Pervasive Intestinal Carriage with Multiple Species of Extended-Spectrum Cephalosporin-Resistant Enterobacterales in Children Admitted for Severe Acute Malnutrition at a Tertiary Hospital in Malawi

Malnutrition is a leading risk factor for community-derived Enterobacterales bacteremia, which has a high rate of mortality in children in sub-Saharan Africa (SSA). International guidelines recommend the use of antibiotics, such as amoxicillin, for children with uncomplicated severe acute malnutrition (SAM), as well as parenteral broad-spectrum antibiotics, such as cephalosporins, for children with SAM who are admitted to the hospital. However, rising rates of infection with extended-spectrum cephalosporin-resistant Enterobacterales (ESCR-E) in SSA call this practice into question. To determine ESCR-E colonization rates, culture-based screening was performed on stool specimens collected from a cohort of children admitted to a hospital in Lilongwe, Malawi, for SAM. Of 188 individuals screened, 80.3% were positive for ESCR-E colonization, and 38.3% were colonized with multiple ESCR-E species. These findings reveal that high rates of ESCR-E colonization exist in some populations of malnourished children in SSA, and guideline-directed empiric antibiotic treatment may need to be reevaluated in this setting.