Tropical Fevers in Indian Intensive Care Units: A Prospective Multicenter Study

Unraveling Sepsis Epidemiology in a Low- and Middle-Income Intensive Care Setting Reveals the Alarming Burden of Tropical Infections and Antimicrobial Resistance: A Prospective Observational Study (MARS-India)

BACKGROUND

Our study addresses the sepsis research gap in lower- and middle-income countries, notably India. Here, we investigate community-acquired sepsis comprehensively and explore the impact of tropical microbiology on etiology and outcomes.

METHODS

MARS-India was a prospective observational study from December 2018 to September 2022 in a tertiary-care hospital in South India. Adult patients within 24 hours of intensive care unit (ICU) admission meeting the Sepsis-3 definition were enrolled, with 6 months of follow-up.

RESULTS

More than 4000 patients were screened on ICU admission, with 1000 unique patients meeting the inclusion criteria. Median age was 55 (interquartile range, 44-65) years, with a male preponderance (66%). Almost half the cohort resided in villages (46.5%) and 74.6% worked in the primary sector. Mortality in-hospital was 24.1%. Overall, about 54% had confirmed microbiological diagnosis and >18% had a viral cause of sepsis. Surprisingly, we identified leptospirosis (10.6%), scrub typhus (4.1%), dengue (3.7%), and Kyasanur forest disease (1.6%) as notable causes of sepsis. All of these infections showed seasonal variation around the monsoon. In community-acquired infections, we observed substantial resistance to third-generation cephalosporins and carbapenems.

CONCLUSIONS

In India, sepsis disproportionally affects a younger and lower-socioeconomic demographic, yielding high mortality. Tropical and viral sepsis carry a significant burden. Analyzing local data, we pinpoint priorities for public health and resources, offering valuable insights for global sepsis research. Clinical Trials Registration. NCT03727243.

Maternal Mortality due to Pregnancy-Related Acute Kidney Injury (PRAKI); A Study of the Epidemiological Factors and Possible Solutions

Objective

This prospective observational study aimed to explore the epidemiology, causes, and outcomes of Pregnancy-Related Acute Kidney Injury (PRAKI) in a tertiary care center in North India and identify risk factors for mortality.

Methods

We enrolled adult obstetric patients with PRAKI according to Kidney disease improving global outcomes criteria between February 2021 and April 2022. Data on demographic characteristics, clinical features, causes of PRAKI, and outcomes were collected. Univariate and multivariate analyses were conducted to identify factors associated with mortality. PRAKI prevention bundles for patients and obstetricians were proposed on the basis of key findings of the study.

Results

Of the 89 patients included, pre-eclampsia/eclampsia/HELLP syndrome, hemorrhage, and sepsis were the primary causes of PRAKI. Maternal mortality was alarmingly high at 24.7%. Factors independently associated with mortality were the need for vasopressor support and renal replacement therapy.

Conclusion

This study highlights the urgent need for preventive and therapeutic interventions to reduce maternal mortality related to PRAKI. On the basis of the key findings, PRAKI prevention bundles were proposed. The PRAKI prevention (patient) bundle included regular BP measurement during ANC visits, healthcare check-up if there is fever or drop in urine during pregnancy or immediate postpartum. The PRAKI prevention (obstetrician) bundle included regular BP measurement, urine culture, avoidance of nephrotoxic agents and hourly urine output monitoring during delivery and immediate postpartum. Implementing preventive measures, enhancing obstetric intensive care units, and improving antenatal care compliance may help mitigate the devastating impact of PRAKI.

Etioepidemiological and Laboratory Profile of Tropical Fever in Patients Presenting With Acute Febrile Illness in Wardha District in Central India: An Observational Study

