News24 | ANALYSIS | Sepsis shows us where health systems are failing, but where repair is possible

Improvements in sepsis outcomes show that prevention is working, that healthcare is accessible, that systems are functioning, and that people are receiving the care they need, write Shabir A Madhi, Robyn Hayes-Badenhorst and Andrew Argent.

A woman who develops an infection after giving birth can deteriorate within hours. Her temperature rises. Her pulse quickens. Her breathing changes. In a busy maternity ward, staff may miss these signs.

Across 59 hospitals in Malawi and Uganda, APT-Sepsis tested whether better implementation of existing guidance could improve outcomes.

All hospitals received guidelines and obtained medicines through the usual procurement. APT-Sepsis hospitals also engaged leaders, appointed staff champions, trained multidisciplinary teams, introduced practical tools and gave staff performance feedback. Extra soap and alcohol-based hand rub were supplied where needed.

Colour-coded vital-sign charts identified deterioration. Red flags triggered the FAST-M treatment bundle: fluids, antibiotics, infection control, transfer where necessary, and monitoring.

More than 431 000 women gave birth during the trial. Severe infection-related outcomes occurred in 1.4% of women in APT-Sepsis facilities, compared with 1.9% in usual-care facilities: a 32% relative reduction.

It used no new drugs or clinical protocols and did not rely on expensive technology. Leadership, behaviour, teamwork and accountability changed outcomes.

The canary in the coal mine

Can one medical emergency show us where South Africa’s health system is failing and where repair is possible? Sepsis can.

Sepsis is an infection accompanied by the failure of one or more organs. It can follow illness, childbirth, hospital care or cancer treatment. It cuts across the health system, but the response is divided between medical silos.

The African Sepsis Alliance connects clinicians, researchers, policymakers, patients and families around an African response that strengthens existing health programmes rather than creating another silo.

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Paediatric intensivist and chair of the African Sepsis Alliance Professor Andrew Argent has seen resistant pathogens narrow treatment options for critically ill children.

Vaccination, clean water, sanitation, nutrition and safe facilities can prevent infection. Early treatment can stop it progressing to sepsis. Infection control and careful antibiotic use can limit resistant organisms.

When someone reaches intensive care, the emergency may be the final point in a longer chain. Was the infection prevented or recognised? Could the patient reach care? Were laboratory services and appropriate antibiotics available?

About 15 years ago, Cape Town researchers found that more than 80% of families lived within three kilometres of a clinic open during working hours. After hours, the median distance to emergency care was about 10km, making emergency help difficult to reach at night.

For one of us, Robyn Hayes-Badenhorst, this hits close to home. Her father died from preventable septic shock. Families often recognise deterioration quickly: the person is behaving differently, struggling to breathe or has stopped passing urine. Listening to them is critical.

Improvements in sepsis outcomes show us that prevention is working, that healthcare is accessible, that systems are working, and that people are receiving the care they need.

What routine surveillance misses 

To understand what is happening with sepsis we need routine surveillance and careful research. While incredibly useful, routine surveillance may miss infections in multiple settings. Antibiotics may precede sampling, blood volumes tested may be inadequately small, and many infections are never microbiologically confirmed.

The Child Health and Mortality Prevention (CHAMP) Surveillance network used post-mortem investigation to look beyond infections confirmed during life. In 2 609 neonatal deaths examined through 2023, infection formed part of the causal pathway in 44%. More than 80% were judged potentially avoidable.

Gram-negative bacteria accounted for 74% of infection-related deaths. K. pneumoniae was implicated in 42%, followed by Acinetobacter baumannii in 26%.

Linking mortality findings with clinical and laboratory surveillance can show which pathogens are circulating, where infections are acquired and whether antibiotics still work. That evidence can strengthen infection prevention, laboratories and treatment guidelines, and direct vaccine development.

When antibiotics stop working 

Among the tested Klebsiella pneumoniae isolates in CHAMPS deaths in children under five, 84% were resistant to ceftriaxone and 75% to gentamicin. In South Africa, Acinetobacter baumannii was implicated in 74.3% of presumed hospital-acquired neonatal deaths. Some of these bacteria resist every available class of antibiotic.

A hospital may use state-of-the-art care to help a premature baby survive birth, only for that baby to die days later from a hospital-acquired infection that should have been prevented.

Antimicrobial resistance complicates the clinical dilemma. Delaying administration of an effective antibiotic can be fatal. But routine broad-spectrum prescribing drives the development of resistance. In some neonatal units, clinicians must use colistin, a last-resort antibiotic, because no suitable alternative is available. The pipeline for new antibiotics is empty at the moment, which is deeply concerning.

READ | Antibiotic-resistant bugs claim over 200k infants globally per year, finds major study

Speed and antibiotic stewardship must work together. Healthcare workers need rapid testing, local organism data and protocols that change with resistance patterns. That means that laboratory and reporting systems must work. If laboratory evidence never reaches the prescribing clinician, another part of the system has failed.

From evidence to action

CHAMPS shows where systems are breaking down. APT-Sepsis shows that identifying those failures can lead to measurable improvement.

Training and early-warning charts cannot compensate for staff shortages, overcrowding, water interruptions, failing laboratories or broken referrals. South Africa should adapt similar programmes for maternity and neonatal services, beginning where hospital-acquired infections, delayed recognition or failed referrals cause serious harm.

Maternal immunisation could protect babies during early infancy. Developing a K. pneumoniae vaccine will be difficult because the bacterium is highly diverse, varies geographically and can colonise without causing invasive disease. It would complement infection prevention, diagnostics and treatment.

Facilities should measure infections acquired during care, response times, antibiotic use, whether laboratory results reach treating teams and whether patients are transferred in time.

Sepsis cannot become another stand-alone programme. It belongs within vaccination, maternal and newborn health, primary healthcare, infection prevention, antimicrobial resistance, emergency services and universal health coverage.

This year’s World Sepsis Day theme is “Invest in Sepsis – Save Lives”. For South Africa, that investment should strengthen the connections between clinics, ambulances, laboratories, hospitals, rehabilitation and critical care.

Fewer hospital-acquired infections, shorter treatment delays and antibiotic guidelines that respond to local resistance data would show improvement. If preventable sepsis deaths fall, we will have evidence that parts of the health system are working better.

– Shabir A Madhi is a professor of vaccinology at the University of the Witwatersrand and director of the SA Medical Research Council Vaccines and Infectious Diseases Analytics Research Unit at Wits.

– Robyn Hayes-Badenhorst is the founder and co-executive director of the Supporting Health Initiatives and a lifelong patron of the Global Sepsis Alliance.

– Professor Andrew Argent is chairperson of the African Sepsis Alliance, a board member of the Global Sepsis Alliance, a paediatric intensivist and former head of the department of paediatrics at the University of Cape Town.

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