Revisión bibliográfica / Literature review

A literature review of the epidemiology

of sepsis in Latin America
Fabián Jaimes1

Suggested citation Jaimes F. A literature review of the epidemiology of sepsis in Latin America. Rev Panam Salud Publica.
2005;18(3):163–71.

ABSTRACT Objectives. Epidemiological studies from the United States of America and from Europe
have shown that sepsis is a widely prevalent syndrome, with either steady or slightly decreas-
ing rates of morbidity and of mortality in recent decades. The objective of this paper is to pro-
vide a systematic review regarding the description and characterization of sepsis in Latin
America.
Methods. To locate materials on sepsis in Latin America, a comprehensive search strategy
was employed with three medical bibliographic databases, using combinations of the terms “sep-
sis,” “septicemia,” “bacteremia,” “sepsis syndrome,” “epidemiology,” “incidence,” and “preva-
lence.” The materials selected were in English, Spanish, or Portuguese.
Results. The titles of more than 1 000 potentially relevant articles were screened, and more
than 600 selected abstracts were reviewed in detail. Twenty papers published from 1990
through 2004 were selected and analyzed. The studies described in the 20 articles were ex-
tremely heterogeneous in design, population, sample size, end points, and follow-up. The stud-
ies did not all apply the same clinical definition for sepsis, thus making it impossible to pro-
duce a precise overall estimate of the magnitude of the problem of sepsis in Latin America.
Conclusions. The results of the literature review suggest that the clinical and epidemiolog-
ical approaches to the problem of sepsis in Latin America have sometimes been inappropriate
with respect to research design, study population, and clinical outcome. Further, some data
suggest that in terms of both frequency and mortality the situation with sepsis and severe sys-
temic infections may be worse in Latin America than it is in developed countries.

Key words Sepsis, hospital mortality, intensive care units, Latin America.

At the congress of the European So- the Surviving Sepsis Campaign issued wide (1). As such, any effort made to-
ciety of Intensive Care Medicine held the “Barcelona Declaration,” a call for ward improving prevention, diagno-
in Barcelona, Spain, in October 2002, global action against sepsis. The Cam- sis, and treatment represents a poten-
paign, a collaborative effort of the Eu- tially valuable response to an urgent
ropean Society of Intensive Care Med- need.
1
icine, the Society of Critical Care This paper provides an overview of
Universidad de Antioquia, Medellín, Antioquia,
Colombia, and Johns Hopkins Bloomberg School Medicine, and the International Sepsis the global challenges with sepsis, gives
of Public Health, Department of Epidemiology, Forum, estimates that the number of a clinical definition of sepsis, and de-
Baltimore, Maryland, Unites States of America.
Send correspondence to: Fabián Jaimes, Universi- sepsis cases in the world has reached scribes the magnitude of the problem
dad de Antioquia, Departamento de Medicina In- 18 million annually. With a mortality in North America and Europe. In ad-
terna, AA 1226, Medellín, Antioquia, Colombia;
e-mail: fjaimes@catios.udea.edu.co and fjaimesb@ rate of almost 30%, sepsis is consid- dition, a systematic review of the sci-
jhsph.edu; telephone and fax: 574-2637947. ered a leading cause of death world- entific literature describes and charac-

