Severe sepsis in two Ugandan hospitals

A prospective observational study of management and outcomes in a predominantly HIV-1 infected population

Shevin T. Jacob, Christopher C. Moore, Patrick Banura, Relana Pinkerton, David Meya, Pius Opendi, Steven James Reynolds, Nathan Kenya-Mugisha, Harriet Mayanja-Kizza, W. Michael Scheld, Cassim Kalisa, Kasozi Kimuli, Angelo Nganizi, Samson Omongot, Rebecca Burke, Cheryl Lynn Horton, Francis Ssali, Scholastica Sekayiba, Patrick Ddikusoka

Research output: Contribution to journalArticle

Abstract

Background: Sepsis likely contributes to the high burden of infectious disease morbidity and mortality in low income countries. Data regarding sepsis management in sub-Saharan Africa are limited. We conducted a prospective observational study reporting the management and outcomes of severely septic patients in two Ugandan hospitals. We describe their epidemiology, management, and clinical correlates for mortality. Methodology/Results: Three-hundred eighty-two patients fulfilled enrollment criteria for a severe sepsis syndrome. Vital signs, management and laboratory results were recorded. Outcomes measured included in-hospital and post-dischargemortality. Most patients were HIV-infected (320/377, 84.9%) with a median CD4+ T cell (CD4) count of 52 cells/mm3 (IQR, 16-131 cells/mm3). Overall mortality was 43.0%, with 23.7% in-hospital mortality (90/380) and 22.3% post-discharge mortality (55/247). Significant predictors of in-hospital mortality included admission Glasgow Coma Scale and Karnofsky Performance Scale (KPS), tachypnea, leukocytosis and thrombocytopenia. Discharge KPS and early fluid resuscitation were significant predictors of post-discharge mortality. Among HIV-infected patients, CD4 count was a significant predictor of post-discharge mortality. Median volume of fluid resuscitation within the first 6 hours of presentation was 500 mLs (IQR 250-1000 mls). Fifty-two different empiric antibacterial regimens were used during the study. Bacteremic patients were more likely to die in hospital than non-bacteremic patients (OR 1.83, 95% CI = 1.01-3.33). Patients with Mycobacterium tuberculosis (MTB) bacteremia (25/249) had higher in-hospital mortality (OR 1.97, 95% CI = 1.19-327) and lower median CD4 counts (p = 0.001) than patients without MTB bacteremia. Conclusion: Patients presenting with sepsis syndromes to two Ugandan hospitals had late stage HIV infection and high mortality. Bacteremia, especially from MTB, was associated with increased in-hospital mortality. Most clinical predictors of in-hospital mortality were easily measurable and can be used for triaging patients in resource-constrained settings. Procurement of low cost and high impact treatments like intravenous fluids and empiric antibiotics may help decrease sepsis-associated mortality in resource-constrained settings.

Original languageEnglish (US)
Article numbere7782
JournalPLoS One
Volume4
Issue number11
DOIs
StatePublished - Nov 11 2009

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sepsis (infection)
observational studies
Human immunodeficiency virus 1
Observational Studies
HIV-1
Sepsis
Prospective Studies
Hospital Mortality
Mortality
Population
Discharge (fluid mechanics)
Resuscitation
CD4 Lymphocyte Count
Bacteremia
Mycobacterium tuberculosis
bacteremia
Karnofsky Performance Status
Systemic Inflammatory Response Syndrome
Fluids
HIV

ASJC Scopus subject areas

  • Agricultural and Biological Sciences(all)
  • Biochemistry, Genetics and Molecular Biology(all)
  • Medicine(all)

Cite this

Severe sepsis in two Ugandan hospitals : A prospective observational study of management and outcomes in a predominantly HIV-1 infected population. / Jacob, Shevin T.; Moore, Christopher C.; Banura, Patrick; Pinkerton, Relana; Meya, David; Opendi, Pius; Reynolds, Steven James; Kenya-Mugisha, Nathan; Mayanja-Kizza, Harriet; Scheld, W. Michael; Kalisa, Cassim; Kimuli, Kasozi; Nganizi, Angelo; Omongot, Samson; Burke, Rebecca; Horton, Cheryl Lynn; Ssali, Francis; Sekayiba, Scholastica; Ddikusoka, Patrick.

In: PLoS One, Vol. 4, No. 11, e7782, 11.11.2009.

