Risks of infection in people with SCD

• People with SCD in general have functional asplenia and are at risk of infection, in particular from encapsulated bacteria such as Neisseria meningitides, Streptococcus pneumonia and Haemophilus influenzae. Compared to people without SCD, individuals with SCD have 36-fold increased odds of invasive Streptococcus pneumonia infection and 13-fold greater odds of invasive Haemophilus influenza infection (142). People with SCD also have an increased risk of urinary tract infections (143). In adults with SCD, 14–18% of deaths are attributed to infectious causes (144). Risks of infection in pregnant women
• People with SCD who become pregnant are more vulnerable to infections (27).
• Urinary tract infection is one of the most common infections in pregnancy, with a reported prevalence of 20% among pregnant women and higher prevalence in LICs than in HICs (145).
• Pregnant women with SCD are at increased risk of bacterial infections (OR 2.48) (77). Infection prophylaxis in people with SCD
• Infection prevention and treatment is a key aspect of effective care for people with SCD. This highlights the need for access to local non-pharmacological infection prevention measures such as clean water, sanitation, hygiene and local immunization programmes. Guidance from the WHO African Region is that specific infection prevention measures for people with SCD include: extended immunization against encapsulated organisms and hepatitis B; antibiotic prophylaxis with penicillin; malaria prevention using physical methods or chemoprophylaxis according to local guidelines; and systematic deworming for children (23). Antimicrobial resistance
• Prolonged antibiotic use can promote the development of resistance. In a United Kingdom of Great Britain and Northern Ireland cohort of children with SCD, 71% of whom were receiving penicillin prophylaxis, nasopharyngeal carriage of penicillin-resistant Streptococcus pneumoniae was observed in 55% of isolates (146). Similarly, in a Ghanaian cohort of individuals with SCD, over a third of Streptococcus pneumoniae isolates were resistant to penicillin (147).
• Antimicrobial resistance is a major global public health threat (148). It is important to optimize care for people with SCD, while reducing the development of antimicrobial resistance. The WHO AWaRe (access, watch, reserve) antibiotic book (149) provides guidance on the use of “Access” antibiotics, which have a narrow spectrum of activity, lower cost, a good safety profile and generally low resistance potential. Considerations in women with SCD
• WHO recommends a seven-day antibiotic regimen for all pregnant women with asymptomatic bacteriuria to prevent persistent bacteriuria, preterm birth and low birthweight (14). Antibiotic prophylaxis is only recommended to prevent recurrent urinary tract infections in pregnant women in the context of rigorous research (14).
• Regardless of whether a pregnant woman with SCD is on prophylactic antibiotics, it is important for the health-care provider to have a high degree of suspicion for infection, and to screen and conduct clinical examinations to promptly diagnose and treat any infections, being cognizant of the potential for antibiotic resistance.