Aetiology and outcomes of sepsis in adults in sub-Saharan Africa: a systematic review and meta-analysis

Joseph M Lewis,Jamie Rylance,Nicholas A Feasey

doi:10.1186/s13054-019-2501-y

Abstract

BackgroundAetiology and outcomes of sepsis in sub-Saharan Africa (sSA) are poorly described; we performed a systematic review and meta-analysis to summarise the available data.MethodsSystematic searches of PubMed and Scopus were undertaken to identify prospective studies recruiting adults (> 13 years) with community-acquired sepsis in sSA post-2000. Random effects meta-analysis of in-hospital and 30-day mortality was undertaken and available aetiology data also summarised by random effects meta-analysis.ResultsFifteen studies of 2800 participants were identified. Inclusion criteria were heterogeneous. The majority of patients were HIV-infected, and Mycobacterium tuberculosis was the most common cause of blood stream infection where sought. Pooled in-hospital mortality for Sepsis-2-defined sepsis and severe sepsis was 19% (95% CI 12–29%) and 39% (95% CI 30–47%) respectively, and sepsis mortality was associated with the proportion of HIV-infected participants. Mortality and morbidity data beyond 30 days were absent.ConclusionsSepsis in sSA is dominated by HIV and tuberculosis, with poor outcomes. Optimal antimicrobial strategies, including the role of tuberculosis treatment, are unclear. Long-term outcome data are lacking. Standardised sepsis diagnostic criteria that are easily applied in low-resource settings are needed to establish an evidence base for sepsis management in sSA.

Highlights

Sepsis, defined most recently as a syndrome of lifethreatening organ dysfunction due to a dysregulated host response to infection [1], is common worldwide and carries a high mortality: recent estimates suggest 19.4 million yearly cases and 5.3 million deaths [2]
It is clear that sepsis protocols developed in high-income settings should not be exported unchanged to sub-Saharan Africa (sSA): aggressive fluid resuscitation has been shown to be harmful in one randomised controlled trial (RCT) in adults and one in children [6, 7] and caution is warranted before proposing fluid management guidelines for sSA
One article was a secondary analysis of the aetiology of a previously presented cohort [23], meaning 15 articles were included, reporting on 14 prospective clinical studies from nine centres in six countries

Summary

Introduction

Sepsis, defined most recently as a syndrome of lifethreatening organ dysfunction due to a dysregulated host response to infection [1], is common worldwide and carries a high mortality: recent estimates suggest 19.4 million yearly cases and 5.3 million deaths [2]. In high-income settings, outcomes are improving, due in part to a comprehensive application of an expanding evidence base for early recognition, rapid administration of appropriate antimicrobials, and aggressive fluid resuscitation paired with intensive monitoring of physiology and provision for organ support [3, 4]. In low-resource settings including sub-Saharan Africa (sSA), data are limited but some studies have identified high mortality [5]. It is clear that sepsis protocols developed in high-income settings should not be exported unchanged to sSA: aggressive fluid resuscitation has been shown to be harmful in one randomised controlled trial (RCT) in adults and one in children [6, 7] and caution is warranted before proposing fluid management guidelines for sSA. Aetiology and outcomes of sepsis in sub-Saharan Africa (sSA) are poorly described; we performed a systematic review and meta-analysis to summarise the available data

Methods

Results

Discussion

Conclusion