The long sepsis journey in low- and middle-income countries begins with a first step...but on which road?

“The most efficacious critical care is the critical care intervention that a patient never needs.” JC Farmer [1]. “A leader is best when people barely know he exists. When his work is done, his aim fulfilled, they will say: we did it ourselves.” Lao Tzu [2]. Infection and sepsis [3] are among the most frequent acute medical conditions worldwide and result in approximately eight million premature deaths each year, most of which occur in low and lower-middle income countries (LMICs) (Fig. 1) [4]. The United Nations World Health Assembly has recognized sepsis as a global health priority and adopted a resolution to improve its worldwide prevention, diagnosis and management [5]. Despite the rising global awareness, there are no successful approaches to reduce the sepsis burden in LMICs. This is exacerbated by the reality that contemporary scientific evidence and guidelines on sepsis management almost exclusively originate in high-income countries (HICs). International sepsis guidelines focus on critical care aspects of bacterial or fungal sepsis [6, 7] and cannot be extrapolated to resource-limited settings or patients with non-bacterial sepsis such as malaria or tropical viral diseases. Furthermore, implementation of international guidelines in LMICs may even have harmful effects [8, 9], particularly in vulnerable populations such as children [10]. Strategies specifically designed to reduce the burden of sepsis in LMICs are therefore greatly needed. Solutions must be simple, easily applicable, reliant on frugal and ubiquitous technology, and cost-effective. Delayed or inadequately treated infection accounts for a relevant number of patients with sepsis in LMIC hospitals. This implies that early and appropriate management of patients with acute infection could reduce the incidence of sepsis-associated morbidity and mortality. Such an approach may conserve already scarce resources where intensive care expertise and required technologies to care for critically ill patients (with sepsis) are widely unavailable or only accessible at excessive costs. In striking contrast to current strategies to reduce sepsis deaths in high-income countries, such a “preventive” approach would paradoxically not focus on critically ill patients but interrupt the pathway from acute infection to sepsis and hence avert organ dysfunction. Following early recognition of at-risk patients, appropriate infection management would focus on timely and adequate antimicrobial therapy as well as surgical source control. All of these interventions should be simple, also available in non-physicianstaffed primary care facilities (e.g. dispensaries, health care centres) and not depend on technology or sophisticated interventions. Sepsis “prevention” in LMICs is an incomplete approach. Some patients either present late in their disease course or have sepsis that is pre-determined by the type and severity of infection (e.g. peritonitis), premorbid conditions or individual genotypes. Thus, a strategy to reduce sepsis mortality in LMICs should also include a rational treatment plan for patients with infection-induced organ dysfunction. Achievable interventions (in addition to adequate source control) may * Correspondence: [email protected] Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital, Johannes Kepler University Linz, Linz, Austria Full list of author information is available at the end of the article