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Current challenges in the management of sepsis in ICUs in resource-poor settings and suggestions for the future.
Intensive Care Med. 2017 May; 43(5):612-624.IC

Abstract

BACKGROUND

Sepsis is a major reason for intensive care unit (ICU) admission, also in resource-poor settings. ICUs in low- and middle-income countries (LMICs) face many challenges that could affect patient outcome.

AIM

To describe differences between resource-poor and resource-rich settings regarding the epidemiology, pathophysiology, economics and research aspects of sepsis. We restricted this manuscript to the ICU setting even knowing that many sepsis patients in LMICs are treated outside an ICU.

FINDINGS

Although many bacterial pathogens causing sepsis in LMICs are similar to those in high-income countries, resistance patterns to antimicrobial drugs can be very different; in addition, causes of sepsis in LMICs often include tropical diseases in which direct damaging effects of pathogens and their products can sometimes be more important than the response of the host. There are substantial and persisting differences in ICU capacities around the world; not surprisingly the lowest capacities are found in LMICs, but with important heterogeneity within individual LMICs. Although many aspects of sepsis management developed in rich countries are applicable in LMICs, implementation requires strong consideration of cost implications and the important differences in resources.

CONCLUSIONS

Addressing both disease-specific and setting-specific factors is important to improve performance of ICUs in LMICs. Although critical care for severe sepsis is likely cost-effective in LMIC setting, more detailed evaluation at both at a macro- and micro-economy level is necessary. Sepsis management in resource-limited settings is a largely unexplored frontier with important opportunities for research, training, and other initiatives for improvement.

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    • Authors+Show Affiliations

    Schultz MJ
    Mahidol University, Bangkok, Thailand. marcus.j.schultz@gmail.com. Department of Intensive Care, Academic Medical Center and University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands. marcus.j.schultz@gmail.com.
    Dunser MW
    University College of London Hospital, London, UK.
    Dondorp AM
    Mahidol University, Bangkok, Thailand. Department of Intensive Care, Academic Medical Center and University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
    Adhikari NK
    Sunnybrook Health Sciences Centre and University of Toronto, Toronto, ON, Canada.
    Iyer S
    Bharati Vidyapeeth Deemed University Medical College, Pune, India.
    Kwizera A
    Mulago National Referral Hospital, Kampala, Uganda.
    Lubell Y
    Department of Intensive Care, Academic Medical Center and University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
    Papali A
    University of Maryland School of Medicine, Baltimore, MD, USA.
    Pisani L
    Mahidol University, Bangkok, Thailand. Department of Intensive Care, Academic Medical Center and University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
    Riviello BD
    Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA.
    Angus DC
    University of Pittsburgh, Pittsburgh, PA, USA.
    Azevedo LC
    Hospital Sirio-Libanes, Saõ Paulo, Brazil.
    Baker T
    Karolinska Institute, Stockholm, Sweden.
    Diaz JV
    California Pacific Medical Center, San Francisco, CA, USA.
    Festic E
    Mayo Clinic, Jacksonville, FL, USA.
    Haniffa R
    Mahidol University, Bangkok, Thailand.
    Jawa R
    Stony Brook University Medical Center, Stony Brook, NY, USA.
    Jacob ST
    University of Washington, Seattle, WA, USA.
    Kissoon N
    British Columbia Children's Hospital, Vancouver, Canada.
    Lodha R
    All India Institute of Medical Science, Delhi, India.
    Martin-Loeches I
    St. James's University Hospital, Dublin, Ireland.
    Lundeg G
    Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia.
    Misango D
    Aga Khan University Hospital, Nairobi, Kenya.
    Mer M
    Johannesburg Hospital and University of the Witwatersrand, Johannesburg, South Africa.
    Mohanty S
    Ispat General Hospital, Sundargarh, Rourkela, Odisha, India.
    Murthy S
    British Columbia Children's Hospital, Vancouver, Canada.
    Musa N
    Seattle Children's Hospital and University of Washington, Seattle, WA, USA.
    Nakibuuka J
    Mulago National Referral Hospital, Kampala, Uganda.
    Serpa Neto A
    Department of Intensive Care, Academic Medical Center and University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands. Medical Intensive Care Unit, Hospital Israelita Albert Einstein, Sao Paulo, Brazil.
    Nguyen Thi Hoang M
    Oxford University Clinical Research Unit, Hospital for Tropical Diseases, District 5, Ho Chi Minh City, Vietnam.
    Nguyen Thien B
    Trung Vuong Hospital, Ho Chi Minh City, Vietnam.
    Pattnaik R
    Ispat General Hospital, Sundargarh, Rourkela, Odisha, India.
    Phua J
    National University Hospital, Singapore, Singapore.
    Preller J
    Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.
    Povoa P
    Nova Medical School, CEDOC, New University of Lisbon and Hospital de Sao Francisco Xavier , Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal.
    Ranjit S
    Appolo Hospitals, Chennai, India.
    Talmor D
    Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA.
    Thevanayagam J
    Mzuzu Central Hospital, Mzuzu, Malawi.
    Thwaites CL
    Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.
    Global Intensive Care Working Group of the European Society of Intensive Care Medicine
    No affiliation info available