Rev Panam Salud Publica/Pan Am J Public Health 18(3), 2005 163

Literature review Jaimes • A literature review of sepsis in Latin America

terizes the situation with sepsis in TABLE 1. Potential sepsis-related markers

Latin America.
General variables
Temperature > 38.3 °C or < 36.0 °C
Heart rate > 90 beats/min
Definition of sepsis Tachypnea (respiratory rate > 20 breaths/min in adults)
Altered mental status
Over the last three decades the syn- Inflammatory response variables
drome now commonly referred to as White blood cell count > 12 000 cells/μL, < 4 000 cells/μL, or with > 10% immature forms
Plasma C-reactive protein > 2 standard deviations above the normal value
sepsis has alternately been called sep- Plasma procalcitonin > 2 standard deviations above the normal value
ticemia (2), sepsis syndrome (3), and Hemodynamic variables
simply sepsis. One definition of sepsis Systolic blood pressure < 90 mmHg or mean arterial blood pressure < 70 mmHg
was described jointly with the closely Mixed venous oxygen saturation > 70%
Cardiac index > 3.5 L/min/m2
related concept of systemic inflam-
Organ dysfunction variables
matory response syndrome (SIRS) (4). PaO2/FiO2 < 300
SIRS is considered present when pa- Urine output < 0.5 mL/kg/hr or creatinine increase > 0.5 mg/dL
tients show more than one of the fol- International normalized ratio > 1.5 or activated partial thromboplastin time > 60 sec
lowing four clinical characteristics: Platelet count < 100 000 cells/μL
Plasma total bilirubin > 4 mg/dL
(1) body temperature > 38 °C or < 36 °C; Tissue perfusion variables
(2) heart rate > 90 beats/min; (3) hyper- Hyperlactatemia > 1 mmol/L
ventilation, evidenced by a respiratory Decreased capillary refill or mottling
rate > 20 breaths/min or PaCO2 < 32
Source: Levy et al. (8), with modifications.
mmHg; and (4) white blood cell count
> 12 000 cells/μL or < 4 000 cells/μL or
with > 10% immature forms.
A statement from a 1991 consensus
conference of the American College of
Chest Physicians and the Society of tions Conference, which was held in staging system proposes to stratify pa-
Critical Care Medicine hypothesized 2001, a diagnosis of sepsis should be tients based on their predisposition
that sepsis is a systemic response to in- considered in the presence of a docu- (P), the type and extent of the infection
fection (4). Infection, in turn, was de- mented or suspected infection concur- (I), the nature and magnitude of the
fined as a process whereby pathogenic rent with markers of general illness, host response (R), and the degree of
or potentially pathogenic microorgan- inflammation, hemodynamic distur- associated organ dysfunction (O).
isms invade normally sterile tissues, bance, organ dysfunction, or tissue However, comprehensive evaluation
fluids, or body cavities. According to perfusion abnormalities (Table 1) (8). and further improvements on the
this definition, a diagnosis of sepsis re- Notwithstanding the lack of conclu- PIRO approach are needed.
quires the presence of both infection sive criteria for sepsis, the definitions
(usually caused by bacteria) and SIRS. of severe sepsis (sepsis complicated by
Following the same model, sepsis with organ dysfunction) and septic shock The magnitude of the sepsis
signs of organ dysfunction would be (systolic blood pressure below 90 problem in the United States
characterized as severe sepsis, and mmHg, or a reduction of > 40 mmHg
sepsis with acute circulatory failure from baseline despite adequate vol- The first relevant general public dis-
would be defined as septic shock (4). ume resuscitation) remain undis- closure of the magnitude of the sepsis
However, as various reports (5–7) puted. In fact, most studies concerning problem in United States came from
have indicated, despite the fact that the epidemiology of sepsis, as well as the Centers for Disease Control and
the SIRS definition states that a sys- virtually all recent clinical trials for Prevention (CDC) in 1990, in a com-
temic inflammatory response can be new therapies, have focused on these parison of hospital discharge rates for
triggered by a variety of conditions, two study populations. Unfortunately, septicemia from 1979 through 1987
this combination of criteria is neither this simple classification and range of (10). The data were obtained from the
specific nor sufficiently sensitive to be definitions have strong limitations for National Hospital Discharge Survey of
useful in clinical practice. It now precise characterization of sepsis, and the CDC’s National Center for Health
seems clear that even though no epi- mainly for the early staging of pa- Statistics. The report used the dis-
demiological evidence exists to sup- tients. Therefore, on the basis of ideas charge diagnosis of septicemia (“sys-
port a change in the syndrome’s defin- that arose in October 2000 at the Fifth temic disease associated with the pres-
ition, the list of signs and symptoms of Toronto Sepsis Roundtable (9), the ence and persistence of pathogenic
sepsis should be expanded to reflect 2001 International Sepsis Definitions microorganisms or their toxins in the
clinical bedside experience. According Conference proposed a classification blood”) of the International Classifica-
to the last International Sepsis Defini- scheme called “PIRO” (8). The PIRO tion of Diseases, Ninth Revision, Clin-

