Community-acquired coinfections in adults with severe imported malaria: a systematic review and meta-analysis

Severe imported malaria poses diagnostic challenges due to its overlap with bacterial sepsis, often prompting empirical antibiotic use. However, the burden of community-acquired coinfections in adults for non-endemic settings remains uncertain, leading to inconsistent recommendations.

MEDLINE, Embase, LILACS, and the Cochrane Central Register of Controlled Trials were searched from inception to March 2025, without language or date restrictions, with additional screening of reference lists.

We included experimental and observational studies reporting acute community-acquired coinfections in adults with parasitologically confirmed severe imported malaria, defined according to contemporaneous WHO criteria.

Adults diagnosed with severe malaria after traveling to endemic areas and managed in non-endemic settings.

Two authors independently screened studies, extracted data, and assessed risk of bias using a validated tool for prevalence studies. Pooled proportions of coinfections were estimated using random-effects meta-analysis with Freeman-Tukey transformation.

Fourteen studies involving 1,421 patients were included, predominantly retrospective cohorts. The pooled proportion of community-acquired coinfections was 5.4% (95% CI 2.7 -8.7;11 studies I²=72.9%). Microbiologically confirmed coinfections accounted for 3.3% (95% CI 1.4-5.8; I²=57.1%), with pneumonia and bloodstream infections as the main sources of infection. Limited data suggested higher in-hospital case fatality rate among coinfected patients (pooled proportion 18%; 95% CI 8-31).

Community-acquired coinfections are uncommon in adults with severe imported malaria. These findings support a shift away from systematic empirical antibiotic use toward a risk-based strategy in non-endemic settings, with improved prospective data needed to guide antimicrobial stewardship.