Introduction This study examined acute febrile illness (AFI) patients for several epidemiological and etiological factors. Acute febrile fever can result from various illnesses, including dengue, malaria, leptospirosis, and scrub typhus. The ranges of clinical outcomes of these cases were investigated as well. Methods This retrospective observational study was conducted from January 2023 to January 2024 for one year in the Medicine Department of Jawaharlal Nehru Medical College and Acharya Vinoba Bhave Rural Hospital, Datta Meghe Institute of Higher Education & Research (Deemed to be University), a tertiary care teaching medical college in Wardha District of Maharashtra in Central India. Six hundred patients with acute febrile illness who tested positive for leptospirosis, dengue, scrub typhus, and malaria were included in the study. A pre-made proforma was used to record the data. Results Out of 600 patients, 150 (25%) were dengue, malaria (62 (10.3%)), scrub typhus (45 (7.5%)) cases, and leptospirosis (41 (6.8%)) cases. In 150 cases of dengue, 63 (42%) had hepatitis as a complication at the time of presentation. Twenty-seven (43.55%) had presented with shock in 62 patients of malaria, 13 (31.71%) had acute respiratory distress syndrome (ARDS) and pneumonia in 41 cases of leptospira, and 13 (28.8%) had hepatitis in 45 cases of scrub typhus patients. Among 38 deaths, three (2%) died due to dengue, two (3.23%) due to malaria, one (2.44%) due to leptospirosis, one (2.44%) due to scrub typhus, and 31 (10.36%) due to acute febrile illness. Conclusion Dengue, malaria, scrub typhus, and leptospirosis were the four primary illnesses that led to AFI in hospitalized patients, with dengue being the most prevalent. Using a mix of clinical, epidemiological, and laboratory information, a pertinent action plan should be created to treat and prevent such fevers in any hospital setting.

The symptomatology of fever: A step towards qualitative definition of fever

Background:

The old definitions of fever are based on cross-sectional surveys of the population without analyzing the associated symptomatology as fever is a sign, not symptom. Therefore, a longitudinal follow-up study is the need of hour to analyze associated symptoms with fever.

Methods:

In a longitudinal study over one year, 196 participants recorded three temperature readings daily, one after waking up, one between 12 and 3 PM, one before sleeping, and filled the symptomatology questionnaire in a thermometry diary.

Results:

Per protocol analysis was done for febrile participants (n = 144). Fatigue (50.3%), warmth (47.3%), headache/head heaviness (47.0%), feeling malaise/general weakness (46.7%), loss of appetite (46.5%), muscle cramps/muscle aches (45.6%), chills/shivering (44.6%), increased sweating (43.0%), nausea (42.5%), irritability (38.9%), increased breathing rate (37.1%), and restlessness/anxiety/palpitations (36.5%) were the symptoms maximally seen during the febrile phase. A higher number of associated symptoms are associated with higher temperature readings. Dehydration suggested the numerically highest temperature values (100.86 ± 1.70°F) but seen in few febrile patients.

Conclusions:

Incorporation of symptom analysis in febrile patients is the need of the hour. Fatigue and warmth are found to be the most prevalent symptoms during febrile phase. Associated symptoms can help in predicting the intensity of fever also.

The symptomatology of fever: A step towards qualitative definition of fever

BACKGROUND

The old definitions of fever are based on cross-sectional surveys of the population without analyzing the associated symptomatology as fever is a sign, not symptom. Therefore, a longitudinal follow-up study is the need of hour to analyze associated symptoms with fever.

METHODS

In a longitudinal study over one year, 196 participants recorded three temperature readings daily, one after waking up, one between 12 and 3 PM, one before sleeping, and filled the symptomatology questionnaire in a thermometry diary.

RESULTS

Per protocol analysis was done for febrile participants (n = 144). Fatigue (50.3%), warmth (47.3%), headache/head heaviness (47.0%), feeling malaise/general weakness (46.7%), loss of appetite (46.5%), muscle cramps/muscle aches (45.6%), chills/shivering (44.6%), increased sweating (43.0%), nausea (42.5%), irritability (38.9%), increased breathing rate (37.1%), and restlessness/anxiety/palpitations (36.5%) were the symptoms maximally seen during the febrile phase. A higher number of associated symptoms are associated with higher temperature readings. Dehydration suggested the numerically highest temperature values (100.86 ± 1.70°F) but seen in few febrile patients.

CONCLUSIONS

Incorporation of symptom analysis in febrile patients is the need of the hour. Fatigue and warmth are found to be the most prevalent symptoms during febrile phase. Associated symptoms can help in predicting the intensity of fever also.

Comparison of Multisystem Inflammatory Syndrome (MIS-C) and Dengue in Hospitalized Children

OBJECTIVE

Multisystem inflammatory syndrome (MIS-C) in children is a febrile illness that has overlapping presentation with other locally prevalent illnesses. Clinicolaboratory profile of children admitted with MIS-C and dengue were compared to understand their presentation at the outset.

METHODS

This was a retrospective study of children ≤ 12 y admitted with MIS-C (WHO definition) or laboratory-confirmed dengue between August 2020 and January 2021 at a tertiary center in North India.

