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Management of adult sepsis in resource-limited settings: global expert consensus statements using a Delphi method

Thwaites L 1 , Nasa P 2 , Abbenbroek B 3 , Dat VQ 4 , Finfer S 3 , Kwizera A 5 Show all authors , Ling L 6 , Lobo SM 7 , Sinto R 8 , Aditianingsih D 9 , Antonelli M 10 , Arabi YM 11 , Argent A 12 , Azevedo L 13 , Bennett E 14 , Chakrabarti A 15 , De Asis K 16 , De Waele J 17 , Divatia JV 18 , Estenssoro E 19 , Evans L 20 , Faiz A 21 , Hammond NE 3 , Hashmi M 22 , Herridge MS 23 , Jacob ST 24 , Jatsho J 25 , Javeri Y 26 , Khalid K 27 , Chen LK 8 , Levy M 28 , Lundeg G 29 , Machado FR 30 , Mehta Y 31 , Mer M 32 , Son DN 33 , Ospina-Tascón GA 34 , Ostermann M 35 , Permpikul C 36 , Prescott HC 37 , Reinhart K 38 , Rodriguez Vega G 39 , S-Kabara H 40 , Shrestha GS 41 , Waweru-Siika W 42 , Tan TL 43 , Todi S 44 , Tripathy S 45 , Venkatesh B 3 , Vincent JL 46 , Myatra SN 47

Affiliations 

  • 1 Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
  • 2 Critical Care Medicine, NMC Specialty Hospital, Dubai, United Arab Emirates
  • 3 Asia Pacific Sepsis Alliance, Sydney, Australia
  • 4 Department of Infectious Diseases, Hanoi Medical University, Hanoi, Vietnam
  • 5 Department of Anaesthesia and Critical Care, Makerere University College of Health Sciences, Kampala, Uganda
  • 6 Department Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong SAR, China
  • 7 Intensive Care Division, FAMERP and Hospital de Base, São José do Rio Preto (SP), Brazil
  • 8 Division of Tropical and Infectious Diseases, Department of Internal Medicine, Cipto Mangunkusumo National Hospital, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
  • 9 Department of Anaesthesiology and Intensive Care, Cipto Mangunkusumo Hospital, Universitas Indonesia, Jakarta, Indonesia
  • 10 Department Anaesthesiology, Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
  • 11 King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Centre, Riyadh, Saudi Arabia
  • 12 Department Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
  • 13 Hospital Israelita Albert Einstein, São Paulo, Brazil
  • 14 Intensive Care Unit Colonial War Memorial Hospital, Suva, Fiji
  • 15 Doodhadhari Burfani Hospital and Research Institute, Haridwar, India
  • 16 Intensive Care Medicine, St Luke's Medical Centre, Quezon City, Philippines
  • 17 Department of Intensive Care Medicine, Ghent University Hospital, Ghent, Belgium
  • 18 Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
  • 19 Department of Research, Ministry of Health of the Province of Buenos Aires, Buenos Aires, Argentina
  • 20 Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, USA
  • 21 Toxicology Society of Bangladesh, Dhaka, Bangladesh
  • 22 Department of Critical Care Medicine, Ziauddin University, Karachi, Pakistan
  • 23 Critical Care and Respiratory Medicine, Institute of Medical Sciences, Interdepartmental Division of Critical Care Medicine, University Health Network, Toronto General Research Institute, University of Toronto, Toronto, Canada
  • 24 Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
  • 25 Paediatric Nephrology, National Medical Services, Gyaltsuen Jetsun Pema Wangchuck Mother and Child Hospital, Thimphu, Bhutan
  • 26 Critical Care and Emergency Medicine, Regency Super Specialty Hospital, Indian Sepsis Forum, Lucknow, India
  • 27 Department Anaesthesiology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
  • 28 Division of Pulmonary, Critical Care and Sleep Medicine, Warren Albert Medical School of Brown University, Providence, USA
  • 29 Critical Care and Anaesthesiology Department, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia
  • 30 Intensive Care Department, Hospital São Paulo, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil
  • 31 Medanta Institute of Critical Care and Anesthesiology, Medanta the Medicity, Gurgaon, Haryana, India
  • 32 Divisions of Critical Care and Pulmonology, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa
  • 33 Centre for Critical Care Medicine, Bach Mai Hospital, University of Medicine and Pharmacy, Vietnam National University, Hanoi, Vietnam
  • 34 Department Intensive Care Medicine, Fundación Valle del Lili- Universidad Icesi, Cali, Colombia
  • 35 Department Critical Care and Nephrology, King's College London, Guy's & St Thomas' Hospital London, London, UK
  • 36 Department of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
  • 37 Division of Pulmonary & Critical Care Medicine, University of Michigan, Ann Arbor, MI, USA
  • 38 Department of Anaesthesiology and Operative Intensive Care Medicine, Charité Universitäts Medizin, Berlin, Germany
  • 39 Department of Critical Care Medicine, Neurosurgical ICU, HIMA-San Pablo Caguas, Puerto Rico, USA
  • 40 Sepsis Research Group SIDOK, Aminu Kano Teaching Hospital, Bayero University Kano, Kano, Nigeria
  • 41 Department of Critical Care Medicine, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
  • 42 Department of Anaesthesia, Aga Khan University Nairobi, Nairobi, Kenya
  • 43 Department of Emergency Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Selangor, Malaysia
  • 44 Critical Care, Manipal Hospitals, Dhakuria, Kolkata, India
  • 45 Department Anaesthesia and Critical Care, AIIMS Bhubaneswar, Bhubaneswar, India
  • 46 Department of Intensive Care, Erasme University Hospital, University of Brussels, Brussels, Belgium
  • 47 Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India. sheila150@hotmail.com
Intensive Care Med, 2025 Jan;51(1):21-38.
PMID: 39714613 DOI: 10.1007/s00134-024-07735-7

