1
|
Wagstaff D, Arfin S, Korver A, Chappel P, Rashan A, Haniffa R, Beane A. Interventions for improving critical care in low- and middle-income countries: a systematic review. Intensive Care Med 2024; 50:832-848. [PMID: 38748264 DOI: 10.1007/s00134-024-07377-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 02/27/2024] [Indexed: 05/28/2024]
Abstract
PURPOSE To systematically review the typology, impact, quality of evidence, barriers, and facilitators to implementation of Quality Improvement (QI) interventions for adult critical care in low- and middle-income countries (LMICs). METHODS MEDLINE, EMBASE, Cochrane Library and ClinicalTrials.gov were searched on 1st September 2022. The studies were included if they described the implementation of QI interventions for adult critical care in LMICs, available as full text, in English and published after 2000. The risks of bias were assessed using the ROB 2.0/ROBINS-I tools. Intervention strategies were categorised according to a Knowledge Translation framework. Interventions' effectiveness were synthesised by vote counting and assessed with a binomial test. Barriers and facilitators to implementation were narratively synthesised using the Consolidated Framework for Implementation Research. RESULTS 78 studies were included. Risk of bias was high. The most common intervention strategies were Education, Audit & Feedback (A&F) and Protocols/Guidelines/Bundles/Checklists (PGBC). Two multifaceted strategies improved both process and outcome measures: Education and A&F (p = 0.008); and PGBC with Education and A&F (p = 0.001, p < 0.001). Facilitators to implementation were stakeholder engagement, organisational readiness for implementation, and adaptability of interventions. Barriers were lack of resources and incompatibility with clinical workflows. CONCLUSIONS The evidence for QI in critical care in LMICs is sparse and at high risk of bias but suggests that multifaceted interventions are most effective. Co-designing interventions with and engaging stakeholders, communicating relative advantages, employing local champions and adapting to feedback can improve implementation. Hybrid study designs, process evaluations and adherence to reporting guidelines would improve the evidence base.
Collapse
Affiliation(s)
| | - Sumaiya Arfin
- The George Institute for Global Health, New Delhi, India.
| | - Alba Korver
- Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | | | | | - Rashan Haniffa
- Pandemic Sciences Hub and Institute for Regeneration and Repair, University of Edinburgh, Edinburgh, UK
- NICS-MORU, Colombo, Sri Lanka
| | - Abi Beane
- Pandemic Sciences Hub and Institute for Regeneration and Repair, University of Edinburgh, Edinburgh, UK
- NICS-MORU, Colombo, Sri Lanka
| |
Collapse
|
2
|
Wixon-Genack J, Wright SW, Cobb Ortega NL, Hantrakun V, Rudd KE, Teparrukkul P, Limmathurotsakul D, West TE. Prognostic Accuracy of Screening Tools for Clinical Deterioration in Adults With Suspected Sepsis in Northeastern Thailand: A Cohort Validation Study. Open Forum Infect Dis 2024; 11:ofae245. [PMID: 38756761 PMCID: PMC11097208 DOI: 10.1093/ofid/ofae245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 04/29/2024] [Indexed: 05/18/2024] Open
Abstract
Background We sought to assess the performance of commonly used clinical scoring systems to predict imminent clinical deterioration in patients hospitalized with suspected infection in rural Thailand. Methods Patients with suspected infection were prospectively enrolled within 24 hours of admission to a referral hospital in northeastern Thailand between 2013 and 2017. In patients not requiring intensive medical interventions, multiple enrollment scores were calculated including the National Early Warning Score (NEWS), the Modified Early Warning Score, Between the Flags, and the quick Sequential Organ Failure Assessment score. Scores were tested for predictive accuracy of clinical deterioration, defined as a new requirement of mechanical ventilation, vasoactive medications, intensive care unit admission, and/or death approximately 1 day after enrollment. The association of each score with clinical deterioration was evaluated by means of logistic regression, and discrimination was assessed by generating area under the receiver operating characteristic curve. Results Of 4989 enrolled patients, 2680 met criteria for secondary analysis, and 100 of 2680 (4%) experienced clinical deterioration within 1 day after enrollment. NEWS had the highest discrimination for predicting clinical deterioration (area under the receiver operating characteristic curve, 0.78 [95% confidence interval, .74-.83]) compared with the Modified Early Warning Score (0.67 [.63-.73]; P < .001), quick Sequential Organ Failure Assessment (0.65 [.60-.70]; P < .001), and Between the Flags (0.69 [.64-.75]; P < .001). NEWS ≥5 yielded optimal sensitivity and specificity for clinical deterioration prediction. Conclusions In patients hospitalized with suspected infection in a resource-limited setting in Southeast Asia, NEWS can identify patients at risk of imminent clinical deterioration with greater accuracy than other clinical scoring systems.