Research output: Contribution to journalArticle

Jacob, ST, Moore, CC, Banura, P, Pinkerton, R, Meya, D, Opendi, P, Reynolds, SJ, Kenya-Mugisha, N, Mayanja-Kizza, H, Scheld, WM, Kalisa, C, Kimuli, K, Nganizi, A, Omongot, S, Burke, R, Horton, CL, Ssali, F, Sekayiba, S & Ddikusoka, P 2009, 'Severe sepsis in two Ugandan hospitals: A prospective observational study of management and outcomes in a predominantly HIV-1 infected population', PLoS One, vol. 4, no. 11, e7782. https://doi.org/10.1371/journal.pone.0007782
Jacob, Shevin T. ; Moore, Christopher C. ; Banura, Patrick ; Pinkerton, Relana ; Meya, David ; Opendi, Pius ; Reynolds, Steven James ; Kenya-Mugisha, Nathan ; Mayanja-Kizza, Harriet ; Scheld, W. Michael ; Kalisa, Cassim ; Kimuli, Kasozi ; Nganizi, Angelo ; Omongot, Samson ; Burke, Rebecca ; Horton, Cheryl Lynn ; Ssali, Francis ; Sekayiba, Scholastica ; Ddikusoka, Patrick. / Severe sepsis in two Ugandan hospitals : A prospective observational study of management and outcomes in a predominantly HIV-1 infected population. In: PLoS One. 2009 ; Vol. 4, No. 11.
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abstract = "Background: Sepsis likely contributes to the high burden of infectious disease morbidity and mortality in low income countries. Data regarding sepsis management in sub-Saharan Africa are limited. We conducted a prospective observational study reporting the management and outcomes of severely septic patients in two Ugandan hospitals. We describe their epidemiology, management, and clinical correlates for mortality. Methodology/Results: Three-hundred eighty-two patients fulfilled enrollment criteria for a severe sepsis syndrome. Vital signs, management and laboratory results were recorded. Outcomes measured included in-hospital and post-dischargemortality. Most patients were HIV-infected (320/377, 84.9{\%}) with a median CD4+ T cell (CD4) count of 52 cells/mm3 (IQR, 16-131 cells/mm3). Overall mortality was 43.0{\%}, with 23.7{\%} in-hospital mortality (90/380) and 22.3{\%} post-discharge mortality (55/247). Significant predictors of in-hospital mortality included admission Glasgow Coma Scale and Karnofsky Performance Scale (KPS), tachypnea, leukocytosis and thrombocytopenia. Discharge KPS and early fluid resuscitation were significant predictors of post-discharge mortality. Among HIV-infected patients, CD4 count was a significant predictor of post-discharge mortality. Median volume of fluid resuscitation within the first 6 hours of presentation was 500 mLs (IQR 250-1000 mls). Fifty-two different empiric antibacterial regimens were used during the study. Bacteremic patients were more likely to die in hospital than non-bacteremic patients (OR 1.83, 95{\%} CI = 1.01-3.33). Patients with Mycobacterium tuberculosis (MTB) bacteremia (25/249) had higher in-hospital mortality (OR 1.97, 95{\%} CI = 1.19-327) and lower median CD4 counts (p = 0.001) than patients without MTB bacteremia. Conclusion: Patients presenting with sepsis syndromes to two Ugandan hospitals had late stage HIV infection and high mortality. Bacteremia, especially from MTB, was associated with increased in-hospital mortality. Most clinical predictors of in-hospital mortality were easily measurable and can be used for triaging patients in resource-constrained settings. Procurement of low cost and high impact treatments like intravenous fluids and empiric antibiotics may help decrease sepsis-associated mortality in resource-constrained settings.",
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TY - JOUR

T1 - Severe sepsis in two Ugandan hospitals

T2 - A prospective observational study of management and outcomes in a predominantly HIV-1 infected population

AU - Jacob, Shevin T.

AU - Moore, Christopher C.