Abstract

PURPOSE: To generate consensus and provide expert clinical practice statements for the management of adult sepsis in resource-limited settings.

METHODS: An international multidisciplinary Steering Committee with expertise in sepsis management and including a Delphi methodologist was convened by the Asia Pacific Sepsis Alliance (APSA). The committee selected an international panel of clinicians and researchers with expertise in sepsis management. A Delphi process based on an iterative approach was used to obtain the final consensus statements.

RESULTS: A stable consensus was achieved for 30 (94%) of the statements by 41 experts after four survey rounds. These include consensus on managing patients with sepsis outside a designated critical care area, triggers for escalating clinical management and criteria for safe transfer to another facility. The experts agreed on the following: in the absence of serum lactate, clinical parameters such as altered mental status, capillary refill time and urine output may be used to guide resuscitation; special considerations regarding the volume of fluid used for resuscitation, especially in tropical infections, including the use of simple tests to assess fluid responsiveness when facilities for advanced hemodynamic monitoring are limited; use of Ringer's lactate or Hartmann's solution as balanced salt solutions; epinephrine when norepinephrine or vasopressin are unavailable; and the administration of vasopressors via a peripheral vein if central venous access is unavailable or not feasible. Similarly, where facilities for investigation are unavailable, there was consensus for empirical antimicrobial administration without delay when sepsis was strongly suspected, as was the empirical use of antiparasitic agents in patients with suspicion of parasitic infections.

CONCLUSION: Using a Delphi method, international experts reached consensus to generate expert clinical practice statements providing guidance to clinicians worldwide on the management of sepsis in resource-limited settings. These statements complement existing guidelines where evidence is lacking and add relevant aspects of sepsis management that are not addressed by current international guidelines. Future studies are needed to assess the effects of these practice statements and address remaining uncertainties.

* Title and MeSH Headings from MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.

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