164 Rev Panam Salud Publica/Pan Am J Public Health 18(3), 2005

Jaimes • A literature review of sepsis in Latin America Literature review

ical Modification (ICD-9-CM). The mortality rates that were similar to 2.0 ± 0.16 cases per 100 admissions.
analysis covered all records of persons those of the corresponding culture- Among the centers the unadjusted at-
one year old or older in which a dis- positive populations (11). tack rate for sepsis syndrome ranged
charge diagnosis of septicemia was Clearly, these definitions are self- from 1.1 to 3.3 cases per 100 admis-
recorded from 1979 through 1987. contained, since severe sepsis includes sions. Patients in ICUs accounted for
During this period, septicemia rates sepsis, and, in turn, sepsis includes 59% of total extrapolated cases, non-
increased 139%, from 73.6 per 100 000 SIRS. Therefore, only in a tautological ICU patients with positive blood cul-
persons (164 000 discharges) to 175.9 sense might we consider that there is a tures for 11%, and non-ICU patients
per 100 000 persons (425 000 dis- true continuum through different with negative blood cultures for 30%.
charges). Although the septicemia rate stages of an inflammatory response, Septic shock was present at the onset
increased for all age groups, the in- from SIRS to septic shock. Indeed, in of the sepsis syndrome in 25% of pa-
crease was greatest (162%) for persons the same Iowa study (11), among 649 tients. Bloodstream infection was docu-
aged 65 years or older, from 326.3 per patients with sepsis, only 285 of them mented in 28% of patients, and the total
100 000 in 1979 to 854.7 per 100 000 by (44%) had earlier met at least two cri- 28-day mortality was 34%.
1987. The fatality rate for patients with teria for SIRS. Among those who met The most compelling evidence of
a discharge diagnosis of septicemia the criteria for severe sepsis (culture- systemic infection is bacteremia. For
declined during the study period for proven; n = 467), 58% of them (n = 271) this reason, some evaluations of the
all age groups, from 31.0% to 25.3%. had been previously classified as incidence of sepsis have focused on
However, even by 1987, patients were being afflicted with sepsis or SIRS. On bacteremia. Furthermore, requesting
at significantly greater risk of death if the other hand, among those with two blood cultures, as in the study of
septicemia was one of the discharge SIRS criteria, 32% developed sepsis by Sands et al. (12) mentioned above, is
diagnoses (relative risk = 8.6; 95% con- day 14, and for those with three SIRS considered a proxy for clinical sepsis.
fidence interval = 8.14–9.09) (10). criteria, 36% developed sepsis by day Although clinically appealing, this last
The most comprehensive study on 14. Forty-five percent (n = 439) of the “surrogate marker” is not repro-
the clinical significance of the early 975 subjects with four criteria devel- ducible enough, and it should be
stages of septic syndrome appeared in oped sepsis between days 14 and 21. viewed with caution. There are pa-
1995 (11). The study assessed the inci- Thus, even without a categorical pro- tients with potential infection who
dence of SIRS, sepsis, severe sepsis, gression, a close relationship clearly may not have a blood culture per-
and septic shock among 3 708 patients exists between clinical stages reflect- formed, and other patients without in-
admitted during a nine-month period ing some degree of systemic inflam- fection who have cultures requested
to three intensive care units (ICUs) mation and the presence of infection. inappropriately. Furthermore, since
and three wards of a 900-bed teaching Whether infection is confirmed or is patients with comorbidities often are
hospital in the state of Iowa, in the clinically suspected, the outcomes suspected of being at increased risk for
United States. The study found that seem similar in terms of mortality and infection, clinicians may have a lower
68% of the patients met at least two cri- most organ dysfunctions, within each threshold for requesting blood cul-
teria for SIRS at some point during corresponding stage. tures in these patients. Therefore, any
their hospital stay. Of those patients In 1997, Sands et al. (12) evaluated analysis about these cases should take
with SIRS, 26% developed microbio- the incidence of sepsis syndrome in into account the real denominator of
logically confirmed sepsis, 18% devel- both the ICU and ward populations at population at risk. Nevertheless, posi-
oped severe sepsis, and 4% developed eight academic tertiary-care medical tive blood cultures clearly identify in-
septic shock. Positive blood cultures centers in the United States (12). Each fected individuals at higher risk of
were found in 16.5%, 25.4%, and 69.0% center monitored a weighted random mortality, and appropriate inferences
of the samples drawn from patients sample of ICU patients and of non-ICU may be derived from this population.
with sepsis, severe sepsis, and septic patients who had blood cultures drawn Despite using somewhat different
shock, respectively. A noteworthy during a 15-month period. Sepsis syn- definitions, two recent reports have
finding was that fewer than 50% of the drome was defined as the presence of added important information regard-
episodes overall were microbiologi- either a positive blood culture or the ing the epidemiology of sepsis in the
cally documented. This proportion combination of fever, tachypnea, tachy- United States in the last 20 years (13,
ranged from 42% for patients who cardia, clinically suspected infection, 14). Based on hospital discharge
only met the criteria for SIRS to 57% and any one of seven confirmatory cri- records for 1995 for seven large states
for patients with septic shock. Since teria, all of them related to organ dys- in the United States, Angus et al. (13)
clinical suspicion of infection was function. In total, 12 759 patients were estimated that for the United States as a
enough to initiate antibiotic treatment, monitored, and 1 342 episodes of sepsis whole there were 3.0 cases of severe
the precise cause of the systemic in- syndrome were documented. The ex- sepsis per 1 000 population, and 2.26
flammatory response in these culture- trapolated, weighted estimate of hospi- cases per 100 hospital discharges. Of
negative populations is unknown. talwide incidence (mean ± 95% confi- the some 751 000 severe sepsis cases
However, they had morbidity and dence limit) of sepsis syndrome was in the study, almost 70% of them

