title: Severe sepsis in two Ugandan hospitals: a prospective observational study of management and outcomes in a predominantly HIV-1 infected population.
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.
  
  
  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-discharge mortality. Most patients were HIV-infected (320/377, 84.9%) with a median CD4+ T cell (CD4) count of 52 cells/mm(3) (IQR, 16-131 cells/mm(3)). 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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, WA, USA. sjacob2@uw.edu
authors.forename: Shevin T
authors.initials: ST
authors.lastname: Jacob
authors.forename: Christopher C
authors.initials: CC
authors.lastname: Moore
authors.forename: Patrick
authors.initials: P
authors.lastname: Banura
authors.forename: Relana
authors.initials: R
authors.lastname: Pinkerton
authors.forename: David
authors.initials: D
authors.lastname: Meya
authors.forename: Pius
authors.initials: P
authors.lastname: Opendi
authors.forename: Steven J
authors.initials: SJ
authors.lastname: Reynolds
authors.forename: Nathan
authors.initials: N
authors.lastname: Kenya-Mugisha
authors.forename: Harriet
authors.initials: H
authors.lastname: Mayanja-Kizza
authors.forename: W Michael
authors.initials: WM
authors.lastname: Scheld
mesh_terms: D017088:AIDS-Related Opportunistic Infections / Q000175:diagnosis / Q000453:epidemiology / Q000401:mortality; D015496:CD4-Positive T-Lymphocytes / Q000166:cytology; D005260:Female; D015658:HIV Infections / Q000150:complications* / Q000628:therapy*; D017052:Hospital Mortality; D006760:Hospitalization; D006801:Humans; D008297:Male; D009169:Mycobacterium tuberculosis / Q000378:metabolism; D011446:Prospective Studies; D018805:Sepsis / Q000150:complications / Q000175:diagnosis* / Q000453:epidemiology* / Q000401:mortality; D016896:Treatment Outcome; D014454:Uganda