OBJECTIVES:. To identify the epidemiology and outcome of adults and children with and without sepsis in a rural sub-Sahara African setting. DESIGN:. A priori planned substudy of a prospective, before-and-after trial. SETTING:. Rural, sub-Sahara African hospital. PATIENTS:. One-thousand four-hundred twelve patients (adults, n = 491; children, n = 921) who were admitted to hospital because of an acute infection. INTERVENTIONS:. None. MEASUREMENTS AND MAIN RESULTS:. Demographic, clinical, laboratory data, danger signs, and the presence of sepsis (defined as a quick Sequential Organ Failure Assessment score count ≥ 2) at admission were extracted. Sepsis was observed in 69 adults (14.1%) and 248 children (26.9%). Sepsis patients differed from subjects without sepsis in several demographic and clinical aspects. Malaria was the most frequent type of infection in adults (66.7%) and children (63.7%) with sepsis, followed by suspected bacterial and parasitic infections other than malaria. Adults with sepsis more frequently developed respiratory failure (8.7% vs 2.1%; p = 0.01), had a higher in-hospital mortality (17.4% vs 8.3%; p < 0.001), were less often discharged home (81.2% vs 92.2%; p = 0.007), and had higher median (interquartile range) costs of care (30,300 [19,400–49,900] vs 42,500 Rwandan Francs [27,000–64,400 Rwandan Francs]; p = 0.004) than adults without sepsis. Children with sepsis were less frequently discharged home than children without sepsis (93.1% vs 96.4%; p = 0.046). Malaria and respiratory tract infections claimed the highest absolute numbers of lives. The duration of symptoms before hospital admission did not differ between survivors and nonsurvivors in adults (72 [24–168] vs 96 hr [72–168 hr]; p = 0.27) or children (48 [24–72] vs 36 [24–108 hr]; p = 0.8). Respiratory failure and coma were the most common causes of in-hospital death. CONCLUSIONS:. In addition to suspected bacterial, viral, and fungal infections, malaria and other parasitic infections are common and important causes of sepsis in adults and children admitted to a rural hospital in sub-Sahara Africa. The in-hospital mortality associated with sepsis is substantial, primarily in adults.

OBJECTIVE:To assess the value of the inability to walk unassisted to predict hospital mortality in patients with suspected infection in a resource-limited setting. METHODS:This is a post hoc study of a prospective trial performed in rural Rwanda. Patients hospitalized because of a suspected acute infection and who were able to walk unassisted before this disease episode were included. At hospital presentation, the walking status was graded into: 1) can walk unassisted, 2) can walk assisted only, 3) cannot walk. Receiver operating characteristic (ROC) analyses and two-by-two tables were used to determine the sensitivity, specificity, negative and positive predictive values of the inability to walk unassisted to predict in-hospital death. RESULTS:One-thousand-sixty-nine patients were included. Two-hundred-one (18.8%), 315 (29.5%), and 553 (51.7%) subjects could walk unassisted, walk assisted or not walk, respectively. Their hospital mortality was 0%, 3.8% and 6.3%, respectively. The inability to walk unassisted had a low specificity (20%) but was 100% sensitive (CI95%, 90-100%) to predict in-hospital death (p = 0.00007). The value of the inability to walk unassisted to predict in-hospital mortality (AUC ROC, 0.636; CI95%, 0.564-0.707) was comparable to that of the qSOFA score (AUC ROC, 0.622; CI95% 0.524-0.728). Fifteen (7.5%), 34 (10.8%) and 167 (30.2%) patients who could walk unassisted, walk assisted or not walk presented with a qSOFA score count ≥2 points, respectively (p<0.001). The inability to walk unassisted correlated with the presence of risk factors for death and danger signs, vital parameters, laboratory values, length of hospital stay, and costs of care. CONCLUSIONS:Our results suggest that the inability to walk unassisted at hospital admission is a highly sensitive predictor of in-hospital mortality in Rwandese patients with a suspected acute infection. The walking status at hospital admission appears to be a crude indicator of disease severity.

