Sepsis in Africa: practical steps to stem the tide

Sepsis is a leading cause of morbidity and mortality worldwide and particularly in Africa where awareness is low and resources are limited. There are limited reports on the epidemiology, management and outcomes of the sepsis syndromes from Africa. However, this region is likely to account for a significant proportion of the global burden of sepsis which goes unrecognized. It is imperative to address this through research, increased awareness, capacity building and introduction of practical clinical guidelines. Infections are responsible for an estimated 300 million annual deaths worldwide, the majority from developing countries [1]. Sepsis can be triggered by almost any infection and is responsible for an estimated 8 million annual deaths worldwide [1]. In the United Kingdom (UK), sepsis is the third most important cause of death in hospital with an average management cost of £20,000 per admission [2]. Given the high incidence of Human Immunodeficiency Virus (HIV) and other infections in the African continent, it is likely that the burden of sepsis is at least equal if not higher than estimates from Europe and North America.


Introduction
Sepsis is a leading cause of morbidity and mortality worldwide and particularly in Africa where awareness is low and resources are limited. There are limited reports on the epidemiology, management and outcomes of the sepsis syndromes from Africa. However, this region is likely to account for a significant proportion of the global burden of sepsis which goes unrecognized. It is imperative to address this through research, increased awareness, capacity building and introduction of practical clinical guidelines. Infections are responsible for an estimated 300 million annual deaths worldwide, the majority from developing countries [1]. Sepsis can be triggered by almost any infection and is responsible for an estimated 8 million annual deaths worldwide [1]. In the United Kingdom (UK), sepsis is the third most important cause of death in hospital with an average management cost of £20,000 per admission [2]. Given the high incidence of Human Immunodeficiency Virus (HIV) and other infections in the African continent, it is likely that the burden of sepsis is at least equal if not higher than estimates from Europe and North America.

Why are sepsis related cases and deaths under-reported?
Firstly, health care professionals often miss the diagnosis or fail to document it in the clinical notes. Secondly, the World Health Organisation (WHO) Global Burden of Disease Report (GBDR) does not include sepsis as a cause of death. The GBDR is one of the leading information sources for healthcare decision-making worldwide. Although deaths from infections occur most commonly as a result of sepsis, the GBDR lists only the underlying infections as cause of death. It is therefore not surprising that sepsis occurs only as "neonatal" sepsis and is ranked 16th place, despite about 60% of deaths in children under five being due to severe infections. Thirdly, guidelines for coding of sepsis are often difficult to use especially in under resourced and busy developing world healthcare settings. The iSSC guideline also has a 6 hour bundle for severe sepsis and septic shock. It consists of invasive monitoring of physiologic parameters such as central venous pressure and use of vasopressors to maintain mean arterial pressure usually in an intensive care setting. The use of such an intensive resuscitation bundle in the form of early goal directed therapy with resuscitation targeting specific physiologic goals has been shown to significantly reduce mortality in severe sepsis and septic shock when compared to standard therapy. However, recent self-reported survey data strongly suggest that these critical care measures, though beneficial, cannot be implemented in most parts of Africa due to a shortage of resources such as skilled manpower, complex equipment and drugs [3]. A recent trial in the United States of America (USA) also suggests that early recognition and resuscitation of patients with sepsis is way more important than early goal directed therapy [4]. It is therefore reasonable to focus attention on Antibiotic administration: prompt administration of antibiotics in severe sepsis and septic shock has been shown to reduce mortality.
It is advocated that empiric antibiotics be given after blood cultures have been taken. Antibiotics can subsequently be rationalized based on blood culture results. A study from Uganda showed that empiric antibacterial therapy in sepsis was rarely concordant with blood culture sensitivities [6]. Thus, empiric antibiotic regimens need to be updated regularly based on local antimicrobial resistant trends.
There is a need to develop evidence-based formularies for empiric antibiotics based on local antimicrobial sensitivity data. This could be achieved through routine collection of data or annual surveillance surveys.

IV fluids
The aggressive use of IV fluids in sepsis can decrease duration of hypoperfusion of vital organs ultimately resulting in less end-organ damage. However despite numerous studies comparing colloids and crystalloids, research is needed to determine the ideal resuscitation fluid. Recent research suggests lower hospital mortality in patients who receive larger volumes of IV fluids within 3 hours of onset of sepsis [7]. Interestingly, both groups -survivors and patientsreceived the same total amount of fluid in the first 6 hours.
Therefore, timely fluid resuscitation within 3 hours of onset may increase survival. However, a recent report from sub-Saharan Africa calls for caution in applying this to children. This Fluid Expansion as Supportive Therapy (FEAST) trial showed a significant increase in the mortality within 48 hours in febrile children who received boluses of albumin or saline. However critical care facilities were either limited or absent [8].

Recommendations
To address the challenge of sepsis in Africa, the following steps

Conclusion
There is an urgent requirement to explicitly recognize sepsis as a significant cause of morbidity and mortality in Africa and make greater efforts to more precisely describe the burden of disease from sepsis. Sepsis quality improvement programmes are desperately required in Africa to provide context-specific solutions to this catastrophe.