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 J. 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

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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.

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

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ASJC Scopus subject areas

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

Cite this

Jacob, S. T., Moore, C. C., Banura, P., Pinkerton, R., Meya, D., Opendi, P., Reynolds, S. J., Kenya-Mugisha, N., Mayanja-Kizza, H., Scheld, W. M., Kalisa, C., Kimuli, K., Nganizi, A., Omongot, S., Burke, R., Horton, C. L., 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, 4(11), [e7782]. https://doi.org/10.1371/journal.pone.0007782