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

1. Management of sepsis and meningitis in
developing countries
Dr Louisa Pollock
Wellcome Trust Liverpool Glasgow Centre for Global Health Research

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. 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. What is the key to effective
treatment?

5. The key to effective treatment is..
...with the nurse who has gone to lunch

6. What is the most essential tool for
monitoring?

7. The most essential tool
for monitoring is....
....the family

8. Essentials for the management of
meningitis and sepsis
ACCESS TO
CARE
HUMAN
RESOURCES

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. 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. 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. 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out of date or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. 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. 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. 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. 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. 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. 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+”

19. ETAT TRIAGE
PROCESS
NO

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. 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. 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

24. 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

25. • 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)

26. 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

27. 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

28. • 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

29. 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

30. The key to management of sepsis and
meningitis in developing countries..
•
•
•
•
Patience
Resilience
Creativity
Teamwork

31. Thank you
Useful links - Paediatrics
• International Child
Health Review
Collaboration
– www.ichrc.org
• ETAT+ Kenya
– www.idoc-africa.org
Useful links –Adults
• IMAI District Clinician Manual
• www.who.int/hiv/pub/imai/im
ai2011/en/