Prevalence, Etiology, and Outcome of Sepsis among Critically Ill Patients in Malawi

The burden and predictors of hospital-acquired infection in intensive care units across Sub-Sahara Africa: systematic review and metanalysis

BACKGROUND

Hospital-acquired infection (HAI) refers to an infection that occurs during hospitalization and typically manifests 48 h after admission. Evidence suggests that the prevalence of HAIs in Sub-Saharan Africa (SSA) is significantly higher compared to other regions. These infections remain a major concern in low-income countries, contributing to elevated morbidity and mortality rates. This study aimed to assess the burden and identify predictors of HAIs in intensive care units (ICUs) across SSA.

METHODS

This review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We searched PubMed, Scopus, Embase, Web of Science, Africa Index Medicus, ScienceDirect, HINARI, and Google Scholar to identify relevant studies published in English. This systematic review encompasses 44 articles published between 2003 and 2024, with the majority (22 articles) published recently between 2020 and 2024. The actual database search was conducted between January 1, 2025, and February 1, 2025. Articles irrelevant to this study's objectives, those without abstracts or full texts, unpublished reports, editorials, studies that did not clearly define outcomes, and studies written in languages other than English were excluded. The analysis was conducted using Stata version 17. The protocol was registered with PROSPERO under the registration number CRD 63,194,923,892. Quality assessment was performed using the Newcastle-Ottawa Scale, and data extraction followed the Joanna Briggs Institute methodology.

RESULTS

A total of 44 primary samples were included in this meta-analysis. Using the random effect DerSimonian model, we showed that the pooled prevalence of hospital-acquired infections (HAIs) in intensive care units was 28.22% (95% CI: 23.61-32.81). Determinants of HAIs in the intensive care units included neonatal or advanced age (> 50 years), intubation, trauma, surgery, presence of comorbidities, catheterization, prolonged hospital stay, and HIV-positive status.

CONCLUSION AND RECOMMENDATIONS

Individuals in extreme age groups, those with chronic diseases or immunocompromised conditions, and patients with specific risk factors (e.g., catheterization, prolonged hospitalization) were more prone to HAIs. Strengthening the quality of care and implementing effective infection control measures are recommended to reduce the burden of healthcare-associated infections (HAIs) in sub-Saharan Africa.

Progress on implementing the WHO-GLASS recommendations on priority pathogen-antibiotic sensitivity testing in Africa: A scoping review

Introduction

The World Health Organization global antimicrobial resistance surveillance system (GLASS) was rolled out in 2015 to guide antimicrobial resistance (AMR) surveillance. However, its implementation in Africa has not been fully evaluated. We conducted a scoping review to establish the progress of implementing the WHO 2015 GLASS manual in Africa.

Methods

We used MeSH terms to comprehensively search electronic databases (MEDLINE and Embase) for articles from Africa published in English between January 2016 and December 2023. The Arksey and O'Malley's methodological framework for scoping reviews was employed. Data were collected on compliance with WHO GLASS recommendations for AMR surveillance-priority samples, pathogens, and pathogen-antibiotic combinations and analysed using Microsoft Excel.

Results

Overall, 13,185 articles were identified. 7,409 were duplicates, and 5,141 articles were excluded based on titles and abstracts. 609 full-text articles were reviewed, and 147 were selected for data extraction. Of the 147 selected articles, 78.9% had been published between 2020 and 2023; 57.8% were from Eastern Africa. 93.9% of articles were on cross-sectional studies. 96.6% included only one priority sample type; blood (n=56), urine (n=64), and stool (n=22). Of the 60 articles that focused on blood as a priority sample type, 71.7%, 68.3%, 68.3%, 36.7%, 30%, and 10% reported recovery of Escherichia coli, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Salmonella species and Streptococcus pneumoniae, respectively. Salmonella and Shigella species were reported to have been recovered from 91.3% and 73.9% of the 23 articles that focused on stool. E. coli and K. pneumoniae recoveries were also reported from 94.2% and 68.1% of the 69 articles that focused on urine. No article in this review reported having tested all the recommended WHO GLASS pathogen-antibiotic combinations for specific pathogens.

Conclusion

Progress has been made in implementing the GLASS recommendations in Africa, but adoption varies across countries limiting standardisation and comparability of data.