Collapse
Affiliation(s)
- Jenna Wixon-Genack
- Department of Internal Medicine, Alaska Native Medical Center, Anchorage, Alaska, USA
| | - Shelton W Wright
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, Washington, USA
| | - Natalie L Cobb Ortega
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Viriya Hantrakun
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Kristina E Rudd
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Prapit Teparrukkul
- Department of Internal Medicine, Sunpasitthiprasong Hospital, Ubon Ratchathani, Thailand
| | - Direk Limmathurotsakul
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Department of Tropical Hygiene, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - T Eoin West
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington, USA
| |
Collapse
|
3
|
Xia L, Hantrakun V, Teparrukkul P, Wongsuvan G, Kaewarpai T, Dulsuk A, Day NPJ, Lemaitre RN, Chantratita N, Limmathurotsakul D, Shojaie A, Gharib SA, West TE. Plasma Metabolomics Reveals Distinct Biological and Diagnostic Signatures for Melioidosis. Am J Respir Crit Care Med 2024; 209:288-298. [PMID: 37812796 PMCID: PMC10840774 DOI: 10.1164/rccm.202207-1349oc] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 10/09/2023] [Indexed: 10/11/2023] Open
Abstract
Rationale: The global burden of sepsis is greatest in low-resource settings. Melioidosis, infection with the gram-negative bacterium Burkholderia pseudomallei, is a frequent cause of fatal sepsis in endemic tropical regions such as Southeast Asia. Objectives: To investigate whether plasma metabolomics would identify biological pathways specific to melioidosis and yield clinically meaningful biomarkers. Methods: Using a comprehensive approach, differential enrichment of plasma metabolites and pathways was systematically evaluated in individuals selected from a prospective cohort of patients hospitalized in rural Thailand with infection. Statistical and bioinformatics methods were used to distinguish metabolomic features and processes specific to patients with melioidosis and between fatal and nonfatal cases. Measurements and Main Results: Metabolomic profiling and pathway enrichment analysis of plasma samples from patients with melioidosis (n = 175) and nonmelioidosis infections (n = 75) revealed a distinct immuno-metabolic state among patients with melioidosis, as suggested by excessive tryptophan catabolism in the kynurenine pathway and significantly increased levels of sphingomyelins and ceramide species. We derived a 12-metabolite classifier to distinguish melioidosis from other infections, yielding an area under the receiver operating characteristic curve of 0.87 in a second validation set of patients. Melioidosis nonsurvivors (n = 94) had a significantly disturbed metabolome compared with survivors (n = 81), with increased leucine, isoleucine, and valine metabolism, and elevated circulating free fatty acids and acylcarnitines. A limited eight-metabolite panel showed promise as an early prognosticator of mortality in melioidosis. Conclusions: Melioidosis induces a distinct metabolomic state that can be examined to distinguish underlying pathophysiological mechanisms associated with death. A 12-metabolite signature accurately differentiates melioidosis from other infections and may have diagnostic applications.
Collapse
Affiliation(s)
- Lu Xia
- Department of Biostatistics
| | | | - Prapit Teparrukkul
- Department of Internal Medicine, Sunpasitthiprasong Hospital, Ubon Ratchathani, Thailand; and
| | | | | | - Adul Dulsuk
- Department of Microbiology and Immunology, and
| | - Nicholas P. J. Day
- Mahidol Oxford Tropical Medicine Research Unit
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | | | - Narisara Chantratita
- Mahidol Oxford Tropical Medicine Research Unit
- Department of Microbiology and Immunology, and
| | - Direk Limmathurotsakul
- Mahidol Oxford Tropical Medicine Research Unit
- Department of Tropical Hygiene, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | | | - Sina A. Gharib
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, and
| | - T. Eoin West
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, and
- Department of Global Health, University of Washington, Seattle, Washington
| |
Collapse
|
4
|
Mehta Y, Paul R, Rabbani R, Acharya SP, Withanaarachchi UK. Sepsis Management in Southeast Asia: A Review and Clinical Experience. J Clin Med 2022; 11:3635. [PMID: 35806919 PMCID: PMC9267826 DOI: 10.3390/jcm11133635] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 06/17/2022] [Accepted: 06/20/2022] [Indexed: 02/06/2023] Open
Abstract
Sepsis is a life-threatening condition that causes a global health burden associated with high mortality and morbidity. Often life-threatening, sepsis can be caused by bacteria, viruses, parasites or fungi. Sepsis management primarily focuses on source control and early broad-spectrum antibiotics, plus organ function support. Comprehensive changes in the way we manage sepsis patients include early identification, infective focus identification and immediate treatment with antimicrobial therapy, appropriate supportive care and hemodynamic optimization. Despite all efforts of clinical and experimental research over thirty years, the capacity to positively influence the outcome of the disease remains limited. This can be due to limited studies available on sepsis in developing countries, especially in Southeast Asia. This review summarizes the progress made in the diagnosis and time associated with sepsis, colistin resistance and chloramphenicol boon, antibiotic abuse, resource constraints and association of sepsis with COVID-19 in Southeast Asia. A personalized approach and innovative therapeutic alternatives such as CytoSorb® are highlighted as potential options for the treatment of patients with sepsis in Southeast Asia.