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Literature review Jaimes • A literature review of sepsis in Latin America

(513 000) received intensive care. The resources for epidemiological investi- year (17, 18). Of note, nearly half of the
estimated mortality rate was 28.6%, or gations in which the prospective iden- bacteremic episodes were of nosoco-
a total of 215 000 deaths nationally, and tification of patients is difficult or not mial origin (16). Although ICU pa-
the average cost per case was US$ feasible. However, strict reliance on tients were at much higher risk of se-
22 100, with a total annual cost of US$ such data sets for sepsis surveillance vere sepsis than were ward patients,
16.7 billion. Using a more restrictive or research planning may produce bacteremic severe sepsis was propor-
definition that included only a few substantial error. tionally less often encountered in ICU
codes from the ICD-9-CM and working patients than in non-ICU patients (16,
with data from the National Hospital 17). This suggests that there is an im-
Discharge Survey, Martin et al. (14) The magnitude of the sepsis portant subset of patients who have
found an increase in the incidence of problem in Europe overwhelming infections, besides the
sepsis, from 82.7 cases per 100 000 pop- patients in ICUs, which traditionally
ulation in 1979 to 240.4 per 100 000 In Europe the first hospitalwide epi- have been considered the natural set-
population in 2000. This represents an demiologic study on bacteremia and ting for sepsis (19).
annualized increase of 8.7% in the inci- sepsis was a French multicenter one, Despite the broad distribution of
dence. The authors also described a de- conducted in 1993 in 24 public or sepsis and severe bacterial infections
cline in the overall in-hospital mortality public-affiliated hospitals (16, 17). The among hospitalized patients, all the re-
rate, from 27.8% during the 1979–1984 authors performed a two-month pro- cent studies outside the United States
period to 17.9% during the 1995–2000 spective survey of 85 750 admissions have only considered patients admitted
period, even though the total number to adult wards and ICUs, and they to ICUs (20–24). Whether on pro-
of deaths continued to increase. found an overall incidence rate of bac- spective cohorts (20, 23, 24) or with ad-
The results from Angus et al. (13), teremia of 9.8 per 1 000 admissions ministrative databases (21, 22), all of the
Martin et al. (14), and the CDC (10) (16). The bacteremia incidence rate in studies but one (20) have focused on se-
may be limited by the quality of the the ICUs (69/1 000) was more than vere sepsis or septic shock (Table 2.).
state and National Hospital Discharge eight times as high as the rate in the The wide range of incidence and
Survey databases, and by the inability wards (8.2/1 000) (17). Of the 842 bac- mortality rates found in the studies
to audit their data. Moreover, the ac- teremic episodes detected, 63% oc- mentioned above reflects different def-
curacy of the ICD-9-CM coding for the curred in medical wards, 19% in ICUs, initions of outcome measures as well as
identification of specific medical con- and 18% in surgical wards (16). Ex- differences in data collection proce-
ditions, and sepsis in particular, re- trapolating these results to all of dures or methodological approaches.
mains controversial (15). Administra- France would give a figure of approxi- Three of these studies provide some
tive data sets have become essential mately 67 500 bacteremic episodes per understanding of time trends (21–23).

