3.1.1. Frequency

Among the 129 children hospitalized for severe malaria, 45 presented with bacterial co-infection, representing a prevalence of 34.88%.

3.1.2. Sociodemographic Characteristics

The majority of co-infected children were under five years of age (75.6%), male (51.1%), and from rural areas (71.1%). Socioeconomic status was low in 82.2% of cases (Table 1).

Table 1.Sociodemographic characteristics of co-infected children (n = 45).

3.1.3. Therapeutic Pathway

Most children (80%) initially consulted another healthcare facility. The mean duration of illness before admission was 4 days, with 55.55% admitted after more than 3 days of symptoms. Previous hospitalization was noted in 26.67% of children, and 95.56% were referred from another facility.

Among the 45 children with severe malaria-bacterial co-infection, the main clinical and biological characteristics observed are summarized in Table 2.

Table 2.Clinical and biological signs in co-infected children (n = 45).

The mean parasite density was 74,218/μL (range: 117 - 680,000/μL).

Bronchopneumopathies were the most frequent form (33.33%), followed by gastroenteritis (17.78%) and urinary tract infections (15.56%) (Table 3). Microbiological examinations identified infectious agents in 10 cases. Two blood cultures revealed Escherichia coli and Klebsiella pneumoniae. Eight chest X-rays showed bronchopathies and pneumonias.

Table 3.Profile of associated bacterial infections.

Almost all children (97.78%) received a combination of injectable artesunate and antibiotics. The most commonly used regimen was artesunate plus ceftriaxone (73.33%).

The mean duration of hospitalization was 4.93 days. The outcome was favorable in 77.78% of children. Case fatality was 20%.

Several epidemiological, clinical, biological, and outcome-related factors were significantly associated with severe malaria-bacterial co-infection in hospitalized children, as shown in Table 4. The signs most significantly associated with co-infection were hypoglycemia (OR = 5.74; p = 0.002), coma (OR = 4.12; p = 0.0004), and respiratory distress (OR = 3.77; p = 0.001). Nutritional status was not significantly associated with co-infection (OR = 2.00, p = 0.25).

Table 4.Parameters statistically associated with severe malaria-bacterial co-infection.

This study presents the inherent limitations of cross-sectional surveys, which provide a snapshot without allowing causal relationships to be established. It was conducted during the rainy season, a period of high malaria transmission in Burkina Faso, which limits the generalization of results to the dry season. The high cost of certain complementary tests (procalcitonin, blood cultures) restricted their use, reducing the precision of microbiological diagnosis. Furthermore, the broad definition of co-infections may have overestimated their frequency. The temporary closure of pediatric emergency services also impacted the number of patients included. In addition, the widespread empirical use of antibiotics at admission may have reduced the diagnostic yield of microbiological tests such as blood cultures.

The observed frequency (34.88%) is close to that reported by Sagbo et al. in Benin (38.8%) [6] and higher than that observed by Kouéta et al. at CHUP-CDG in Ouagadougou (13.6%) [5]. These differences may be explained by inclusion criteria: some studies were limited to bacteremia confirmed by culture, whereas the present study included both suspected and confirmed bacterial infections. The rainy season, conducive to malaria and respiratory infections, may also have contributed to this high frequency.

A slight male predominance (51.11%) was observed, consistent with the findings of Kouéta et al. [5]. Male morbidity is common in pediatrics, with some authors suggesting that the second X chromosome in girls provides greater immune protection [8][9]. The age group of 1 to 59 months accounted for 77.78% of cases, confirming the vulnerability of young children. This susceptibility may be explained by the loss of maternal immunity after 6 months and the introduction of poorly diversified foods, favoring malnutrition and infections [10]. The majority of children came from rural areas (71.11%), reflecting the reality of CHU-T, a referral facility receiving patients from peripheral communities. This profile is consistent with the findings of Sagbo et al. [6], who also observed a high proportion of patients from rural settings. Children from families with low socioeconomic status accounted for 82.22% of cases. This factor is recognized as a determinant in the occurrence of severe childhood diseases, particularly malaria and malnutrition [10]. Although nutritional status was assessed, it was not significantly associated with co-infection in this cohort, suggesting that other factors such as disease severity and delayed care may have played a more prominent role.

The majority of children (95.56%) were referred from another healthcare facility, which is expected in a tertiary center such as CHU-T. This high referral rate reflects the severity of cases and the proper functioning of the triage system. However, more than half of the children were admitted after over three days of symptoms, and this delay in reaching tertiary care may have contributed to increased clinical severity and poorer outcomes.

The most frequent severity signs were severe anemia (77.78%), coma (51.11%), and respiratory distress (48.89%). These results are similar to those reported by Sagbo et al. [6] and Kouéta et al. [5], who also identified these signs as predictive of co-infection. The mean parasite density was 74,218/µL. Severe anemia was present in 68.89% of children, with a mean hemoglobin level of 4.89 g/dL. Severe hypoglycemia (<2.2 mmol/L) was observed in 26.67% of cases, and CRP > 20 mg/L in 93.33% of cases. These biological abnormalities are consistent with WHO severity criteria [3] and regional studies [5][6].

The most frequent infections were bronchopneumopathies (33.33%), gastroenteritis (17.78%), urinary tract infections (15.56%), acute meningitis (11.11%), and septicemia (11.11%). These findings are consistent with those of Sagbo et al. [6], who observed a similar diversity of infectious sites. Microbiological examinations identified Escherichia coli and Klebsiella pneumoniae in two cases. This diversity highlights the need for comprehensive and tailored management.

Low socioeconomic status was significantly associated with co-infection, confirming its role as a risk factor [10]. Significant deterioration of general condition, coma, and respiratory distress were associated with co-infection, consistent with the findings of Kouéta et al. [5] and Sagbo et al. [6]. These signs reflect the clinical severity of the association between severe malaria and bacterial infections. A significant association was also found with hypoglycemia, which appears to be a relevant biological marker. Mortality was significantly higher among co-infected children (20%), consistent with the findings of Kouéta et al. [5], who reported a case fatality rate of 16% in co-infected cases. This excess mortality underscores the importance of strengthening diagnostic and therapeutic capacities for bacterial infections associated with severe malaria. The identification of coma, respiratory distress, and hypoglycemia as key predictors suggests that these simple clinical and biological signs could guide early screening for co-infection in resource-limited settings.