RESULTS

A total of 84 children (MIS-C - 40; dengue - 44) were included. The mean (SD) age [83.5 (39) vs. 91.6 (35) mo] was comparable. Rash (72.5% vs. 22.7%), conjunctival injection (60% vs. 2.3%), oral mucocutaneous changes (27.5% vs. 0) and gallop rhythm (15% vs. 0) were seen more frequently with MIS-C, while petechiae [29.5% vs. 7.5%], myalgia (38.6% vs. 10%), headache (22.7% vs. 2.5%), and hepatomegaly (68.2% vs. 27.5%) were more common with dengue. Children with MIS-C had significantly higher C-reactive protein (124 vs. 3.2 mg/L) and interleukin 6 (95.3 vs. 20.7 ng/mL), while those with dengue had higher hemoglobin (12 vs. 10.2 g/dL) lower mean platelet count (26 vs. 140 × 10⁹/L), and greater elevation in aspartate (607 vs. 44 IU/L) and alanine (235.5 vs. 56 IU/L) aminotransferases. The hospital stay was longer with MIS-C; however, PICU stay and mortality were comparable.

CONCLUSION

In hospitalized children with acute febrile illness, the presence of mucocutaneous features and highly elevated CRP could distinguish MIS-C from dengue. The presence of petechiae, hepatomegaly, and hemoconcentration may favor a diagnosis of dengue.

Systematic review of the scrub typhus treatment landscape: Assessing the feasibility of an individual participant-level data (IPD) platform

Background

Scrub typhus is an acute febrile illness caused by intracellular bacteria from the genus Orientia. It is estimated that one billion people are at risk, with one million cases annually mainly affecting rural areas in Asia-Oceania. Relative to its burden, scrub typhus is understudied, and treatment recommendations vary with poor evidence base. These knowledge gaps could be addressed by establishing an individual participant-level data (IPD) platform, which would enable pooled, more detailed and statistically powered analyses to be conducted. This study aims to assess the characteristics of scrub typhus treatment studies and explore the feasibility and potential value of developing a scrub typhus IPD platform to address unanswered research questions.

Methodology/principal findings

We conducted a systematic literature review looking for prospective scrub typhus clinical treatment studies published from 1998 to 2020. Six electronic databases (Ovid Embase, Ovid Medline, Ovid Global Health, Cochrane Library, Scopus, Global Index Medicus), ClinicalTrials.gov, and WHO ICTRP were searched. We extracted data on study design, treatment tested, patient characteristics, diagnostic methods, geographical location, outcome measures, and statistical methodology.

Among 3,100 articles screened, 127 were included in the analysis. 12,079 participants from 12 countries were enrolled in the identified studies. ELISA, PCR, and eschar presence were the most commonly used diagnostic methods. Doxycycline, azithromycin, and chloramphenicol were the most commonly administered antibiotics. Mortality, complications, adverse events, and clinical response were assessed in most studies. There was substantial heterogeneity in the diagnostic methods used, treatment administered (including dosing and duration), and outcome assessed across studies. There were few interventional studies and limited data collected on specific groups such as children and pregnant women.

Conclusions/significance

There were a limited number of interventional trials, highlighting that scrub typhus remains a neglected disease. The heterogeneous nature of the available data reflects the absence of consensus in treatment and research methodologies and poses a significant barrier to aggregating information across available published data without access to the underlying IPD. There is likely to be a substantial amount of data available to address knowledge gaps. Therefore, there is value for an IPD platform that will facilitate pooling and harmonisation of currently scattered data and enable in-depth investigation of priority research questions that can, ultimately, inform clinical practice and improve health outcomes for scrub typhus patients.

Scrub typhus is a febrile illness most commonly found in rural tropical areas. It is caused by a Gram-negative bacteria belonging to the family Rickettsiaceae and transmitted by mites when they feed on vertebrates. There is an estimate of one million cases annually, with an estimated one billion people at risk, mostly in Asia-Oceania. But relative to the scale of the problem, scrub typhus is largely understudied. Evidence-based treatment recommendations by policymakers vary or are non-existent. We searched databases and registries for prospective scrub typhus clinical treatment studies published from 1998 to 2020 and reviewed them. Data from clinical trials and particularly for specific groups, such as pregnant women and children, were minimal. The methods used to measure treatment efficacy were heterogeneous, making it difficult to directly compare or conduct a meta-analysis based on aggregated data. One way to improve the current level of evidence would be by pooling and analysing individual participant-level data (IPD), i.e. the raw data from individual participants in completed studies. This review demonstrated that there is scope for developing a database for individual participant data to enable more detailed analyses. IPD meta-analyses could be a way to address knowledge gaps such as optimum dosing for children and pregnant women.