OBJECTIVESTo deploy machine learning tools (random forests) to develop a model that reliably predicts hospital mortality in children with acute infections residing in low- and middle-income countries, using age and other variables collected at hospital admission.DESIGNPost hoc analysis of a single-center, prospective, before-and-after feasibility trial.SETTINGRural district hospital in Rwanda, a low-income country in Sub-Sahara Africa.PATIENTSInfants and children greater than 28 days and less than 18 years of life hospitalized because of an acute infection.INTERVENTIONSNone.MEASUREMENTS AND MAIN RESULTSAge, vital signs (heart rate, respiratory rate, and temperature) capillary refill time, altered mental state collected at hospital admission, as well as survival status at hospital discharge were extracted from the trial database. This information was collected for 1,579 adult and pediatric patients admitted to a regional referral hospital with an acute infection in rural Rwanda. Nine-hundred forty-nine children were included in this analysis. We predicted survival in study subjects using random forests, a machine learning algorithm. Five prediction models, all including age plus two to five other variables, were tested. Three distinct optimization criteria of the algorithm were then compared. The in-hospital mortality was 1.5% (n = 14). All five models could predict in-hospital mortality with an area under the receiver operating characteristic curve ranging between 0.69 and 0.8. The model including age, respiratory rate, capillary refill time, altered mental state exhibited the highest predictive value area under the receiver operating characteristic curve 0.8 (95% CI, 0.78-0.8) with the lowest possible number of variables.CONCLUSIONSA machine learning-based algorithm could reliably predict hospital mortality in a Sub-Sahara African population of 949 children with an acute infection using easily collected information at admission which includes age, respiratory rate, capillary refill time, and altered mental state. Future studies need to evaluate and strengthen this algorithm in larger pediatric populations, both in high- and low-/middle-income countries.

Objectives In many populations, men who have sex with men (MSM) are at a high risk of HIV infection. This study aimed to estimate the burden of HIV, other STIs and risk behaviours among Rwandan MSM. Methods In this cross-sectional study, we recruited through peer referral men aged between 18 and 60 years, who reported sex with men at least once in the 12 months prior to the survey. Representativeness was increased using ‘seeds’ from a variety of sources. Signed informed consent was obtained from all participants. Data on demographics, risk behaviours and self-reported STIs were collected through an interviewer-administered questionnaire. We screened all eligible participants for HIV using the Rwanda-approved protocol for rapid HIV detection. Results 504 MSM were recruited from five major cities in Rwanda. Participants were mostly young (median age 23 years, range 18–55 years) and unmarried (484/504, 96.0%). Thirteen per cent (65/504) of the participants reported past gonorrhoea and/or syphilis infection. Of 504 MSM, 53 (10.5%) reported they were diagnosed and treated for gonorrhoea in the past 12 months and 24 (4.8%) tested positive for HIV. A high proportion (232/504, 46%) reported receiving payment for sex by a man, with almost half of these reporting on more than three occasions (107/232, 46%). Many reported having had an HIV test within the past 12 months (385/504, 76.4%). In multivariate logistic regression models controlling for age, being paid for sex was associated with higher odds of past STI (OR 3.36 (1.82–6.43]; P<0.001) and testing HIV positive (OR 3.13, P<0.05). Conclusion Further research is needed to understand the high rate of payment for sex in this population, which appears to be a major risk factor for STI including HIV.