    MeSH

    AdultBiomedical ResearchChild, PreschoolCost-Benefit AnalysisCritical CareDeveloping CountriesDrug ResistanceGlobal Burden of DiseaseHealth Care CostsHealth ResourcesHumansInfantInfant, NewbornIntensive Care UnitsMiddle AgedPractice Guidelines as TopicQuality of Health CareSepsis

    Pub Type(s)

    Journal Article
    Review

    Language

    eng

    PubMed ID

    28349179

    Citation

    Schultz, Marcus J., et al. "Current Challenges in the Management of Sepsis in ICUs in Resource-poor Settings and Suggestions for the Future." Intensive Care Medicine, vol. 43, no. 5, 2017, pp. 612-624.
    Schultz MJ, Dunser MW, Dondorp AM, et al. Current challenges in the management of sepsis in ICUs in resource-poor settings and suggestions for the future. Intensive Care Med. 2017;43(5):612-624.
    Schultz, M. J., Dunser, M. W., Dondorp, A. M., Adhikari, N. K., Iyer, S., Kwizera, A., Lubell, Y., Papali, A., Pisani, L., Riviello, B. D., Angus, D. C., Azevedo, L. C., Baker, T., Diaz, J. V., Festic, E., Haniffa, R., Jawa, R., Jacob, S. T., Kissoon, N., ... Thwaites, C. L. (2017). Current challenges in the management of sepsis in ICUs in resource-poor settings and suggestions for the future. Intensive Care Medicine, 43(5), 612-624. https://doi.org/10.1007/s00134-017-4750-z
    Schultz MJ, et al. Current Challenges in the Management of Sepsis in ICUs in Resource-poor Settings and Suggestions for the Future. Intensive Care Med. 2017;43(5):612-624. PubMed PMID: 28349179.
    * Article titles in AMA citation format should be in sentence-case
    TY - JOUR T1 - Current challenges in the management of sepsis in ICUs in resource-poor settings and suggestions for the future. AU - Schultz,Marcus J, AU - Dunser,Martin W, AU - Dondorp,Arjen M, AU - Adhikari,Neill K J, AU - Iyer,Shivakumar, AU - Kwizera,Arthur, AU - Lubell,Yoel, AU - Papali,Alfred, AU - Pisani,Luigi, AU - Riviello,Beth D, AU - Angus,Derek C, AU - Azevedo,Luciano C, AU - Baker,Tim, AU - Diaz,Janet V, AU - Festic,Emir, AU - Haniffa,Rashan, AU - Jawa,Randeep, AU - Jacob,Shevin T, AU - Kissoon,Niranjan, AU - Lodha,Rakesh, AU - Martin-Loeches,Ignacio, AU - Lundeg,Ganbold, AU - Misango,David, AU - Mer,Mervyn, AU - Mohanty,Sanjib, AU - Murthy,Srinivas, AU - Musa,Ndidiamaka, AU - Nakibuuka,Jane, AU - Serpa Neto,Ary, AU - Nguyen Thi Hoang,Mai, AU - Nguyen Thien,Binh, AU - Pattnaik,Rajyabardhan, AU - Phua,Jason, AU - Preller,Jacobus, AU - Povoa,Pedro, AU - Ranjit,Suchitra, AU - Talmor,Daniel, AU - Thevanayagam,Jonarthan, AU - Thwaites,C Louise, AU - ,, Y1 - 2017/03/27/ PY - 2016/11/25/received PY - 2017/02/27/accepted PY - 2017/3/30/pubmed PY - 2017/9/15/medline PY - 2017/3/29/entrez KW - Critical care KW - Resource-limited settings KW - Sepsis management SP - 612 EP - 624 JF - Intensive care medicine JO - Intensive Care Med VL - 43 IS - 5 N2 - BACKGROUND: Sepsis is a major reason for intensive care unit (ICU) admission, also in resource-poor settings. ICUs in low- and middle-income countries (LMICs) face many challenges that could affect patient outcome. AIM: To describe differences between resource-poor and resource-rich settings regarding the epidemiology, pathophysiology, economics and research aspects of sepsis. We restricted this manuscript to the ICU setting even knowing that many sepsis patients in LMICs are treated outside an ICU. FINDINGS: Although many bacterial pathogens causing sepsis in LMICs are similar to those in high-income countries, resistance patterns to antimicrobial drugs can be very different; in addition, causes of sepsis in LMICs often include tropical diseases in which direct damaging effects of pathogens and their products can sometimes be more important than the response of the host. There are substantial and persisting differences in ICU capacities around the world; not surprisingly the lowest capacities are found in LMICs, but with important heterogeneity within individual LMICs. Although many aspects of sepsis management developed in rich countries are applicable in LMICs, implementation requires strong consideration of cost implications and the important differences in resources. CONCLUSIONS: Addressing both disease-specific and setting-specific factors is important to improve performance of ICUs in LMICs. Although critical care for severe sepsis is likely cost-effective in LMIC setting, more detailed evaluation at both at a macro- and micro-economy level is necessary. Sepsis management in resource-limited settings is a largely unexplored frontier with important opportunities for research, training, and other initiatives for improvement. SN - 1432-1238 UR - https://www.unboundmedicine.com/medline/citation/28349179/full_citation L2 - https://dx.doi.org/10.1007/s00134-017-4750-z DB - PRIME DP - Unbound Medicine ER -