Comment

International Surviving Sepsis Campaign guidelines 2016: the perspective from low-income and middle-income countries

Gentle S Shrestha, Arthur Kwizera, Ganbold Lundeg, et al

Lancet Infect Dis 2017; 17: 893-895

In the most recent international Surviving Sepsis Campaign guidelines, Rhodes and colleagues¹excellently outline evidence-based management of patients with sepsis and septic shock. Of note, however, is that most of the world's population resides in low-income and middle-income countries (LMICs), where the burden of sepsis is enormous, outcomes are often poor, and socioeconomic consequences are dire.² Of the 655 references supporting the new sepsis guidelines, only a few pertain to studies in LMICs (about 10%).¹ This disparity raises concerns that the challenges and problems inherent to LMICs remain inadequately addressed. The guidelines, for example, mainly focus on management of bacterial and fungal sepsis as most frequently encountered in high-income countries. Strikingly, the specific diagnosis and management of sepsis due to pathogens commonly encountered in LMICs, such as Mycobacterium tuberculosis (which resulted in about 1·8 million deaths in 2015),³ Plasmodium falciparum (429 000 deaths),⁴ and dengue virus (1032 deaths in the Region of the Americas in 2016),⁵ are not included. HIV infection, which poses specific challenges to sepsis care in LMICs, particularly in sub-Saharan Africa and southeast Asia, is also not alluded to. More than 35 million people have lost their lives as a consequence of HIV infection, most related to sepsis, and around 36·7 million people estimated to be living with the disease are potentially at risk.⁶These omissions are unlikely due to oversights or absence of concern of the team producing the guidelines, but rather relate to the paucity of robust scientific evidence, as well as the absence of experts from LMICs in the guidelines group providing appropriate context.

Not only is the disease pattern different, but effective delivery of sepsis care in many LMICs is challenged by the shortage of suitably trained health-care personnel (physicians, nurses, and allied health-care personnel), material resources (equipment, drugs, and supply materials), supporting infrastructure (eg, imaging technology), laboratory facilities (eg, lactate measurement), and basic logistics (eg, water, electricity, and oxygen or pressurised air supply).^{7, 8, 9} A few clinical protocols as well as widespread antimicrobial resistance constitute further major obstacles.^{7, 8, 9} Resource limitations vary considerably between and within LMICs, and only extremely elementary facilities are available in some rural areas. Many patients with sepsis are looked after by health-care professionals with little or no formal training in management of patients with critical illnesses or sepsis. Profound inequities in terms of access to medical care are common in these domains, with sophisticated care often only available in private health-care facilities and general hospitals of middle-income countries.⁷ Given these circumstances, not all of the recommendations of the new guidelines are necessarily applicable to LMICs and in some instances could prove problematic and even deleterious. For example, high mortality after advocated volume resuscitation in both children and adult patients with sepsis has been reported.^{10, 11} The absence of mechanical ventilation or insufficiently trained staff could have been important contributing factors to the noted increased mortality.

What needs to be done? Previous recommendations for management of sepsis in resource-limited settings have most of their statements supported by low levels of scientific evidence,² as sepsis research in LMICs has only emanated from a few selected centres. High-quality research focused on needs assessment, benefit to risk ratios, and cost-effectiveness of therapeutic interventions is desperately required such that stronger recommendations than the current guidelines for sepsis management in LMICs can be developed. The Surviving Sepsis Campaign committee needs to be commended for having introduced the sepsis in resource-limited nations initiative to address some of these elements. To save as many lives as possible, future international sepsis guidelines should aim to be more globally applicable than the current guidelines, with dedicated recommendations for management of sepsis in LMICs. These recommendations should specifically acknowledge the care of critically ill patients with sepsis due to tuberculosis, severe malaria, dengue, and other infectious diseases for which the pathophysiology and management differs from bacterial or fungal sepsis, as commonly seen in high-income countries. Furthermore, future international sepsis guidelines should critically consider evidence-based recommendations for the potential availability of resources as well as their efficacy, safety, and affordability with respect to implementation in LMICs.^{12, 13} These measures should be accompanied by initiatives to improve training in sepsis management and general intensive care. With a concerted collective effort, a better understanding than at present and heightened awareness of the true global challenges of sepsis being faced, and committed collaborations, the practice and delivery of sepsis care could be optimised globally and enhanced in a most favourable fashion for all.

We declare no competing interests.