Management of sepsis and meningitis in developing countries


Published on

Dr Louise Pollock's presentation at Meningitis Research Foundation's 2013 conference, Meningitis and Septicaemia in Children and Adults

Published in: Health & Medicine
  • Be the first to comment

  • Be the first to like this

No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide

Management of sepsis and meningitis in developing countries

  1. 1. Management of sepsis and meningitis in developing countries Dr Louisa Pollock Wellcome Trust Liverpool Glasgow Centre for Global Health Research
  2. 2. The scale of the problem... • Global burden of sepsis huge, highest in countries with least resources • Meningitis – 4% all childhood deaths • Neonatal sepsis/meningitis – 5% all childhood deaths • Mortality for both sepsis and meningitis far higher in high-burden countries • Risk of severe sequelae from bacterial meningitis twice as high in Africa and South-East Asia compared to Europe1 1. Edmond et al 2010
  3. 3. You are on call at Mulanje District Hospital..... • It is midday, everyone is at lunch except you • Chikondi, a 2 year old girl, has been waiting in the queue with... – – – – High fever Fast breathing A stiff neck Irritability • Her malaria test is negative, you are worried she has meningitis...
  4. 4. What is the key to effective treatment?
  5. 5. The key to effective treatment is.. ...with the nurse who has gone to lunch
  6. 6. What is the most essential tool for monitoring?
  7. 7. The most essential tool for monitoring is.... ....the family
  8. 8. Essentials for the management of meningitis and sepsis ACCESS TO CARE HUMAN RESOURCES
  9. 9. Access to care – initial access • No ambulance service • Poor transport infrastructure • Distance to health facility • Primary health care understaffed and underresourced • Minimal “out of hours” service • Costs to family
  10. 10. Access to care - triage • Large numbers of patients – routine and emergencies • No formal triage in many settings • Limited triage capacity • Requirements to register/ pay before triage in some settings
  11. 11. Access to care - diagnosis • Limited culture or biochemistry outside teaching hospitals • Basic microscopy and FBC may be available • PCV/Hb and malaria screen usually available • Imaging generally limited to X-ray +/basic USS
  12. 12. Access to care - drugs • Drugs ordered centrally from essential drugs list • Unpredictable and unreliable supply • Donated drugs often out of date or inappropriate • Fake/poor quality drugs contribute to resistance
  13. 13. Access to care – supportive care • Limited availability of oxygen – O2 concentrator limited to 5l/min – Often shared – Electricity dependent • Bubble CPAP available in some settings • Monitoring limited – Obs, BP, temp, (O2 sats) • Nutritional support variable
  14. 14. Access to care – intensive care • No intensive care in most district hospitals • ITU in teaching hospitals generally limited to adult surgical care • Quality of care provided often poor
  15. 15. Human Resources UK: 500 nurses /50 000 pop Malawi: 30 nurses/ 50 000 pop UK: 135 physicians/ 50 000 pop Malawi: 1 physician/ 50 000 pop •Limited post-graduate training •Limited managerial support and governance •Poorly paid (or unpaid!) •High turnover
  16. 16. Could “Surviving Sepsis” be implemented in developing countries? • 1.2% of surveyed anaesthesia providers in Sub-Saharan Africa reported capacity to deliver full guideline1 – 72% of recommendations implementable – Likely to be an overestimate • Modified bundles of care have been proposed according to local resources2 1. Baelani et al 2011 2.Mahavankul 2012
  17. 17. Should “Surviving Sepsis” be implemented in developing countries? • Different causes of sepsis/meningitis • Wider differential diagnosis • Different co-morbidities – HIV, malnutrition • Different risk:benefit to some interventions – Mechanical ventilation – Invasive monitoring • Evidence base from high-income countries
