Infection Management in Patients with Sepsis and Septic Shock in Resource-Limited Settings

Recommendations on the management of infections in patients with sepsis and septic shock are mainly derived from studies on bacterial sepsis in high-income settings and are not necessarily applicable elsewhere due to differences in etiology and diagnostic or treatment capacity. In this chapter, we provide recommendations on infection management in resource-limited ICUs, taking into account relevant contextual factors such as the availability, affordability, and feasibility of interventions. We recommend empirical antibiotic therapy in patients with sepsis should cover all expected pathogens and likely resistance patterns, based on locally acquired epidemiological data as large regional variations exist. Limited availability of certain classes of antibiotics can complicate implementation of this. We suggest that research groups in collaboration with stakeholders provide microbiological data from sentinel sites throughout resource-limited settings to guide local empirical antibiotic choices. There is weak evidence from resource-limited settings suggesting timely administration of antibiotics is beneficial. Observational data suggest that, in many resource-limited settings, the administration of antibiotics to most patients within 1 h of sepsis or septic shock recognition is feasible. Therefore, given biological plausibility and evidence from resource-rich settings, w e recommend appropriate antibiotics should be given within the first hour following sepsis or septic shock recognition. In resource-limited settings, microbiological laboratory facilities are often restricted, but there was evidence from these settings that taking blood cultures was associated with improved outcome in sepsis and septic shock and with improved appropriateness of antibiotics. We recommend that blood cultures should be taken before the administration of antibiotics in locations where this is possible. Ideally, two sets of blood cultures should be obtained, although the additional yield has not been assessed in resource-limited settings. It is realized that in many hospitals, routine blood culture is unfeasible and expanding microbiological laboratory capacity could improve care. Identification of an infection source and source control are additional challenges in resource-limited settings and are affected by the facilities available. There was weak evidence of reasonable sensitivity of both chest radiography and ultrasound in the diagnosis of abdominal hollow viscus perforation (mainly studied in typhoid or tuberculosis) and abscesses in melioidosis. We found weak evidence that timely surgery was beneficial in typhoidal gastrointestinal perforations. Because of lack of published evidence, we do not provide specific recommendations on the use of chest radiography or ultrasound in resource-limited settings. We suggest that source control is carried out within 12 h of admission to hospital, except in the specific case of pancreatic necrosis, where there is evidence from resource-rich settings that delay in surgical intervention may be beneficial. Combination antimicrobial therapy increases healthcare costs and toxicity. Current SSC guidelines only recommend combination therapy in specific situations, such as when the chances of multidrug resistance are high. Evidence in multidrug-resistant or extensively drug-resistant bacteria was confined to studies of Acinetobacter baumannii infection, where combination therapy was beneficial. Where the chances of multidrug resistance are high, combination antibiotics should be considered. Choice of combination therapy should be guided by local epidemiology and known effective combinations. Antimicrobial therapy should be de-escalated whenever possible. It is recognized that without microbiological information, de-escalation is difficult. The use of biomarkers such as procalcitonin to guide de-escalation of antimicrobial therapy is promising but needs further assessment in resource-limited settings before a recommendation can be made. In conclusion, large variations in disease etiology and high rates of antimicrobial resistance combined with restricted choice of antibiotics and limited microbiological data pose significant challenges in the management of septic patients in resource-limited settings. Increased use of combination therapy and broad-spectrum antibiotic risks increases antimicrobial resistance. Enhanced surveillance necessitates better collaboration between stakeholders and improved microbiological facilities, which in turn requires significant investment. However, newer technologies which negate the need for specialist staff and equipment may become more available. This would not only improve the management of individual patients but, by providing high-quality epidemiological data, may help combat the global threat of antimicrobial resistance.
(Copyright 2019, The Author(s).)