OBJECTIVE:To evaluate whether a focused education program and implementation of a treatment bundle increases the rate of early evidence-based interventions in patients with acute infections.DESIGN:Single-center, prospective, before-and-after feasibility trial.SETTING:Emergency department of a sub-Saharan African district hospital.PATIENTS:Patients > 28 days of life admitted to the study hospital for an acute infection.INTERVENTIONS:The trial had three phases (each of four months). Interventions took place during the second (educational program followed by implementation of the treatment bundle) and third (provision of resources to implement treatment bundle) phases.MEASUREMENTS AND MAIN RESULTS:Demographic, clinical, and laboratory data were collected at study enrollment; 24, 48, and 72 hours after hospital admission; and at discharge. A total of 1,594 patients were enrolled (pre-intervention, n = 661; intervention I, n = 531; intervention II, n = 402). The rate of early evidence-based interventions per patient during Intervention Phase I was greater than during the pre-intervention phase (74 ± 17 vs. 79 ± 15%, p < 0.001). No difference was detected when data were compared between Intervention Phases I and II (79 ± 15 vs. 80 ± 15%, p = 0.58). No differences in the incidence of blood transfusion (pre-intervention, 6%; intervention I, 7%; intervention II, 7%) or severe adverse events in the first 24 hours (allergic reactions: pre-intervention, 0.2%; intervention I, 0%; intervention II, 0%; respiratory failure: pre-intervention, 2%; intervention I, 2%; intervention II, 2%; acute renal failure: pre-intervention, 2%; intervention I, 2%; intervention II, 1%) were observed.CONCLUSIONS:Our results indicate that a focused education program and implementation of an infection treatment bundle in clinical practice increased the rate of early evidence-based interventions in patients with acute infections (mostly malaria) admitted to a sub-Saharan African district hospital. Provision of material resources did not further increase this rate. While no safety issues were detected, this could be related to the very low disease severity of the enrolled patient population (www.clinicaltrials.gov: NCT02697513).

In the most recent international Surviving Sepsis Campaign guidelines, Rhodes and colleagues 1 Rhodes A Evans LE Alhazzani W et al. Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock: 2016. Intensive Care Med. 2017; 43: 304-377 Crossref PubMed Scopus (3650) Google Scholar excellently outline evidence-based management of patients with sepsis and septic shock. Of note, however, is that most of the world's population resides in low-income and middle-income countries (LMICs), where the burden of sepsis is enormous, outcomes are often poor, and socioeconomic consequences are dire. 2 Dünser MW Festic E Dondorp A et al. Recommendations for sepsis management in resource-limited settings. Intensive Care Med. 2012; 38: 557-574 Crossref PubMed Scopus (113) Google Scholar Of the 655 references supporting the new sepsis guidelines, only a few pertain to studies in LMICs (about 10%). 1 Rhodes A Evans LE Alhazzani W et al. Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock: 2016. Intensive Care Med. 2017; 43: 304-377 Crossref PubMed Scopus (3650) Google Scholar This disparity raises concerns that the challenges and problems inherent to LMICs remain inadequately addressed. The guidelines, for example, mainly focus on management of bacterial and fungal sepsis as most frequently encountered in high-income countries. Strikingly, the specific diagnosis and management of sepsis due to pathogens commonly encountered in LMICs, such as Mycobacterium tuberculosis (which resulted in about 1·8 million deaths in 2015), 3 WHOTuberculosis. http://www.who.int/mediacentre/factsheets/fs104/en/Date: March, 2017 Google Scholar Plasmodium falciparum (429 000 deaths), 4 WHOMalaria. http://www.who.int/mediacentre/factsheets/fs094/en/Date: April, 2017 Google Scholar and dengue virus (1032 deaths in the Region of the Americas in 2016), 5 WHODengue and severe dengue. http://www.who.int/mediacentre/factsheets/fs117/en/Date: April, 2017 Google Scholar are not included. HIV infection, which poses specific challenges to sepsis care in LMICs, particularly in sub-Saharan Africa and southeast Asia, is also not alluded to. More than 35 million people have lost their lives as a consequence of HIV infection, most related to sepsis, and around 36·7 million people estimated to be living with the disease are potentially at risk. 6 WHOHIV/AIDS. http://www.who.int/mediacentre/factsheets/fs360/en/Date: July, 2017 Google Scholar These omissions are unlikely due to oversights or absence of concern of the team producing the guidelines, but rather relate to the paucity of robust scientific evidence, as well as the absence of experts from LMICs in the guidelines group providing appropriate context.