Emergency Care of Sepsis in Sub-Saharan Africa: Incidence, Mortality and Non-Physician Clinician Management of Sepsis in rural Uganda from 2010 to 2019

Abstract

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.Methods:Data were obtained for patients seen from 2010-2019 in a rural Ugandan emergency unit staffed by non-physician clinicians. Sepsis was defined as suspected infection with a qSOFA score ≥ 2. Descriptive analysis was performed and a multi-variable logistic regression mortality model was created. Analysis included Wilcoxon rank-sum test, t-test, one-way ANOVA, and Fisher’s exact test.Results:Overall, 48,653 patient visits from 2010-2019 yielded 17,490 encounters for patients age≥18 who had suspected infection, including 3,323 with sepsis. Overall sepsis incidence from 2010 to 2019 decreased from 16.4% to 4.7%, and malarial sepsis incidence decreased from 4.3% to 0.1%. From 2012 to 2019, the proportion of septic patients receiving quality care (both fluids and anti-infectives) increased from 36.2% to 44.7% but observed mortality rates for non-malarial sepsis increased from 6.3% to 14.9% and predicted mortality rates increased from 8.8% to 12.0%. Higher qSOFA scores were significantly associated with higher rates of both interventions and mortality. All interventions for non-malarial sepsis were independently associated with increased relative risks for death: “fluids alone” RR=1.22 [95%CI 0.57 – 1.87]; “antibiotics alone” RR=1.25 [95%CI 0.60 – 1.91]; “both fluids and antibiotics”: RR=1.85 [95%CI 1.02 – 2.69]. Conclusion: The largest study of sepsis management and outcomes ever published in both Uganda and sub-Saharan Africa showed decreasing incidence, increasing quality of non-physician clinician care and increasing predicted and observed mortality from 2010 to 2019. 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.

Persistence is key: unresolved immune dysfunction is lethal in both COVID-19 and non-COVID-19 sepsis

“…This is strikingly similar to severe sepsis, which is life-threatening organ failure caused by a dysregulated host response to infection (4), which is often a bacterial infection but can also be viral and fungal etiologies. Sepsis is estimated to kill 11 million people each year and be involved in 1 in 5 deaths globally (5), having average 30-day mortality rates of 24.4% for sepsis and 34.7% for septic shock in North America, Europe, and Australia (6), and even higher in lower and middle income countries (7). Due to similarities in immune dysfunction, endothelial disruption, cytokine levels, gene expression, and long-term consequences, there is a growing consensus that severe COVID-19 should be classified and treated as a form of viral-associated sepsis (8).…”