emphasises the substantial burden of sepsis worldwide and the disappointing absence of specific drugs to treat it. Development of such new treatments is crucial; however, most of the estimated 15—19 million cases of sepsis globally
are in low-income and middle-income countries,2
which are home to more than 80% of the world's population. Because of the scarcity of many basic necessities that are needed for the provision of medical care in many low-resource settings, novel treatments for sepsis are unlikely to become available to much of the world for many years. For example, many sub-Saharan African hospitals cannot provide supplemental oxygen because this therapy or the necessary delivery equipment are often unavailable.3
In view of the importance of early and appropriate treatment of sepsis, two basic strategies are needed in low-resource settings: development and implementation of standardised, evidence-based approaches to sepsis care, which are pertinent to these settings; and improvement in the capacity of essential health systems to reliably provide the most fundamental treatments of sepsis and its complications—namely, oxygen, antimicrobials, and fluids.
WHO's Integrated Management of Adolescent and Adult Illness (IMAI) initiative has championed the first strategy by developing consensus-based treatment guidelines that are specific to low-resource settings. These guidelines
have been piloted in various countries, including Uganda, Ethiopia, and Malawi. Research is strikingly scarce on the epidemiology, management, and outcomes of sepsis in low-resource settings. This research is important for informing the evidence base for further guideline development and implementation. The unanticipated increase in mortality noted in the treatment group of the Fluid Expansion as Supportive Therapy (FEAST) trial4
of fluid boluses in African children with severe infection underscores the necessity of assessment of interventions in the at-risk population, and the potential dangers of extrapolation of tenets of sepsis management that are established in high-resource settings.
The second strategy requires acknowledgment of the burden of sepsis at the country level and a willingness to apply scarce resources judiciously. Akin to the development of surgical, trauma, and obstetric capacity, a compelling argument about cost-effectiveness exists to the development of essential health systems that can rapidly recognise and treat sepsis and other severe illnesses.5
Quality clinical research and prudent augmentation of essential health-care capacity in low-resource settings deserve an increased priority if we are to reduce the colossal burden of sepsis worldwide.
STJ and EW have served on a WHO working group on sepsis in low-resource settings and contributed to the development of IMAI treatment guidelines for severe illness. STJ is an editor of the IMAI District Clinician Manual: hospital care for adolescents and adults. JRO has served on the Pulmonary Guideline Review Panel for the WHO IMAI District Clinician Manual.