title: Current challenges in the management of sepsis in ICUs in resource-poor settings and suggestions for the future.
abstract: BACKGROUND
  Sepsis is a major reason for intensive care unit (ICU) admission, also in resource-poor settings. ICUs in low- and middle-income countries (LMICs) face many challenges that could affect patient outcome.
  
  
  OBJECTIVE
  To describe differences between resource-poor and resource-rich settings regarding the epidemiology, pathophysiology, economics and research aspects of sepsis. We restricted this manuscript to the ICU setting even knowing that many sepsis patients in LMICs are treated outside an ICU.
  
  
  RESULTS
  Although many bacterial pathogens causing sepsis in LMICs are similar to those in high-income countries, resistance patterns to antimicrobial drugs can be very different; in addition, causes of sepsis in LMICs often include tropical diseases in which direct damaging effects of pathogens and their products can sometimes be more important than the response of the host. There are substantial and persisting differences in ICU capacities around the world; not surprisingly the lowest capacities are found in LMICs, but with important heterogeneity within individual LMICs. Although many aspects of sepsis management developed in rich countries are applicable in LMICs, implementation requires strong consideration of cost implications and the important differences in resources.
  
  
  CONCLUSIONS
  Addressing both disease-specific and setting-specific factors is important to improve performance of ICUs in LMICs. Although critical care for severe sepsis is likely cost-effective in LMIC setting, more detailed evaluation at both at a macro- and micro-economy level is necessary. Sepsis management in resource-limited settings is a largely unexplored frontier with important opportunities for research, training, and other initiatives for improvement.
authors.affiliation: Mahidol University, Bangkok, Thailand. marcus.j.schultz@gmail.com.|Department of Intensive Care, Academic Medical Center and University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands. marcus.j.schultz@gmail.com.
authors.forename: Marcus J
authors.initials: MJ
authors.lastname: Schultz
authors.affiliation: University College of London Hospital, London, UK.
authors.forename: Martin W
authors.initials: MW
authors.lastname: Dunser
authors.affiliation: Mahidol University, Bangkok, Thailand.|Department of Intensive Care, Academic Medical Center and University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
authors.forename: Arjen M
authors.initials: AM
authors.lastname: Dondorp
authors.affiliation: Sunnybrook Health Sciences Centre and University of Toronto, Toronto, ON, Canada.
authors.forename: Neill K J
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authors.affiliation: Bharati Vidyapeeth Deemed University Medical College, Pune, India.
authors.forename: Shivakumar
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authors.lastname: Iyer
authors.affiliation: Mulago National Referral Hospital, Kampala, Uganda.
authors.forename: Arthur
authors.initials: A
authors.lastname: Kwizera
authors.affiliation: Department of Intensive Care, Academic Medical Center and University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
authors.forename: Yoel
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authors.lastname: Lubell
authors.affiliation: University of Maryland School of Medicine, Baltimore, MD, USA.
authors.forename: Alfred
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authors.lastname: Papali
authors.affiliation: Mahidol University, Bangkok, Thailand.|Department of Intensive Care, Academic Medical Center and University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
authors.forename: Luigi
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authors.lastname: Pisani
authors.affiliation: Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA.
authors.forename: Beth D
authors.initials: BD
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authors.affiliation: University of Pittsburgh, Pittsburgh, PA, USA.
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authors.initials: DC
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authors.affiliation: Hospital Sirio-Libanes, Saõ Paulo, Brazil.
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authors.initials: LC
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authors.affiliation: Karolinska Institute, Stockholm, Sweden.
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authors.affiliation: California Pacific Medical Center, San Francisco, CA, USA.
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authors.affiliation: Mayo Clinic, Jacksonville, FL, USA.
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authors.affiliation: Mahidol University, Bangkok, Thailand.
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authors.affiliation: Stony Brook University Medical Center, Stony Brook, NY, USA.
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authors.affiliation: University of Washington, Seattle, WA, USA.
authors.forename: Shevin T
authors.initials: ST
authors.lastname: Jacob
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authors.affiliation: All India Institute of Medical Science, Delhi, India.
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authors.affiliation: St. James's University Hospital, Dublin, Ireland.
authors.forename: Ignacio
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authors.affiliation: Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia.
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authors.affiliation: Aga Khan University Hospital, Nairobi, Kenya.
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authors.forename: Mervyn
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authors.affiliation: Ispat General Hospital, Sundargarh, Rourkela, Odisha, India.
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authors.affiliation: British Columbia Children's Hospital, Vancouver, Canada.
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authors.affiliation: Mulago National Referral Hospital, Kampala, Uganda.
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authors.lastname: Nakibuuka
authors.affiliation: Department of Intensive Care, Academic Medical Center and University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.|Medical Intensive Care Unit, Hospital Israelita Albert Einstein, Sao Paulo, Brazil.
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authors.affiliation: Oxford University Clinical Research Unit, Hospital for Tropical Diseases, District 5, Ho Chi Minh City, Vietnam.
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authors.affiliation: Trung Vuong Hospital, Ho Chi Minh City, Vietnam.
authors.forename: Binh
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authors.affiliation: Ispat General Hospital, Sundargarh, Rourkela, Odisha, India.
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authors.affiliation: Nova Medical School, CEDOC, New University of Lisbon and Hospital de Sao Francisco Xavier , Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal.
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authors.lastname: Povoa
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authors.forename: Suchitra
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authors.lastname: Ranjit
authors.affiliation: Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA.
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authors.forename: Jonarthan
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mesh_terms: D000328:Adult; D035843:Biomedical Research; D002675:Child, Preschool; D003362:Cost-Benefit Analysis; D003422:Critical Care / Q000191:economics* / Q000706:statistics & numerical data; D003906:Developing Countries; D004351:Drug Resistance; D000071219:Global Burden of Disease / Q000706:statistics & numerical data; D017048:Health Care Costs; D006295:Health Resources / Q000600:supply & distribution*; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D007362:Intensive Care Units / Q000191:economics* / Q000706:statistics & numerical data; D008875:Middle Aged; D017410:Practice Guidelines as Topic; D011787:Quality of Health Care; D018805:Sepsis / Q000191:economics / Q000453:epidemiology* / Q000209:etiology / Q000628:therapy
keywords: Critical care; Resource-limited settings; Sepsis management