TABLE 2. Studies on the epidemiology of sepsis in various countries around the world

Number of
intensive care
unit (ICU) Relative
Author, year admissions frequency Mortality
(reference) Countries Design screened Outcome (%) (%)

Alberti, 2002 (20) Six European Prospective cohort 14 364 Infectious episodes 21.1 22.1 vs. 43.6
countries, study (community- vs.
Canada, and hospital-acquired
Israel infection)

Padkin, 2003 (21) England, Wales, Administrative 56 673 Severe sepsis 27.1 35 vs. 47 (ICU vs.
and Northern database hospital mortality)
Ireland

Annane, 2003 (22) France Administrative 100 554 Septic shock 8.2 60.1
database

EPISEPSIS, 2004 (23) France Prospective cohort 3 738 Severe sepsis or 14.6 35 vs. 41.9 (30-day vs.
study septic shock 2-month mortality)

Finfer, 2004 (24) Australia and Prospective cohort 5 878 Severe sepsis 11.8 26.5 vs. 32.4 (ICU vs.
New Zealand study 28-day mortality)

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Jaimes • A literature review of sepsis in Latin America Literature review

Padkin et al. (21) assessed data for 1995 MATERIAL AND METHODS The studies described in the 20 se-
through 2000 from 91 adult general lected articles were extremely hetero-
ICUs in England, Wales, and Northern To begin the review of the sepsis situ- geneous in design, population, sample
Ireland. The relative frequency of se- ation in Latin America, the first step was size, end points, and follow-up. Fur-
vere sepsis for all ICU admissions in- to search bibliographic databases for thermore, the fundamental challenge
creased from 25.9% in 1996 to 29.7% in possibly relevant articles. Three data- of lack of consensus on the clinical def-
1999. In the same period there was a bases were used: PubMed (National Li- inition of sepsis seems to be more criti-
slight decrease in the hospital mortal- brary of Medicine of the United States), cal in Latin American literature. There-
ity rate, from 50.2% to 47.0%. The data- EMBASE (Excerpta Medica (http:// fore, it is impossible to infer any overall
base of the CUB-Réa Network has in- www.embase.com)), and LILACS (Li- estimate of the magnitude of the prob-
formation from 35 ICUs in Paris and its teratura Latino-Americana e do Caribe em lem in Latin America. Moreover, some
suburbs (22). An analysis of the data Ciências da Saúde, of the Latin Ameri- data suggest that in terms of frequency
for 1993 through 2000 showed that the can and Caribbean Center on Health and mortality, the situation with sepsis
overall frequency of septic shock in- Sciences Information, in São Paulo, and severe systemic infections in Latin
creased from 7.0 to 9.7 per 100 admis- Brazil (http://www.bireme.br)). Differ- America may be even worse than in
sions, while the crude mortality rate ent combinations with the search terms developed countries.
declined from 62.1% to 55.9% over that “sepsis,” “septicemia,” “bacteremia,” In an article published in 1990,
same period. Similarly, the EPISEPSIS “sepsis syndrome,” “epidemiology,” Zanon et al. (25) used ICD-9-CM codes
Study Group (23) compared findings “incidence,” and “prevalence” were for septicemia at 10 hospitals in Brazil
for 2001 with studies performed in employed. For PubMed and EMBASE, and estimated a mortality rate of 46%
1993 in France by some of the same the search strategy additionally in- for community-acquired sepsis and of
researchers (16, 17). They found that cluded the terms “Latin America,” 58% for nosocomially acquired sepsis.
there was an increase in the attack rate “South America,” and “Central Amer- In spite of potential underreporting, the
of severe sepsis in ICU patients be- ica,” or restriction to items in Spanish or incidence of bacteremia in these hospi-
tween 1993 and 2001, from 8.4% to Portuguese. The database searching tals was roughly similar to estimates
14.6% for clinically severe sepsis, and produced more than 1 000 potentially for France (16). Studies performed in
from 6.3% to 9.0% for microbiologi- related articles, most of them from ICUs (27, 30, 33, 34, 39) between 1993
cally documented severe sepsis. The LILACS. The next stage of the screening and 2001 found mortality rates ranging
42% hospital mortality rate found for involved a detailed review of more than from 33.6% in a cross-sectional study
2001 (23) was substantially lower than 600 selected abstracts. Articles were re- by Ponce de León-Rosales et al. in Mex-
the 59% rate in 1993 (16, 17). tained based on their appropriateness ico (34) to 56% in a retrospective case-
From the information presented and relevance, with no restrictions on series by Bilevicius et al. in Brazil (39).
above, it is clear that sepsis is a com- design, sample size, year(s) in which the These figures are roughly similar to
mon and frequently fatal condition in study was done, year of publication, or those reported for ICUs elsewhere
developed countries. Dealing with it journal that published the study. around the world. However, all the
involves spending considerable funds Latin American studies but one (33) re-
and other resources. While the overall cruited a general population of sepsis
mortality rate among patients with RESULTS AND DISCUSSION patients, without restrictions as to
sepsis is declining, the incidence and organ dysfunction (i.e., severe sepsis)
the number of sepsis-related deaths The process of searching the data- or septic shock. These patients with se-
have increased substantially over the bases, locating relevant titles, and vere sepsis and/or septic shock have
past two decades. screening the abstracts yielded 20 arti- been the usual study populations for
Developing countries are different cles, which had been published be- sepsis in developed nations (13, 22–24).
from developed nations in many tween 1990 and 2004 (5, 25–43). There Therefore, a much higher mortality
ways. For example, Latin American was a noticeably large number of high- rate for the subset of those with severe
countries differ substantially from the quality papers regarding neonatal sep- sepsis is expected in Latin American
United States and from European na- sis and severe infections in pediatric countries. Two prospective cohort
tions in terms of ethnic background, populations in Latin America. For studies from Colombia (5, 35), in in-
cultural heritage, health services, and adult patients, however, the number fected patients admitted to the emer-
clinical research. These differences and scope of the investigations was gency room with SIRS criteria, found a
highlight the importance of exploring more limited. Additionally, for one ar- mortality rate ranging from 24% (35) to
sepsis in Latin America from an epi- ticle only the abstract could be ob- 31% (5), which increased to 40% for pa-
demiological and clinical point of tained (25), and 7 out of the remaining tients in the ICU or with a positive
view. The objective of the rest of this 19 articles (26, 28, 29, 34, 38, 40, 41) an- blood culture (36). Assuming these co-
paper is to provide a systematic re- alyzed sepsis as a secondary outcome horts correspond to a “less ill” popula-
view of the situation surrounding sep- from a wide definition of nosocomial tion, the mortality rates are similar to
sis in Latin America. infections (Table 3). the global estimates for sepsis.

