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Introduction Little data exists from sub-Saharan Africa describing incidence and outcomes of sepsis in emergency units and uncertainty exists surrounding optimal management of sepsis in low-income settings. There exists limited data regarding quality care metrics for non-physician clinicians trained in emergency care. The objective of this study was to describe changes in septic patients over time and evaluate associations between sepsis care and mortality. Methods Secondary analysis of a prospective cohort of all consecutive patients seen from 2010–2019 in a rural Ugandan emergency unit staffed by non-physician clinicians was performed using an electronic database based on paper charts. Sepsis was defined as suspected infection with a quick Sequential Organ Failure Assessment score (qSOFA)≥1. Multi-variable logistic regression was used to analyze three-day mortality. Results Overall, 48,653 patient visits from 2010–2019 yielded 17,490 encounters for patients age≥18 who had suspected infection, including 10,437 with sepsis. The annual proportion of patients with sepsis decreased from 45.0%% to 21.3% and the proportion with malarial sepsis decreased from 17.7% to 2.1% during the study period. Rates of septic patients receiving quality care (“both fluids and anti-infectives”) increased over time (21.2% in 2012 to 32.0% in 2019, p<0.001), but mortality did not significantly improve (4.5% in 2012 to 6.4% in 2019, p = 0.50). The increasing quality of non-physician clinician care was not associated with reduced mortality, and treatment with “both fluids and antibiotics” was associated with increased mortality (RR = 1.55, 95%CI 1.10–2.00). Conclusion The largest study of sepsis management and outcomes ever published in both Uganda and sub-Saharan Africa showed sepsis and malarial sepsis decreasing from 2010 to 2019. The increasing quality of non-physician clinician care did not significantly reduce mortality and treatment with “both fluids and antibiotics” increased mortality. With causal associations between antibiotics and mortality deemed implausible, associations between sepsis mortality and interventions likely represent confounding by indication. Defining optimal sepsis care regionally will likely require randomized controlled trials.

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Background: There is a paucity of data from Sub-Saharan Africa regarding sepsis outcomes and the impact of sepsis care on those outcomes, including the impact of care provided by non-physician clinicians (NPCs). Methods: Data were retrospectively analyzed from a rural Ugandan emergency department staffed by NPCs using a quality assurance database of adult and pediatric patient visits with and without sepsis from 2010 through 2018. Sepsis was defined as suspected infection with a qSOFA score ≥ 2. Mortality, disposition, and NPC adherence to intravenous fluid and anti-infective therapy were analyzed using chi-squared and multivariable linear regression. Results: Sepsis criteria were met in 4,847 (11.0%) cases. Sepsis cases compared to non-sepsis cases were significantly older, and had higher rates of comorbid malaria, HIV, tuberculosis, and pneumonia. They had higher admission rates (86.8% versus 66.3%), were more likely to still be admitted at three days (40.2% versus 26.2%), and had higher mortality at three days (7.8% versus 2.5%). The incidence of sepsis significantly declined over time from 16.3% in 2010 to 3.1% in 2018 while the proportion of sepsis cases with qSOFA score of ≥ 3 increased significantly over time. The decrease in incidence was largely due to a precipitous drop in malaria smear-positive sepsis. Utilizing a multivariable linear regression model, annual three-day sepsis mortality did not significantly change over time, though adherence to administration of both fluids and anti-infectives increased significantly from 12.3% in 2010 to 35.0% in 2018. Conclusions: Sepsis incidence, especially malaria smear-positive sepsis, decreased over time, while annual mortality did not change despite increased adherence to administration of anti-infectives and intravenous fluids in an NPC-staffed emergency department. Further studies are needed to investigate the contextualized use of anti-infectives and fluid resuscitation.