Prevalence and Outcome of Sepsis: Mortality and Prolonged Intensive Care Unit Stay among Sepsis Patients Admitted to a Tertiary Centre in Malaysia

Background

Sepsis and septic shock are the leading causes of critical care-related mortality worldwide. This study aimed to determine the prevalence of sepsis, its intensive care unit (ICU) mortality rate and the factors associated with both ICU mortality and prolonged stay.

Methods

A prospective cohort study was conducted from January 2019 to December 2019 with adult patients presenting evidence of sepsis who were admitted to the ICU. Parameters were assessed in the ICU to determine the association with all-cause ICU mortality and prolonged stay.

Results

Out of 607 adults, 292 with sepsis were admitted to the ICU in 2019, with a mean age of 50.98 (standard deviation [SD] = 17.75) years old. There was, thus, a 48% incidence of sepsis. Mortality was observed in 78 patients (mortality rate = 26.7%) (95% confidence interval [CI]: 21.7, 32.2). Patients with higher Glasgow coma scale (GCS) scores had lower odds of ICU mortality (adjusted odds ratio [OR] = 0.90; 95% CI: 0.82, 0.98; P = 0.019), while patients with higher sequential organ failure assessment (SOFA) scores had higher odds (adjusted OR = 1.22; 95% CI: 1.11, 1.35; P < 0.001). Eighty patients (37.4%) who survived had prolonged ICU stays (95% CI: 30.9, 44.2). Patients with higher albumin levels had lower odds of a prolonged ICU stay (adjusted OR = 0.94; 95% CI: 0.90, 0.98; P = 0.006) and patients on renal replacement therapy had higher odds of a prolonged ICU stay (adjusted OR = 1.25; 95% CI: 1.74, 7.12; P < 0.001).

Conclusion

Our study identified a sepsis prevalence of 48% and an ICU mortality rate of 26.7% among adult patients admitted to the ICU. GCS and SOFA scores were the most important factors associated with ICU mortality.

Critical Care Units in Malawi: A Cross-Sectional Study

Background

The global burden of critical illness falls disproportionately outside high-income countries. Despite younger patient populations with similar or lower disease severity, critical illness outcomes are poor outside high-income countries. A lack of data limits attempts to understand and address the drivers of critical care outcomes outside high-income countries.

Objectives

We aim to characterize the organization, available resources, and service capacity of public sector critical care units in Malawi and identify barriers to improving care.

Methods

We conducted a secondary analysis of the Malawi Emergency and Critical Care Survey, a cross-sectional study performed from January to February 2020 at all four central hospitals and a simple random sample of nine out of 24 public sector district hospitals in Malawi, a predominantly rural, low-income country of 19.6 million in southern Africa. Data from critical care units were used to characterize resources, processes, and barriers to care.

Findings

There were four HDUs and four ICUs across the 13 hospitals in the Malawi Emergency and Critical Care Survey sample. The median critical care beds per 1,000,000 catchment was 1.4 (IQR: 0.9 to 6.7). Absent equipment was the most common barrier in HDUs (46% [95% CI: 32% to 60%]). Stockouts was the most common barriers in ICUs (48% [CI: 38% to 58%]). ICUs had a median 3.0 (range: 2 to 8) functional ventilators per unit and reported an ability to perform several quality mechanical ventilation interventions.

Conclusions

Although significant gaps exist, Malawian critical care units report the ability to perform several complex clinical processes. Our results highlight regional inequalities in access to care and support the use of process-oriented questions to assess critical care capacity. Future efforts should focus on basic critical care capacity outside of urban areas and quantify the impact of context-specific variables on critical care mortality.

Scope and mortality of adult medical ICU patients in an Eastern Cape tertiary hospital

Background

The characteristics and mortality outcomes of patients admitted to South African intensive care units (ICUs) owing to medical conditions are unknown. Available literature is derived from studies based on data from high-income countries.

Objectives

To determine ICU utilisation by medical patients and evaluate the scope of admissions and clinical associations with hospital mortality in ICU patients 12 years and older admitted to an Eastern Cape tertiary ICU, particularly in the subset with HIV disease.

Methods

A retrospective descriptive one-year cohort study. Data were obtained from the LivAKI study database and demographic data, comorbidities, diagnosis, and mortality outcomes and associations were determined.

