Date Published: September 26, 2018
Publisher: Public Library of Science
Author(s): Viriya Hantrakun, Ranjani Somayaji, Prapit Teparrukkul, Chaiyaporn Boonsri, Kristina Rudd, Nicholas P. J. Day, T. Eoin West, Direk Limmathurotsakul, Florian Mayr.
Infection and sepsis are leading causes of death worldwide but the epidemiology and outcomes are not well understood in resource-limited settings. We conducted a four-year prospective observational study from March 2013 to February 2017 to examine the clinical epidemiology and outcomes of adults admitted with community-acquired infection in a resource-limited tertiary-care hospital in Ubon Ratchathani province, Northeast Thailand. Hospitalized patients with infection and accompanying systemic manifestations of infection within 24 hours of admission were enrolled. Subjects were classified as having sepsis if they had a modified sequential organ failure assessment (SOFA) score ≥2 at enrollment. This study was registered with ClinicalTrials.gov, number NCT02217592. A total of 4,989 patients were analyzed. Of the cohort, 2,659 (53%) were male and the median age was 57 years (range 18–101). Of these, 1,173 (24%) patients presented primarily to the study hospital, 3,524 (71%) were transferred from 25 district hospitals or 8 smaller hospitals in the province, and 292 (6%) were transferred from one of 30 hospitals in other provinces. Three thousand seven hundred and sixteen (74%) patients were classified as having sepsis. Patients with sepsis had an older age distribution and a greater prevalence of comorbidities compared to patients without sepsis. Twenty eight-day mortality was 21% (765/3,716) in sepsis and 4% (54/1,273) in non-sepsis patients (p<0.001). After adjusting for gender, age, and comorbidities, sepsis on admission (adjusted hazard ratio [HR] 3.30; 95% confidence interval [CI] 2.48–4.41, p<0.001), blood culture positive for pathogenic organisms (adjusted HR 2.21; 95% CI 1.89–2.58, p<0.001) and transfer from other hospitals (adjusted HR 2.18; 95% CI 1.69–2.81, p<0.001) were independently associated with mortality. In conclusion, mortality of community-acquired sepsis in Northeast Thailand is considerable and transferred patients with infection are at increased risk of death. To reduce mortality of sepsis in this and other resource-limited setting, facilitating rapid detection of sepsis in all levels of healthcare facilities, establishing guidelines for transfer of sepsis patients, and initiating sepsis care prior to and during transfer may be beneficial.
Sepsis is a syndrome defined by a dysregulated response to infection resulting in significant organ dysfunction and death. Sepsis is a major public health concern. With an aging population, some estimates from the United States (US) and other high-income countries suggest a rising sepsis incidence, albeit with lowered case fatality rates [1–8]. Based on data from seven high-income countries, globally 19 million cases of sepsis (formerly severe sepsis) and 5.3 million deaths were estimated to occur annually [9–11]. Many patients who survive sepsis may incur long-term morbidities [12, 13]. However, these numbers are extrapolated from published population estimates and likely underestimate the true burden of disease, especially in low and middle income countries (LMIC)—which encompass ~87% of the world’s population [10, 14]. Notably, there is a significant paucity of data about the epidemiology and outcomes relating to sepsis in LMIC settings. This is attributable to lack of awareness , poor diagnostic classification of sepsis, and resource and cost related issues [16–23]. Even comprehensive disease quantifying initiatives such as the Global Burden of Disease (GBD) 2016 do not currently report sepsis as a cause of death and morbidity [24, 25], hence sepsis could be underrecognized as a health care burden. Given the global threat of sepsis, the World Health Assembly has recently adopted a resolution to improve the approach to sepsis with a specific acknowledgment of LMIC populations .
In this large prospective observational study in a tertiary care hospital in Northeast Thailand, we demonstrated that sepsis is a significant cause of mortality and morbidity in persons presenting with community-acquired infection. Approximately 75% of enrolled patients had evidence of organ dysfunction consistent with sepsis, and 21% of these patients died. Of surviving patients, those with sepsis had longer hospital stays than patients admitted without sepsis, reflecting the added burden of sepsis to patients and to the healthcare system.