Rev Panam Salud Publica/Pan Am J Public Health 18(3), 2005 167

Literature review Jaimes • A literature review of sepsis in Latin America

TABLE 3. Research on sepsis in Latin America

Frequency
of sepsis or
Author, year of bacteremia Mortality
(reference) Country Design Study population(n) Main clinical outcome (denominator) (%)

Zanon, 1990 Brazil Administrative Discharges at 10 hospitals Septicemia 3/1 000 vs. 7/1 000b 45.8 vs. 58.2
(25)a registers (n = 23 079) (discharges) (community- vs.
nosocomially
acquired)

Del Río, 1993 Cuba Surveillance Surgical patients in Nosocomial infection 184/324c Not reported
(26) community hospital (nosocomial infections)
(n = 324)

Pazmiño, 1993 Ecuador Prospective Sepsis patients in intensive Characterization of Not reportedc 50.6
(27) case-series care unit (ICU) (n = 435) sepsis patients

Ponce de León, Mexico Case-control Patients with nosocomial Risk factors for primary 25/1 000 40
1994 (28) bacteremia (n = 245) nosocomial bacteremia (hospital discharges)

Bembibre, 1997 Cuba Surveillance Patients with nosocomial Nosocomial infection 91/299c Not reported
(29) infection (n = 299) (nosocomial infections)

Arcienega, 1998 Bolivia Retrospective Sepsis patients in ICU Characterization of Not reported 30
(30) case-series (n = 222) sepsis patients

Jaimes, 1998 Colombia Retrospective Patients with bacteremia Characterization of 1.7/100 vs. 7/100e 38
(31, 32)d case-series (n = 432) bacteremic patients (hospital discharges)

Hernández, Chile Cross-sectional SIRSf plus organ Clinical course of severe 79/518 43 vs. 51 (ICU vs.
1999 (33) dysfunction in five ICUs SIRS vs. severe sepsis (ICU admissions) hospital mortality)
(n = 102)

Ponce de León, Mexico Cross-sectional Admissions to 254 ICUs 1-day prevalence of 294/895 33.6
2000 (34) (n = 895) infections (ICU admissions)

