Management of Adult Sepsis in Resource-Limited Settings: Global Expert Consensus Statements Using a Delphi Method
Authors: Thwaites Louise , Nasa Prashant , Abbenbroek Brett , Dat Vu Quoc , Finfer Simon , Kwizera Arthur , Ling Lowell , Lobo Suzana M , Sinto Robert , Aditianingsih Dita , Antonelli Massimo , Arabi Yaseen M , Argent Andrew , Azevedo Luciano , Bennett Elizabeth , Chakrabarti Arunaloke , De Asis Kevin , De Waele Jan , Divatia Jigeeshu Vasishtha , Estenssoro Elisa , Evans Laura , Faiz Abul , Hammond Naomi E , Hashmi Madiha , Herridge Margaret S , Jacob Shevin T , Jatsho Jimba , Javeri Yash , Khalid Karima , Chen Lie Khie , Levy Mitchell , Lundeg Ganbold , Machado Flavia R , Mehta Yatin , Mer Mervyn , Son Do Ngoc , Ospina-Tascón Gustavo A , Ostermann Marlies , Permpikul Chairat , Prescott Hallie C , Reinhart Konrad , Vega Gloria Rodriguez , S-Kabara Halima , Shrestha Gentle S , Siika Wangari , Tan Toh Leong , Todi Subhash , Tripathy Swagata , Venkatesh Bala , Vincent Jean-Louis , Myatra Sheila Nainan 
Published: August 2024

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.