviews (especially related to co-infection with malaria). Hence, it is challenging to utilize the data available in the existing systematic reviews or meta-analyses to make proper diagnostic decisions in the presence of co-infections.

The non-specific clinical features of co-existing infections, especially viral & tropical diseases, make co-infection diagnosis even more challenging. Patients often get treatment covering two or more causes, thus adding to unnecessary antimicrobial overuse. Although co-infections occur occasionally, empiric therapy in stable patients without proven co-infection will add to the burden of antimicrobial resistance. Moreover, in low-income and poor-resource countries, an empirical approach would increase the cost of treatment, thereby increasing the economic burden of the disease on the patients as well as the public health authorities. However, in complicated illnesses, empiric therapy covering expected organisms may be considered. Thus, a systemic review of data from endemic countries is urgently required to help clinicians make diagnostic decisions and workup treatment strategies when malaria presents with an underlying co-infection.