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

BACKGROUND: 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. DATA SOURCES: 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. STUDY ELIGIBILITY CRITERIA: 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. PARTICIPANTS: Adults diagnosed with severe malaria after traveling to endemic areas and managed in non-endemic settings. METHODS: 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. RESULTS: 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). CONCLUSIONS: 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.