Challenges and Solutions in translating sepsis guidelines into practice in resource-limited settings

Abstract

Sepsis and septic shock are major contributors to the global burden of disease, with a large proportion of patients and deaths with sepsis estimated to occur in low- and middle-income countries (LMICs). There are numerous barriers to reducing the large global burden of sepsis including challenges in quantifying attributable morbidity and mortality, poverty, inadequate awareness, health inequity, under-resourced public health, and low-resilient acute health care delivery systems. Context-specific approaches to this significant problem are necessary on account of important differences in populations at-risk, the nature of infecting pathogens, and the healthcare capacity to manage sepsis in LMIC. We review these challenges and propose an outline of some solutions to tackle them which include strengthening the healthcare systems, accurate and early identification of sepsis the need for inclusive research and context-specific treatment guidelines, and advocacy. Specifically, strengthening pediatric intensive care units (PICU) services can effectively treat the life-threatening complications of common diseases, such as diarrhoea, respiratory infections, severe malaria, and dengue, thereby improving the quality of pediatric care overall without the need for expensive interventions. A thoughtful approach to developing paediatric intensive care services in LMICs begins with basic fundamentals: training healthcare providers in knowledge and skills, selecting effective equipment that is resource-appropriate, and having an enabling leadership to provide location-appropriate care. These basics, if built in sustainable manner, have the potential to permit an efficient pediatric critical care service to be established that can significantly improve sepsis and other critical care outcomes.

Keywords: Low- and middle-income countries (LMIC); antibiotics; fluids; sepsis; shock.

Figure 1

A suggested pediatric septic shock pathway in resource-limited settings. (A) (I) Definition of shock and hypotension: WHO (78). Triad of cold hands and/or feet (temperature gradient), CRT >3 s and weak and fast pulse (note: BP measurement de-emphasized, “fast” pulse is subjective). PALS: tachycardia, cold extremities, capillary refill time >3 secs, BP normal (compensated shock) or low (hypotensive shock) (79). (II) Criteria for hypotension by age based on systolic BP (PALS). Term neonates (0 to 28 days) <60 mmHg; infants (1–12 months) <70 mmHg; children 1–10 years <70+ (age in years ×2); children >10 years <90 mmHg. (III) Criteria for Hypotension by Age based on FEAST trial (80). History of fever and impaired consciousness and/or respiratory distress; with tachycardia heart rate (HR) >180 (<12 months), >160 (12 months to 5 years), >140 (age >5 years); poor extremity perfusion CRT >2 s; core-peripheral temperature gradient; feeble extremity pulse; severe hypotension with systolic blood pressure (SBP) <50 mmHg (<2 months), <60 mmHg (1−5 years), <70 mmHg (age >5 years). *, tachycardia: suggested limits: (HR) >180 (<12 months), >160 (12 months–5 years), >140 (age >5 years) (80). **, the definition/criteria for shock for hypotension are variable (80), and caregivers are advised to apply the definition they are familiar with. ^#, chronic co-morbidity. Permission granted by the World Health Organization for reproducing the contents of this figure from the IMAI District Clinician Manual (81). The pathway takes into consideration potential resource limitations, recognizing that many some parts of the world do not have access to ICU support. Modified from Jacob et al. (2) and Ranjit et al. (44) and IMAI District Clinician Manual: WHO 2011 (81). TB, tuberculosis; HIV, human immunodeficiency virus; SpO₂, oxygen saturation; AVPU, mental status score (awake; response to voice; response to pain; unresponsive); PCP, pneumocystis pneumonia. NIV, non-invasive ventilation; HFNC, high flow nasal cannula; CPAP, continuous positive airway pressure; BiPAP, bilevel positive airway pressure.

Figure 2

A suggested priority order for oxygen and respiratory support in LMIC. Modified from Inglis et al. (45).