Hyperferritinemia in children hospitalized with scrub typhus

BACKGROUND

Hyperferritinemia is increasingly associated with mortality in sepsis. Studies estimating the prevalence of hyperferritinemia in pediatric scrub typhus are limited.

METHODS

This was a secondary analysis of a prospective observational study (FERRIS) from a tertiary care teaching hospital in North India where 72 children with confirmed scrub typhus, 4 (5.5%) PCR positive, 55 (76.4%)-IgM ELISA positive, and 13 (18.1%)-both PCR and ELISA positive, were analyzed. Serum ferritin was measured in 62 children to identify the prevalence of hyperferritinemia and determine its association with mortality.

RESULTS

Hyperferritinemia (> 500 μg/L) was seen in 72.6% [n = 45] children; 26 (41.9%) were mild (500-2000 μg/L), 13 (21%) were moderate (2000-10,000 μg/L), and 6 (9.7%) were severe (> 10,000 μg/L). Early presentation to hospital (≤ 7 days of febrile illness) had more survivors than late presentation (> 7 days). Non-survivors had significantly higher PRISM III, PELOD-2, hyperlactatemia, hypoalbuminemia, organ dysfunction, need for mechanical ventilation, and need of RRT. Ferritin had poor sensitivity and specificity in predicting survival with AUC of 0.56. Organ dysfunction and risk scores as PRISM III, PELOD 2, and VIS at admission were better predictors with AUC (95% CI) of 0.72 (0.56, 0.89), 0.77 (0.63, 0.92), and 0.90 (0.78, 1.0) respectively.

CONCLUSIONS

Hyperferritinemia is common in scrub typhus but it did not predict survival. Organ dysfunction and risk scores were better predictors of mortality than ferritin.

Tropical Infections in the Indian Intensive Care Units: The Tip of the Iceberg!

How to cite this article: Karnad DR, Patil VP, Kulkarni AP. Tropical Infections in the Indian Intensive Care Units: The Tip of the Iceberg! Indian J Crit Care Med 2021; 25(Suppl 2):S115–S117.

An Approach to a Patient with Tropical Infection in the Intensive Care Unit

How to cite this article: Karnad DR, Amin P. An Approach to a Patient with Tropical Infection in the Intensive Care Unit. Indian J Crit Care Med 2021;25(Suppl 2):S118–S121.

Clinical outcome of severe sepsis and septic shock in critically ill children

Information concerning the clinical outcome of severe sepsis and septic shock among the burden of tropical infections in children is limited, particularly in low-income settings. We conducted a prospective consecutive cohort study in all children aged 1 month to 16 years needing paediatric intensive care between 1 January 2017 and 31 December 2018. Demographic details, presenting symptoms and duration, associated co-morbidity and organ dysfunction were recorded. Clinical and laboratory parameters discriminating between survivors and non-survivors were evaluated. Most presented with respiratory or central nervous system derangement along with cardiovascular dysfunction. Haematological involvement was almost invariably found on diagnostic evaluation. Those children with ≥3 systems involved had higher odds of mortality. Dengue was seen in half the patients, being the commonest tropical infection. Not surprisingly, non-survivors were younger, had rapid progression of illness and needed ventilation more often within the first hour of admission. However, in multivariable regression analysis, only procalcitonin levels were associated with increased risk of mortality. We conclude that that tropical infections causing severe sepsis and septic shock are an important cause of mortality. There are, however, no clinical parameters which differentiate reliably between survivors and non-survivors.

Clinical Profile and Predictors of Intensive Care Unit Admission in Pediatric Scrub Typhus: A Retrospective Observational Study from North India

Introduction

Children with scrub typhus may present with one or more organ failures. Identifying the predictors of severe disease and need for pediatric intensive care unit (PICU) admission would help clinicians during outbreak seasons.

Materials and methods

This observational study included 160 children admitted to the emergency department (ED) with scrub typhus confirmed by polymerase chain reaction (PCR) between January 2013 and December 2015. Demographic, clinical, and laboratory data were collected and predictors for PICU admission were identified.

Results

There was a seasonal trend with peak presentation in post-monsoon months between August and October. Mean (SD) age at presentation was 6.8 (3.2) years. Fever was present in all with a median (IQR) duration of 9 (6–11) days. Respiratory distress (42%), altered sensorium (24%), hepatomegaly (93%), splenomegaly (57%), and lymphadenopathy (54%) were other features. Rash and eschar were noted in 24% each. Thrombocytopenia (83%), hypoalbuminemia (63%), and hyponatremia (62%) were common laboratory abnormalities. Meningoencephalitic presentation was noted in 29%; acute kidney injury (AKI) (16%), acute respiratory distress syndrome (ARDS) (11%), and myocarditis (3%) were other organ dysfunctions. Sixty-six (41%) children required PICU admission. Intensive care needs include invasive ventilation (n = 27, 17%), vasoactive drugs therapy for hemodynamic support (n = 43, 27%), osmotherapy to treat raised intracranial pressure (n = 27, 17%), and renal replacement therapy (n = 3, 2%). Mortality was 8.8%. On multivariable analysis, lymphadenopathy, respiratory distress, shock, elevated lactate, and meningoencephalitis predicted the requirement of PICU admission.