Results

There were 261 (29.8%) medical ICU admissions. The mean age of the cohort was 40.2 years; 51.7% were female. When compared with the surgical emergencies, the medical subgroup had higher sequential organ failure assessment (SOFA) scores (median score 5 v. 4, respectively) and simplified acute physiology score III (SAPS 3) scores (median 52.7 v. 48.5), a higher incidence of acute respiratory distress syndrome (ARDS) (7.7% v. 2.9%) and required more frequent dialysis (20.3% v. 5.5%). Of the medical admissions, sepsis accounted for 32.4% of admission diagnoses. The HIV seroprevalence rate was 34.0%, of whom 57.4% were on antiretroviral therapy. ICU and hospital mortality rates were 11.1% and 21.5% respectively, while only acute kidney injury (AKI) and sepsis were independently associated with mortality. The HIV-positive subgroup had a higher burden of tuberculosis (TB), higher admission SOFA and SAPS 3 scores and required more organ support.

Conclusion

Among medical patients admitted to ICU, there was a high HIV seroprevalence with low uptake of antiretroviral therapy. Sepsis was the most frequently identified ICU admission diagnosis. Sepsis and AKI (not HIV) were independent predictors of mortality. Co-infection with HIV and TB was associated with increased mortality.

Contributions of the study

The epidemiology and outcomes of adults who are critically ill from medical conditions in South African intensive care units was previously unknown but has been described in this study. The association of sepsis, TB, HIV and acute kidney injury with mortality is discussed.

The Malawi emergency and critical care survey: A cross-sectional national facility assessment

BACKGROUND

Data on emergency and critical care (ECC) capacity in low-income countries (LICs) are needed to improve outcomes and make progress towards realizing the goal of Universal Health Coverage.

METHODS

We developed a novel research instrument to assess public sector ECC capacity and service readiness in LICs. From January 20th to February 18th, 2020 we administered the instrument at all four central hospitals and a simple random sample of nine of 24 district hospitals in Malawi, a landlocked and predominantly rural LIC of 19·1 million people in Southern Africa. The instrument contained questions on the availability of key resources across three domains and was administered to hospital administrators and clinicians from outpatient departments, emergency departments, and inpatient units. Results were used to generate an ECC Readiness Score, with a possible range of 0 to 1, for each facility.

FINDINGS

A total of 114 staff members across 13 hospitals completed interviews for this study. Three (33%) district hospitals and all four central hospitals had ECC Readiness Scores above 0·5 (p-value 0·070). Absent equipment was identified as the most common barrier to ECC Readiness. Central hospitals had higher median ECC Readiness Scores with less variability 0·82 (interquartile range: 0·80-0·89) than district hospitals (0·33, 0·23 to 0·50, p-value 0·021).

INTERPRETATION

This is the first study to employ a systematic approach to assessing ECC capacity and service readiness at both district and central hospitals in Malawi and provides a framework for measuring ECC capacity in other LICs. Prior ECC assessments potentially overestimated equipment availability and our methodology may provide a more accurate approach. There is an urgent need for investments in ECC services, particularly at district hospitals which are more accessible to Malawi's predominantly rural population. These findings highlight the need for long-term investments in health systems strengthening and underscore the importance of understanding capacity in LIC settings to inform these efforts.

FUNDING

Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital and Department of Emergency Medicine, Brigham and Women's Hospital.

A retrospective study of ulinastatin for the treatment of severe sepsis

This retrospective study aimed to investigate the efficacy and safety of existing approach of ulinastatin for the treatment of severe sepsis (SS).A total of 130 eligible patients with SS were included in this study. We divided them into an intervention group (n = 65) and a control group (n = 65). Patients in both groups received conventional therapy. In addition, patients in the intervention group received ulinastatin for 7 days. Outcomes were measured by Acute Physiology and Chronic Health Evaluation II (APACHE II), Multiple Organ Failure (MOF), Glasgow Coma Scale (GCS), CD3, CD4, CD8, CD4/CD8, and adverse events. We assessed all outcomes before and after treatment.After treatment, patients in the intervention group showed better improvement in APACHE II (P < .01), MOF (P < .01), GCS (P < .01), CD3 (P = .03), CD4 (P = .03), and CD4/CD8 (P < .01), than those of patients in the control group. There are similar safety profiles between both groups.This study suggests that ulinastatin may be beneficial for SS. Future studies are still needed to warrant the results of this study.