Feasibility of Modified Surviving Sepsis Campaign Guidelines in a Resource-Restricted Setting Based on a Cohort Study of Severe S. Aureus Sepsis

Abstract

BackgroundThe Surviving Sepsis Campaign (SSC) guidelines describe best practice for the management of severe sepsis and septic shock in developed countries, but most deaths from sepsis occur where healthcare is not sufficiently resourced to implement them. Our objective was to define the feasibility and basis for modified guidelines in a resource-restricted setting.Methods and FindingsWe undertook a detailed assessment of sepsis management in a prospective cohort of patients with severe sepsis caused by a single pathogen in a 1,100-bed hospital in lower-middle income Thailand. We compared their management with the SSC guidelines to identify care bundles based on existing capabilities or additional activities that could be undertaken at zero or low cost. We identified 72 patients with severe sepsis or septic shock associated with S. aureus bacteraemia, 38 (53%) of who died within 28 days. One third of patients were treated in intensive care units (ICUs). Numerous interventions described by the SSC guidelines fell within existing capabilities, but their implementation was highly variable. Care available to patients on general wards covered the fundamental principles of sepsis management, including non-invasive patient monitoring, antimicrobial administration and intravenous fluid resuscitation. We described two additive care bundles, one for general wards and the second for ICUs, that if consistently performed would be predicted to improve outcome from severe sepsis.ConclusionIt is feasible to implement modified sepsis guidelines that are scaled to resource availability, and that could save lives prior to the publication of international guidelines for developing countries.

Patient Characteristics, Management, and Predictors of Outcome from Severe Community-Onset Staphylococcal Sepsis in Northeast Thailand: A Prospective Multicenter Study

“…A previous single center study in this region from 2006 to 2007 reported a mortality rate of 20% at 12 weeks in hospitalized patients with non-nosocomial invasive S. aureus infection (defined as S. aureus cultured from a sterile site) 13. In a related analysis of patients with S. aureus bacteremia—including nosocomial infection—who met criteria for severe sepsis, the 28-day mortality rate was 53% 18. Together, these results underscore the significant burden of severe staphylococcal sepsis in northeast Thailand.…”

Healthcare infrastructure capacity to respond to severe acute respiratory infection (SARI) and sepsis in Vietnam: A low-middle income country

“…In Vietnam, the national guidance of management for emerging respiratory diseases are established to use as reference for the clinical management at all level of hospitals in the country but are not regularly updated and may lead to mismatch with international guidelines. As well, because of the considerable facility shortages seen around the world, several modified sepsis guidelines for resource-restricted settings have been recommended [33][34][35][36]. Future national guidelines and training materials need to be adapted and modified according to the reality of the resource-constraints and health system organization.…”

Infection Management in Patients with Sepsis and Septic Shock in Resource-Limited Settings

“…Definitive microbiological diagnosis allows the administration of appropriate antibiotics. A prospective survey of 72 adults with severe sepsis or septic shock with S. aureus bacteremia in Thailand reported 78% patients were empirically treated with appropriate antibiotics, but after culture result, 98% were given effective antibiotic therapy [49]. In addition, as discussed above, by detecting infections such as tuberculosis or melioidosis, the necessary treatment to prevent relapse or resistance can be given.…”

“…Ultrasound and X-ray are the most available and inexpensive investigations to aid the anatomical infection site, and we found low-grade evidence of both investigations showing reasonable sensitivity in abdominal perforation and melioidosis. Radiological examination was available in 86% of patients with severe sepsis and septic shock associated with S. aureus bacteremia in Thailand [49], and in 15 out of 46 cases where an anatomical site of infection was identified, appropriate source control procedures occurred, although in five further cases, the patient was deemed unfit for the appropriate surgical procedure.…”