Zapata, 2001 Colombia Prospective Patients with nontraumatic Sepsis Not reported 23.5
(35, 36)d cohort study SIRS at 2 hospitals
(n = 533)

Sifuentes, 2001 Mexico Cross-sectional Patients with bacteremia Characterization of 3 428/19 530g 28
(37) (n = 600) bacteremic patients (blood cultures)

Morales, 2001 Cuba Cross-sectional Hospitalized patientsh Nosocomial infections 4/100c,h (discharges) Not reported
(38)

Bilevicius, 2001 Brazil Retrospective Admissions to ICU Sepsis 54/249 56

(39) case-series (n = 249) (ICU admissions)

Luján, 2002 (40) Cuba Surveillance Patients with nosocomial Nosocomial infections 5.3/100c,h (discharges) Not reported
infections at 3 hospitalsh

Cordero, 2002 Cuba Retrospective Patients with nosocomial Nosocomial infections 219/1 241c Not reported
(41) case-series infection (n = 1 241) (nosocomial infections)

Notario, 2003 Argentina Retrospective Patients with bacteremia Characterization of 596/6 605g Not reported
(42) case-series (n = 596) bacteremic patients (blood cultures)

Jaimes, 2003 Colombia Prospective Patients admitted at two Sepsis 657/734 (infection as 30.7
(5) cohort study emergency rooms (n = 734) cause for admission)

Jaimes, 2004 Colombia Cross-sectional Patients with request for Nosocomial bacteremia 89/500g 22.6 vs. 36
(43) blood cultures (n = 500) (blood cultures) (negative vs. positive
blood cultures)

a Only abstract available. e Positive blood cultures vs. requested blood cultures.
b Community-acquired vs. nosocomially acquired. f SIRS = systemic inflammatory response syndrome.
c The definition of sepsis was not clearly established. g Positive blood cultures among total requested.
d Two different research questions with the same study population. h Only rates reported.

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Jaimes • A literature review of sepsis in Latin America Literature review

For a tertiary center in Mexico in the mortality rate also remained al- Even so, these one-day point preva-
1989, Ponce de León et al. (28) found most the same whether the bacteremia lence figures in Mexico are higher than
a rate of nosocomial bacteremia with- was community-acquired or nosoco- those in corresponding prospective co-
out an identified source (designated mially acquired. Their findings con- hort studies performed in ICUs in Eu-
“primary bacteremia”) of 25/1 000 trast with the description of decreas- rope and Australia (23, 24, 46).
discharges, with a mortality rate of ing trends of mortality in the United In summary, sepsis is a problem
40%. This subset of primary bac- States and Europe over the last two around the world, and the problem is
teremia may represent less than 20% decades (14, 21–23). growing. It produces a high burden of
of the total affected population with An additional concern with the mortality and morbidity, and it con-
bacteremia and/or sepsis (44, 45); published literature on sepsis in Latin sumes large amounts of resources. The
hence, the real estimate for bacteremia America is that only the study by results of this study suggest that in
or sepsis should be more than 100 Hernández et al. (33) had an average Latin America the clinical and epi-
cases per 1 000 discharges for this hos- patient age higher than 50 years; that demiological approaches to the prob-
pital. Jaimes et al. (31, 32) estimated study had a population with a mean lem have sometimes been inappropri-
that severe infections and/or bac- age of 61 years and a range of 18 to 87 ate in terms of research design, study
teremia were the main causes for years. All of the other study popu- population, and clinical outcome. It is
emergency admission in 7 out of 100 lations, whether in ICUs, general unlikely that in Latin America there is
patients at a university hospital in wards, or emergency rooms, had a lower incidence of sepsis or a better
Colombia. Similarly, in the same hos- mean ages of 50 years or below. This prognosis for the condition than there
pital, blood cultures were requested in contrasts sharply with the studies is in the developed countries of the
2 out of 10 in-patients at some time done in Europe and the United States, world. Instead, it seems that the first
during their hospitalization (32, 43). in which the mean age was 60 years two points of the action plan stated
Working with data from a referral or above (13, 14, 20, 22, 24). Whatever by the “Barcelona Declaration” (1) are
center in Mexico, Sifuentes-Osornio et the demographic or epidemiological especially needed in the countries of
al. (37) developed the only study that explanation, it seems that Latin Amer- Latin America: (1) “Increase awareness
gives some information on time ica doctors and health care systems of health care professionals, govern-
trends. Those authors found an over- are facing sepsis in a younger and ments, health and funding agencies,
all frequency of bacteremia of 18% probably “healthier” population, but and the public of the high frequency
among patients from whom a blood with morbidity and mortality rates at and mortality associated with sepsis”
culture was requested. The crude mor- least as high as those from developed and (2) “Improve the early and accu-
tality rate was 70% for nosocomially countries. rate diagnosis of sepsis by developing
acquired bacteremia, and 30% for Finally, in a cross-sectional study of a clear and clinically relevant defini-
community-acquired bacteremia. The 254 multidisciplinary ICUs through- tion of sepsis and disseminating it to
authors analyzed randomly selected out Mexico in 1995, Ponce de León- our peers.”
samples of positive blood cultures for Rosales et al. (34) found a one-day
three different periods: from 1981 to point prevalence of 16% for sepsis and Acknowledgements. I am indebted
1984, from 1985 to 1988, and from 1989 of 17% for severe sepsis or septic to Mónica Pineda and Diana Chalarca
to 1992. Surprisingly, the overall mor- shock. For sepsis and other diseases (Biblioteca Médica, Universidad de An-
tality rate showed a modest decrease with short duration and early mortal- tioquia) for technical and bibliographic
for the three study periods, with it ity, prevalence studies may underesti- support. I appreciate the helpful sug-
being 29.5%, 27.5%, and 27.0%, respec- mate their frequency, and the studies gestions from Luis Gabriel Cuervo and
tively. The authors pointed out that do not provide a true estimate of risk. the three anonymous referees.

