Recommendations for infection management in patients with sepsis and septic shock in resource-limited settings

Introduction Studies indicate that sepsis and septic shock in resourcelimited settings are at least as common as in resourcerich settings. The surviving sepsis campaign (SSC) guidelines have been widely adopted throughout the world, but in resource-limited settings are often unfeasible 1. The guidelines are based almost exclusively on evidence from resource-rich settings and are not necessarily applicable elsewhere due to differences in etiology and diagnostic or treatment capacity. An international team of physicians with extensive practical experience in resource-limited intensive care units (ICUs) identified key questions concerning the SSC’s infection management recommendations, and evidence from resourcelimited settings regarding these was evaluated using the grading of recommendations assessment, development and evaluation (GRADE) tools. This article focuses primarily on bacterial causes of sepsis and septic shock. Other infections common in resource-limited settings, such as malaria, are covered in a separate article in this series. Evidence quality was scored as high (grade A), moderate (B), low (C), or very low (D), and recommendations as strong (1) or weak (2). The major difference from the grading of recommendations in the SSC-guidelines was in taking account of contextual factors relevant to resource-limited settings, such as the availability, affordability and feasibility of interventions in resource-limited ICUs. Strong recommendations have been worded as ‘we recommend’ and weak recommendations as ‘we suggest’ (details in online supplement).