Collapse
Affiliation(s)
- Yatin Mehta
- Institute of Critical Care and Anesthesiology, Medanta the Medicity, Sector-38, Gurugram 22001, India
| | - Rajib Paul
- Internal Medicine, Apollo Hospitals, Road Number 72, Jubilee Hills, Hyderabad 500033, India;
| | - Raihan Rabbani
- Critical Care & Internal Medicine, Square Hospitals Ltd., 18 Bir Uttam Qazi NuruzzamanSarak West, Panthapath, Dhaka 1205, Bangladesh;
| | - Subhash Prasad Acharya
- Critical Care Medicine, Institute of Medicine, Tribhuvan University, Maharajgunj, Kathmandu 44618, Nepal;
| | | |
Collapse
|
5
|
Somayaji R, Hantrakun V, Teparrukkul P, Wongsuvan G, Rudd KE, Day NPJ, West TE, Limmathurotsakul D. Comparative clinical characteristics and outcomes of patients with community acquired bacteremia caused by Escherichia coli, Burkholderia pseudomallei and Staphylococcus aureus: A prospective observational study (Ubon-sepsis). PLoS Negl Trop Dis 2021; 15:e0009704. [PMID: 34478439 PMCID: PMC8415581 DOI: 10.1371/journal.pntd.0009704] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Accepted: 08/04/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Community acquired bacteremia (CAB) is a common cause of sepsis in low and middle-income countries (LMICs). However, knowledge about factors associated with outcomes of CAB in LMICs is limited. METHODOLOGY/PRINCIPAL FINDINGS A prospective observational study (Ubon-sepsis) of adults admitted to a referral hospital with community-acquired infection in Northeastern Thailand was conducted between March 1, 2013 and February 1, 2017. In the present analysis, patients with a blood culture collected within 24 hours of admission that was positive for one of the three most common pathogens were studied. Clinical features, management, and outcomes of patients with each cause of CAB were compared. Of 3,806 patients presenting with community-acquired sepsis, 155, 131 and 37 patients had a blood culture positive for Escherichia coli, Burkholderia pseudomallei and Staphylococcus aureus, respectively. Of these 323 CAB patients, 284 (89%) were transferred from other hospitals. 28-day mortality was highest in patients with B. pseudomallei bactaeremia (66%), followed by those with S. aureus bacteraemia (43%) and E. coli (19%) bacteraemia. In the multivariable Cox proportional hazards model adjusted for age, sex, transfer from another hospital, empirical antibiotics prior to or during the transfer, and presence of organ dysfunction on admission, B. pseudomallei (aHR 3.78; 95%CI 2.31-6.21) and S. aureus (aHR 2.72; 95%CI 1.40-5.28) bacteraemias were associated with higher mortality compared to E. coli bacteraemia. Receiving empirical antibiotics recommended for CAB caused by the etiologic organism prior to or during transfer was associated with survival (aHR 0.58; 95%CI 0.38-0.88). CONCLUSIONS/SIGNIFICANCE Mortality of patients with CAB caused by B. pseudomallei was higher than those caused by S. aureus and E. coli, even after adjusting for presence of organ dysfunction on admission and effectiveness of empirical antibiotics received. Improving algorithms or rapid diagnostic tests to guide early empirical antibiotic may be key to improving CAB outcomes in LMICs.
Collapse
Affiliation(s)
- Ranjani Somayaji
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Viriya Hantrakun
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Prapit Teparrukkul
- Department of Internal Medicine, Sunpasitthiprasong Hospital, Ubon Ratchathani, Thailand
| | - Gumphol Wongsuvan
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Kristina E. Rudd
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Nicholas P. J. Day
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Churchill Hospital, Oxford, United Kingdom
| | - T. Eoin West
- Department of Pulmonology, Critical Care and Sleep Medicine, University of Washington, Seattle, Washington, United States of America
- Department of Microbiology and Immunology, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Direk Limmathurotsakul
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Churchill Hospital, Oxford, United Kingdom
- Department of Tropical Hygiene, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- * E-mail:
| |
Collapse
|