Sepsis Management in Low- and Middle-Income Countries: A Systematic Review

Abstract

Background Optimal sepsis management in low-resource settings is the subject of active debate. Given resource limitations, prevalent co-morbidities, and unique infectious epidemiology, resuscitation strategies conceived in resource-rich settings may be difficult to apply more broadly. Evidence from low- and middle-income country (LMIC) settings is disparate and frequently discordant. We sought to synthesize the available data. Methods A systematic search of sepsis resuscitation interventions in LMIC was performed in PubMed, EMBASE, Scopus, Global Health Library databases, and the gray literature in accordance with PRSIMA guidelines. Studies were included if they defined a fluid or antibiotic intervention and measured the effect on in-hospital mortality for patients with undifferentiated sepsis. Studies were categorized based on the volume of fluid administered and the time to antibiotic administration. Results The search yielded 22,088 unique articles, of which 26 studies, encompassing 15,667 patients met the inclusion and were included. Over half the studies (14/26) evaluated the effect of fluid administration on mortality and found a trend toward increased mortality when more than 2 L were administered in the first 6 hours, while 1–2 L was associated with reduced mortality. Among the 15 studies evaluating the impact of antibiotic timing, administration within 3 hours was associated with reduced likelihood of in-hospital mortality. However, there was wide heterogeneity across study methodologies, outcomes, and resource variation. Conclusion Synthesis of the available data suggests that a judicious fluid strategy (between 1 and 2 liters within the first 6 hours) and early antibiotic administration are the most appropriate strategies for undifferentiated sepsis. More research is needed, especially in rural low-resource settings where we found a dearth of available research.