Conclusion

Scrub typhus presents with organ dysfunction during post-monsoon months. We identified predictors of intensive care in children with scrub typhus admitted to ED.

Clinical significance

Our results would help clinicians identify severe cases and prioritize resources.

How to cite this article

Nallasamy K, Gupta S, Bansal A, Biswal M, Jayashree M, Zaman K, et al. Clinical Profile and Predictors of Intensive Care Unit Admission in Pediatric Scrub Typhus: A Retrospective Observational Study from North India. Indian J Crit Care Med 2020;24(6):445–450.

Serum Ferritin Predicts Neither Organ Dysfunction Nor Mortality in Pediatric Sepsis Due to Tropical Infections

Objective: To evaluate serial ferritin levels measured in the initial 72 h of admission as a biomarker for new and progressive multi organ dysfunction syndrome (NPMODS) and mortality (unfavorable outcomes) in critically ill children with sepsis due to tropical infections. Material and Methods: In this prospective observational study from a tertiary care teaching hospital in India, children 3 month to 12 years with a diagnosis of acute febrile illness and any two features suggesting tropical infections [cytopenia (platelet count <1,00,000/cu.mm, total leucocyte count <4,000/cu.mm), hepatomegaly and/or splenomegaly, lymphadenopathy, systemic signs (rash, edema), respiratory distress, and encephalopathy not accounted by localized infection] were eligible for inclusion. Children with known or suspected disorder of iron metabolism were excluded. Primary outcome was to determine the association of serial ferritin levels with mortality and NPMODS. Secondary outcomes included estimation of the prevalence of hyperferritinemia and comparison of risk prediction scores with serial ferritin measurement in predicting unfavorable outcomes. Measurements and Main Results: In the 202 children enrolled, diagnosis could be established in 133 (65.8%) children. Scrub typhus and dengue were the most common infections. Median (IQR) ferritin measured at admission (n = 183) and on day 3 (n = 120) of hospital stay were 798 (378, 3,205) μg/L and 429 (213,680) μg/L, respectively. Majority (n = 180, 89.1%) had MODS at admission defined as per International pediatric sepsis consensus conference. NPMODS occurred in 47 (23.3%) children of whom 37 (18.3%) died. Children with three or less organ dysfunctions had lower mortality. Neither admission ferritin values nor the percentage change over 72 h was different between children with favorable and unfavorable outcomes. Pediatric Risk of Mortality (PRISM-III) and daily Pediatric Logistic Organ Dysfunction score (dPELOD2 score) were significantly different in those with unfavorable outcomes. Admission ferritin levels and percentage change in 72 h had poor discriminatory power for mortality with AUC of 0.53 (0.53, 0.67) and 0.50 (0.50, 0.64), respectively. dPELOD2 had the best discriminatory power for mortality with AUC of 0.89 (0.89, 0.95). Conclusions: Serial ferritin estimation predicted neither organ dysfunction nor mortality in pediatric sepsis with tropical infections. dPELOD-2 and PRISM-III predicted unfavorable outcomes better than ferritin. The current diagnostic criteria for MODS overestimated organ dysfunctions in tropical infections and hence may need modification with further validation in this epidemiological cohort.

Challenges in the management of septic shock: a narrative review

While guidelines provide important information on how to approach a patient in septic shock, "many challenges remain" for the management of these patients. In this narrative review, the panel discusses the challenges in identifying the right hemodynamic target, optimization of fluid therapy, selection of vasopressor agents, identification of patients who may benefit from inotropic agents or on the contrary beta-blockade, and use of steroids. The place for microcirculation-targeted therapy is debated as well as the use of alternative techniques (blood purification) and therapies (vitamin C). The implications of hemodynamic alterations on antibiotic doses is discussed. Finally, the specific challenges in low- and middle-income countries are addressed. Ongoing trials address some of these challenges, but many uncertainties will remain, and individualized therapies based on careful clinical assessment will continue to be essential to optimizing the care of patients with septic shock.