Early management of sepsis in medical patients in rural Thailand: a single-center prospective observational study

Suchart Booraphun,Direk Limmathurotsakul,Prapit Teparrukkul,Viriya Hantrakun,Nicholas P. J. Day,T. Eoin West,Kristina E. Rudd,Annette L. Fitzpatrick,Chaiyaporn Boonsri,Ranjani Somayaji

doi:10.1186/s40560-019-0407-z

Abstract

BackgroundThe burden of sepsis is highest in low- and middle-income countries, though the management of sepsis in these settings is poorly characterized. Therefore, the objective of this study was to assess the early management of sepsis in Thailand.MethodsPre-planned analysis of the Ubon-sepsis study, a single-center prospective cohort study of Thai adults admitted to the general medical wards and medical intensive care units (ICUs) of a regional referral hospital with community-acquired sepsis.ResultsBetween March 2013 and January 2017, 3,716 patients with sepsis were enrolled. The median age was 59 years (IQR 44-72, range 18-101), 58% were male, and 88% were transferred from other hospitals. Eighty-six percent of patients (N = 3,206) were evaluated in the Emergency Department (ED), where median length of stay was less than 1 hour. Within the first day of admission, most patients (83%, N = 3,089) were admitted to the general medical wards, while 17% were admitted to the ICUs. Patients admitted to the ICUs had similar age, gender, and comorbidities, but had more organ dysfunction and were more likely to receive measured sepsis management interventions. Overall, 84% (N = 3,136) had blood cultures ordered and 89% (N = 3,308) received antibiotics within the first day of hospital admission. Among the 3,089 patients admitted to the general medical wards, 38% (N = 1,165) received an adrenergic agent, and 21% (N = 650) received invasive mechanical ventilation. Overall mortality at 28 days was 21% (765/3,716), and 28-day mortality in patients admitted to the ICUs was higher than that in patients admitted to the general medical wards within the first day (42% [263/627] vs. 16% [502/3,089], p < 0.001).ConclusionsSepsis in a regional referral hospital in rural Thailand, where some critical care resources are limited, is commonly managed on general medical wards despite high rates of respiratory failure and shock. Enhancing sepsis care in the ED and general wards, as well as improving access to ICUs, may be beneficial in reducing mortality.Trial registrationThe Ubon-sepsis study was registered on clinicaltrials.gov (NCT02217592).

Highlights

The burden of sepsis is highest in low- and middle-income countries, though the management of sepsis in these settings is poorly characterized
The burden of sepsis is high in resource-limited settings such as low- and middle-income countries (LMICs) [3]
We evaluated patients with sepsis, defined as infection plus the presence of organ dysfunction as per sepsis-3 guidelines [1]

Summary

Introduction

The burden of sepsis is highest in low- and middle-income countries, though the management of sepsis in these settings is poorly characterized. The objective of this study was to assess the early management of sepsis in Thailand. The burden of sepsis is high in resource-limited settings such as low- and middle-income countries (LMICs) [3]. While sepsis outcomes have been improving in recent years, perhaps due to increased clinical awareness [5, 6], the optimal approach to management remains unclear [7,8,9,10]. As most studies of sepsis management have been conducted in high-income countries, the applicability of these results to settings in low- or middle-income countries (LMICs) is uncertain

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