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170 Rev Panam Salud Publica/Pan Am J Public Health 18(3), 2005

Jaimes • A literature review of sepsis in Latin America Literature review

RESUMEN Objetivos. Algunos estudios epidemiológicos realizados en Estados Unidos de Amé-

rica y en Europa han demostrado que la septicemia es un síndrome de muy amplia dis-
tribución cuya frecuencia ha permanecido estable o ha descendido ligeramente en los
Revisión bibliográfica últimos decenios. El presente trabajo tiene por objetivo presentar los resultados de una
de la distribución revisión bibliográfica sistemática a fin de describir y caracterizar el problema de la sep-
epidemiológica de la ticemia en América Latina.
Métodos. Para localizar materiales sobre el tema de la septicemia en América Latina,
septicemia en América Latina se efectuó una búsqueda global en tres bases de datos médicas usando los términos
“sepsis”, “septicemia”, “bacteremia”, “sepsis syndrome”, “epidemiology”, “incidence”
y “prevalence”. Se abarcaron materiales en inglés, español y portugués.
Resultados. Se examinaron los títulos de más de 1 000 artículos de posible interés, y
se revisaron detenidamente los resúmenes de más de 600 de ellos. En total se escogie-
ron y analizaron 20 trabajos publicados entre 1990 y 2004 con gran heterogeneidad en
cuanto a diseño, población, tamaño muestral, criterios de valoración y seguimiento. No
en todos se aplicó la misma definición clínica de septicemia, lo cual impidió calcular
con precisión la magnitud general del problema de la septicemia en América Latina.
Conclusiones. Según los resultados de la revisión bibliográfica, algunos estudios de
carácter clínico u epidemiológico efectuados en América Latina en torno a la septice-
mia han sido deficientes en cuanto a diseño, población estudiada y resultado clínico
evaluado. Además, hay datos que apuntan a que la septicemia y las infecciones gene-
ralizadas graves podrían ser más frecuentes y acarrear mayor mortalidad en países de
América Latina que en países desarrollados.

Palabras clave Sepsis, mortalidad hospitalaria, unidades de terapia intensiva, América Latina.

ERRATUM

Ferrero F et al. Prevalencia del consumo de tabaco

en médicos residentes de pediatría en Argentina.
(Rev Panam Salud Publica/Pan Am J Public Health
2004;15(6):395–99).

La redacción llama la atención de los lectores a un error en la ver-

sión publicada del artículo señalado.

P. 395, tercera línea de la tercera nota al pie de página: Versión equivo-

cada: “Verónica Rodríguez”. Versión correcta: “Viviana Rodríguez”.

Rev Panam Salud Publica/Pan Am J Public Health 18(3), 2005 171