AU - Banura, Patrick

AU - Pinkerton, Relana

AU - Meya, David

AU - Opendi, Pius

AU - Reynolds, Steven James

AU - Kenya-Mugisha, Nathan

AU - Mayanja-Kizza, Harriet

AU - Scheld, W. Michael

AU - Kalisa, Cassim

AU - Kimuli, Kasozi

AU - Nganizi, Angelo

AU - Omongot, Samson

AU - Burke, Rebecca

AU - Horton, Cheryl Lynn

AU - Ssali, Francis

AU - Sekayiba, Scholastica

AU - Ddikusoka, Patrick

PY - 2009/11/11

Y1 - 2009/11/11

N2 - Background: Sepsis likely contributes to the high burden of infectious disease morbidity and mortality in low income countries. Data regarding sepsis management in sub-Saharan Africa are limited. We conducted a prospective observational study reporting the management and outcomes of severely septic patients in two Ugandan hospitals. We describe their epidemiology, management, and clinical correlates for mortality. Methodology/Results: Three-hundred eighty-two patients fulfilled enrollment criteria for a severe sepsis syndrome. Vital signs, management and laboratory results were recorded. Outcomes measured included in-hospital and post-dischargemortality. Most patients were HIV-infected (320/377, 84.9%) with a median CD4+ T cell (CD4) count of 52 cells/mm3 (IQR, 16-131 cells/mm3). Overall mortality was 43.0%, with 23.7% in-hospital mortality (90/380) and 22.3% post-discharge mortality (55/247). Significant predictors of in-hospital mortality included admission Glasgow Coma Scale and Karnofsky Performance Scale (KPS), tachypnea, leukocytosis and thrombocytopenia. Discharge KPS and early fluid resuscitation were significant predictors of post-discharge mortality. Among HIV-infected patients, CD4 count was a significant predictor of post-discharge mortality. Median volume of fluid resuscitation within the first 6 hours of presentation was 500 mLs (IQR 250-1000 mls). Fifty-two different empiric antibacterial regimens were used during the study. Bacteremic patients were more likely to die in hospital than non-bacteremic patients (OR 1.83, 95% CI = 1.01-3.33). Patients with Mycobacterium tuberculosis (MTB) bacteremia (25/249) had higher in-hospital mortality (OR 1.97, 95% CI = 1.19-327) and lower median CD4 counts (p = 0.001) than patients without MTB bacteremia. Conclusion: Patients presenting with sepsis syndromes to two Ugandan hospitals had late stage HIV infection and high mortality. Bacteremia, especially from MTB, was associated with increased in-hospital mortality. Most clinical predictors of in-hospital mortality were easily measurable and can be used for triaging patients in resource-constrained settings. Procurement of low cost and high impact treatments like intravenous fluids and empiric antibiotics may help decrease sepsis-associated mortality in resource-constrained settings.

AB - Background: Sepsis likely contributes to the high burden of infectious disease morbidity and mortality in low income countries. Data regarding sepsis management in sub-Saharan Africa are limited. We conducted a prospective observational study reporting the management and outcomes of severely septic patients in two Ugandan hospitals. We describe their epidemiology, management, and clinical correlates for mortality. Methodology/Results: Three-hundred eighty-two patients fulfilled enrollment criteria for a severe sepsis syndrome. Vital signs, management and laboratory results were recorded. Outcomes measured included in-hospital and post-dischargemortality. Most patients were HIV-infected (320/377, 84.9%) with a median CD4+ T cell (CD4) count of 52 cells/mm3 (IQR, 16-131 cells/mm3). Overall mortality was 43.0%, with 23.7% in-hospital mortality (90/380) and 22.3% post-discharge mortality (55/247). Significant predictors of in-hospital mortality included admission Glasgow Coma Scale and Karnofsky Performance Scale (KPS), tachypnea, leukocytosis and thrombocytopenia. Discharge KPS and early fluid resuscitation were significant predictors of post-discharge mortality. Among HIV-infected patients, CD4 count was a significant predictor of post-discharge mortality. Median volume of fluid resuscitation within the first 6 hours of presentation was 500 mLs (IQR 250-1000 mls). Fifty-two different empiric antibacterial regimens were used during the study. Bacteremic patients were more likely to die in hospital than non-bacteremic patients (OR 1.83, 95% CI = 1.01-3.33). Patients with Mycobacterium tuberculosis (MTB) bacteremia (25/249) had higher in-hospital mortality (OR 1.97, 95% CI = 1.19-327) and lower median CD4 counts (p = 0.001) than patients without MTB bacteremia. Conclusion: Patients presenting with sepsis syndromes to two Ugandan hospitals had late stage HIV infection and high mortality. Bacteremia, especially from MTB, was associated with increased in-hospital mortality. Most clinical predictors of in-hospital mortality were easily measurable and can be used for triaging patients in resource-constrained settings. Procurement of low cost and high impact treatments like intravenous fluids and empiric antibiotics may help decrease sepsis-associated mortality in resource-constrained settings.

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