Unraveling Sepsis Epidemiology in a Low- and Middle-Income Intensive Care Setting Reveals the Alarming Burden of Tropical Infections and Antimicrobial Resistance: A Prospective Observational Study (MARS-India)

Abstract

Background: Our study addresses the sepsis research gap in lower- and middle-income countries, notably India. Here, we investigate community-acquired sepsis comprehensively and explore the impact of tropical microbiology on etiology and outcomes.

Methods: MARS-India was a prospective observational study from December 2018 to September 2022 in a tertiary-care hospital in South India. Adult patients within 24 hours of intensive care unit (ICU) admission meeting the Sepsis-3 definition were enrolled, with 6 months of follow-up.

Results: More than 4000 patients were screened on ICU admission, with 1000 unique patients meeting the inclusion criteria. Median age was 55 (interquartile range, 44-65) years, with a male preponderance (66%). Almost half the cohort resided in villages (46.5%) and 74.6% worked in the primary sector. Mortality in-hospital was 24.1%. Overall, about 54% had confirmed microbiological diagnosis and >18% had a viral cause of sepsis. Surprisingly, we identified leptospirosis (10.6%), scrub typhus (4.1%), dengue (3.7%), and Kyasanur forest disease (1.6%) as notable causes of sepsis. All of these infections showed seasonal variation around the monsoon. In community-acquired infections, we observed substantial resistance to third-generation cephalosporins and carbapenems.

Conclusions: In India, sepsis disproportionally affects a younger and lower-socioeconomic demographic, yielding high mortality. Tropical and viral sepsis carry a significant burden. Analyzing local data, we pinpoint priorities for public health and resources, offering valuable insights for global sepsis research. Clinical Trials Registration. NCT03727243.

Keywords: AMR; ICU; LMIC; sepsis; tropical infection.

Figure 1.

Distribution of clinical presentation and pathogens identified in 1000 patients with sepsis. Numbers in parentheses are number of clinical presentations of each pathogen identified. In some patients, >1 clinical presentation or >1 pathogen was identified. Abbreviations: A. baumannii, Acinetobacter baumannii; B. pseudomallei, Burkholderia pseudomallei; CNS, central nervous system; E. cloacae, Enterobacter cloacae; E. faecalis, Enterococcus faecalis; E. coli, Escherichia coli; H. influenzae, Haemophilus influenzae; K. pneumoniae, Klebsiella pneumoniae; M. tuberculosis, Mycobacterium tuberculosis; O. tsutsugamushi, Orientia tsutsugamushi; P. aeruginosa, Pseudomonas aeruginosa; SARS-CoV-2, severe acute respiratory syndrome coronavirus 2; S. aureus, Staphylococcus aureus; S. agalactiae, Streptococcus agalactiae; S. pneumoniae, Streptococcus pneumoniae; S. pyogenes, Streptococcus pyogenes; V. cholerae, Vibrio cholerae.