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Our data suggest a causal pathway whereby malaria history and multiple bacteremia contribute to bBSI mortality. It must be emphasised that the available sample size is too small to draw any definite conclusions on how the different factors relate to each other and larger studies are needed to further investigate the robustness of this relationship.
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Bacterial bloodstream infection is increasingly recognized as a complication in children with severe Plasmodium falciparum malaria. Church and Maitland recently conducted a systematic review of 25 studies across 11 African countries and reported that children with recent or acute malaria are at an increased risk of bBSI, which results in an increased risk of mortality [ 19 ].
Although the majority of bacterial pathogens involved were enteric Gram-negative organisms in particular non-typhoidal Salmonella NTS , the exact nature of the interaction between malaria and bBSI is still not clear. Other hypotheses are macrophage dysfunctions due to reduced cytokine production after ingestion the malaria pigment haemozoin [ 22 ], competition between bacteria and damaged red blood cells for phagocytic sites [ 21 ], and reduced production of cytokines such as IL [ 23 ]. Cunnington et al.
The detection of translocated bacteria from the gut into the blood has clinical significance as it indicates critical illness. Indeed, we observed that confirmed bBSI patients with multiple Gram-negative bacterial species in the blood showed a significant 9-fold higher risk for poor clinical outcome compared to patients in which only a single bacterial species was detected.
Seven out of the 9 patients classified as possible bBSI were also acute or recent malaria patients. Hence it is possible that the detected bacteria in these patients, which were unusual bBSI agents for our study settings, may also originate from the gut. However we should interpret the results of the possible bBSI patients with care as we cannot exclude that some of the detected bacteria correspond to environmental contaminants picked up during sample collection and work-up.
The power of 16S metagenomics is that it provides an assumption-free approach to identify bacteria. However, the broad range of bacteria that can be detected limits the specificity of the assay. First of all, it can be unclear whether the detected bacteria are truly clinically significant or merely environmental contaminants picked up during sample preparation, as was the case with the possible bBSI patients.
We expect that including quality control samples that are collected at the same time and location as the index samples will largely resolve this issue. Secondly, species such as E.
This is further complicated by the fact that several bacteria show intra-genomic heterogeneity in the sequences of their 16S rRNA genes [ 25 ]. Confirmatory genotyping tests based on additional genomic markers may thus be advisable in situations where high specificity is required. Some limitations in our study should be taken into account. The negative control samples used to filter out environmental contaminants were collected from a different location and at a different time point than the patient samples.
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In addition, the blood samples tested were left-over samples from tubes that had been accessed for other diagnostic tests, potentially introducing environmental contaminants. The lack of appropriate controls made it difficult to distinguish such environmental contaminants from clinically relevant bacteria. For future 16S metagenomics studies on blood samples, we suggest that blood samples should be collected in dedicated tubes for 16S metagenomics and that control samples are collected at the same place and time as the patient samples.
Secondly, the blood sample volumes that were available for 16S metagenomics may have been too low for some patients to allow accurate detection of bacteria. Thirdly, no data of other molecular tests, such as diagnostic PCRs, are available for our study samples. Fourthly, read depths of pathogens varied largely between the replicate 16S metagenomics runs and this may have affected the reproducibility of our 16S metagenomics assay.
This is probably due to the limited blood volumes tested, possible amplification bias by PCR during the library preparation [ 26 ] and the inherent variation between deep sequencing runs [ 27 ]. In conclusion, our proof-of-concept study shows that 16S metagenomics is a powerful approach to identify bacteria in the blood of patients and complementary to microbiological culture based approaches.
It provides an assumption-free method to study invasive bacterial disease and can detect multiple bacterial species present in a blood sample in one single run.
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Our data show that 16S metagenomics has the potential to revolutionize the diagnosis of bBSI in reference hospitals with molecular biology facilities and surveillance studies mapping bBSI incidences. We thank Dr.
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Erika Vlieghe for the clinical interpretation of the data. Abstract Background Bacterial bloodstream infection bBSI is one of the leading causes of death in critically ill patients and accurate diagnosis is therefore crucial. Author Summary Bacterial bloodstream infection bBSI is one of the biggest causes of mortality in critically ill patients and standard diagnosis is still done by blood culture methods.
Introduction Bacterial bloodstream infection bBSI is one of the biggest causes of mortality in critically ill patients [ 1 , 2 ]. Methods Ethics statement Ethical approval was obtained from the ethics committees of the Institute of Tropical Medicine Antwerp and the University Hospital Antwerp in Belgium and the national ethics committee of Burkina Faso. Download: PPT. Fig 1.