  18. 18. ETAT: Emergency Triage, Assessment and Treatment • WHO Paediatric emergency care guidelines for resource-limited settings • Training programme and quality improvement strategy • Designed to fit with IMCI • Uses systematic ABCD approach to assessment and treatment • Modified in East Africa to include admission care, malnutrition and neonatal care “ETAT+”
  20. 20. Impact of ETAT • Improved triage and emergency care halved inpatient mortality in QECH Malawi • ETAT+ RCT improved patient outcomes and processes of care in Kenya • Impact greatest with ongoing monitoring and MoH support • Ongoing RCPCH supported programme in East Africa
  21. 21. New WHO sepsis guidelines for adults • IMAI (Integrated Management of Adolescent and Adult Illness) District Clinician Manual • Provide guidelines to care in 1st 2 hours, 2-6 hours, 6-24 hours and post-resuscitation
  22. 22. IMAI sepsis guidelines * • Emphasise – Early recognition hypotension/ resp distress – Treat infection broadly and early, while seeking source – Fix physiology with judicious oxygen and fluids • Additional guidance – Pulmonary oedema in severe malaria – Specific fluid management for dengue – Specific antimicrobials for TB, malaria, maternal sepsis and viral haemorrhagic fevers *Jacob et al BMC Medicine 2013
  23. 23. Evidence for ETAT/IMAI • Systematic review of evidence – International Child Health Review Collaboration – ETAT+ • Early monitored sepsis management in Ugandan adults reduced 30 day mortality by 26%* • Ongoing study in Malawi assessing impact of clinical care bundle in bacterial meningitis, aiming to reduce mortality (Dr E Wall) *Jacob et al 2012
  24. 24. • 3141 children in Kenya, Tanzania and Uganda • Malnutrition, severe dehydration, trauma or severe hypotensive shock excluded • Key finding – 20-40mls/kg bolus over 1 hour associated with increased mortality vs maintenance fluids only (10.6% vs 7.3%) in children severe febrile illness and signs of reduced tissue perfusion • Mortality difference highest in children fulfilling ETAT definition of shock (54% vs 20%) but numbers very small (n=65)
  25. 25. The Impact of FEAST on ETAT 1. Accept FEAST as best available evidence –change guideline to a “no bolus” strategy Kenyan Paediatric Association (ETAT+) 1. Keep current guideline until further evidence available WHO (by default) 1. Develop a new consensus based conservative fluid bolus strategy eg boluses 5mls/kg, assess response ETAT Gambia 1. Keep current guideline with caution advised for specific groups ETAT Gambia
  26. 26. Fluid Guideline 4: Shock due to Severe Infection Give Oxygen Get IV/IO access Give 20mls/kg bolus normal saline over 20 mins Check: Blood Glucose FBC (priority Hb/PCV) UE (priority Na/ K) MPS, Blood Cultures Closely monitor HR, RR, CRT, BCS Child improves Maintenance Fluids Ringers or 0.9% saline with dextrose Child stable but signs of shock not improving Give 20mls/kg bolus 0.9% saline over 20 mins (max 3x20mls/kg) If still not improved give blood 20mls/kg over 1 h Child getting worse THINK ?Fluid overload? ?Anaemia? Consider blood or slowing fluid down
  27. 27. • Evidence for paediatric fluid management limited • Urgent need for trial evidence from high burden, high mortality settings • Both undertaking research and delivering clinical care challenging in this context • Improving triage and basic standard of care can dramatically improve mortality
  28. 28. Urgent research gaps... • Optimal fluid management for septic shock in high burden, high mortality settings • Efficacy, safety and costeffectiveness of components of sepsis clinical care bundles in resource-limited settings • Health systems and operational research to improve access to care and human resources worldwide
  29. 29. The key to management of sepsis and meningitis in developing countries.. • • • • Patience Resilience Creativity Teamwork
  30. 30. Thank you Useful links - Paediatrics • International Child Health Review Collaboration – • ETAT+ Kenya – Useful links –Adults • IMAI District Clinician Manual • ai2011/en/