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Increasing Evidence-Based Interventions in Patients with Acute Infections in a Resource-Limited Setting

A Before-and-After Feasibility Trial in Gitwe, Rwanda

Urayeneza, Olivier, MD, FACS1,2; Mujyarugamba, Pierre, MSc1; Rukemba, Zacharie, MD1; Nyiringabo, Vincent, MD1; Ntihinyurwa, Polyphile, MD1; Baelani, John I., PhD3; Kwizera, Arthur, MD4; Bagenda, Danstan, PhD5; Mer, Mervyn, MD, PhD6; Musa, Ndidiamaka, MD7; Hoffman, Julia T., RN, BSN5; Mudgapalli, Ashok, PhD5; Porter, Austin M.5; Kissoon, Niranjan, MD, FCCM8; Ulmer, Hanno, PhD9; Harmon, Lori A., RRT, MBA10; Farmer, Joseph C., MD, FCCM11; Dünser, Martin W., MD12; Patterson, Andrew J., MD, PhD5 for the Sepsis in Resource-Limited Nations Workgroup of the Surviving Sepsis Campaign

doi: 10.1097/CCM.0000000000003227
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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 ( NCT02697513).

1Gitwe Hospital and Gitwe School of Medicine, Gitwe, Rwanda.

2Department of Surgery, California Medical Center, Los Angeles, United States of America.

3Great Lakes Free University, Goma, Democratic Republic of Congo.

4Department of Anaesthesia and Critical Care, Makerere University College of Health Sciences, Kampala, Uganda

5Department of Anesthesiology, University of Nebraska Medical Center, Omaha, United States of America.

6Department of Medicine, Divisions of Critical Care and Pulmonology, Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.

7Seattle Children’s Hospital, University of Washington, Seattle, United States of America.

8BC Children’s Hospital, University of British Columbia, Vancouver, Canada.

9Institute of Medical Statistics, Informatics and Health Economics, Innsbruck Medical University, Innsbruck, Austria.

10Society of Critical Care Medicine on behalf of the Surviving Sepsis Campaign Mount Prospect, IL, United States of America.

11Department of Critical Care Medicine, Mayo Clinic, Phoenix, AZ, United States of America.

12Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University Linz, Linz, Austria.

*See also p. 1380.

This article is being published simultaneously in Critical Care Medicine and Intensive Care Medicine in the August issue of both journals.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (

This study was funded by the Life Priority Fund, the Hellman Foundation, and the King Baudouin Foundation. The research project was supported by the European Society of Intensive Care Medicine and the Society of Critical Care Medicine through the Surviving Sepsis Campaign.

Dr. Mujyarugamba’s institution received funding from Gitwe Hospital. Dr. Nyiringabo received funding from the Society of Critical Care Medicine (SCCM). Dr. Kwizera received travel and accommodation to assist in the training portion of the study. Dr. Bagenda received funding from SCCM and the European Society of Intensive Care Medicine (ESICM); he received support for article research from SCCM and ESICM, and he disclosed having two shares in Mylan NV. Dr. Mer received funding (honoraria for advisory boards and education talks delivered) from Pfizer, AstraZeneca, MSD, Gilead, Aspen, Sun, and 3M. Ms. Harmon’s institution received funding from King Baudouin Foundation ($25,000), Hellman Foundation ($50,000), and BD Corporation (provided supplies of $5,000 utilized for sepsis carts at Gitwe Hospital in Rwanda and a donation to the project of $2,500, which was used for the cart purchases and instructional materials). Dr. Farmer received support for article research from the Hellman Foundation. Dr. Patterson received funding from American Board of Anesthesiology, Accreditation Council for Graduate Medical Education, SCCM, Society of Academic Anesthesiology Associations (paid partial expenses after inviting him to give presentations at the Annual Meeting in 2016), and Dickie McCamey LLC (paid expert witness for the defense); he disclosed that his son (Ryan) and daughter (Julia) both received grant funding for projects in Gitwe, Rwanda from the Hellman Foundation (which partially supported this current project via a grant to SCCM); and he received support for article research from the Hellman Foundation. The remaining authors have disclosed that they do not have any potential conflicts of interest.

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