Chapter 11 : Sepsis in Sub-Saharan Africa

MyBook is a cheap paperback edition of the original book and will be sold at uniform, low price.

Preview this chapter:
Zoom in

Sepsis in Sub-Saharan Africa, Page 1 of 2

| /docserver/preview/fulltext/10.1128/9781555816803/9781555815257_Chap11-1.gif /docserver/preview/fulltext/10.1128/9781555816803/9781555815257_Chap11-2.gif


This chapter addresses a number of topics and strategies for managing the septic patient in sub-Saharan Africa (SSA). It focuses on the interaction of malaria and HIV infection with invasive bacterial infections, and highlights the need for different strategies regarding diagnosis and treatment of sepsis due to lack of resources when compared to resource-rich regions where comprehensive but heavily resource-dependent early goal-directed therapy and sepsis “bundles” are the standard of care. The authors of this chapter show that, among Ugandan patients presenting with sepsis, those with the highest expected mortality can be quickly identified through use of a handheld lactate monitor. In a study of lactate in Ugandan septic patients, it was found that a point-of-care device produced more reliable results than standard results from a local private laboratory due to increased discrepancies at higher lactate concentrations. Potential benefits of distributing miniaturized devices and systems designed specifically for low-income countries (LICs) include access to diagnostic tools not previously available and, thus, faster and more accurate diagnoses; better epidemiological data that can be used for disease modeling and vaccine introduction; better utilization of minimally trained healthcare workers; and better use of existing therapeutics. After antimicrobial therapy is begun, the cornerstone of sepsis management is early and adequate fluid resuscitation. Recent animal studies have shown the potential benefit of artemisinins as adjunctive therapy for sepsis. Attention to source control, including drainage of abscesses, may eradicate a nidus of infection.

Citation: Moore C, Jacob S, Banura P, Scheld W. 2010. Sepsis in Sub-Saharan Africa, p 223-239. In Scheld W, Grayson M, Hughes J (ed), Emerging Infections 9. ASM Press, Washington, DC. doi: 10.1128/9781555816803.ch11
Highlighted Text: Show | Hide
Loading full text...

Full text loading...


Image of Figure 1.
Figure 1.

Receiver operating characteristic curve, with sensitivity on the axis and 1-specificity on the axis, for prediction of in-hospital mortality on the basis of different portable whole-blood lactate (PWBL) concentrations. Reprinted from reference (© 2007 by the Infectious Diseases Society of America; all rights reserved).

Citation: Moore C, Jacob S, Banura P, Scheld W. 2010. Sepsis in Sub-Saharan Africa, p 223-239. In Scheld W, Grayson M, Hughes J (ed), Emerging Infections 9. ASM Press, Washington, DC. doi: 10.1128/9781555816803.ch11
Permissions and Reprints Request Permissions
Download as Powerpoint
Image of Figure 2.
Figure 2.

Typical conditions for intensive care of septic patients found in regional referral hospitals in SSA.

Citation: Moore C, Jacob S, Banura P, Scheld W. 2010. Sepsis in Sub-Saharan Africa, p 223-239. In Scheld W, Grayson M, Hughes J (ed), Emerging Infections 9. ASM Press, Washington, DC. doi: 10.1128/9781555816803.ch11
Permissions and Reprints Request Permissions
Download as Powerpoint
Image of Figure 3.
Figure 3.

Typical laboratory conditions found adjacent to medical and surgical wards in regional referral hospitals in SSA.

Citation: Moore C, Jacob S, Banura P, Scheld W. 2010. Sepsis in Sub-Saharan Africa, p 223-239. In Scheld W, Grayson M, Hughes J (ed), Emerging Infections 9. ASM Press, Washington, DC. doi: 10.1128/9781555816803.ch11
Permissions and Reprints Request Permissions
Download as Powerpoint
Image of Figure 4.
Figure 4.

In-hospital mortality due to sepsis at two hospitals in Uganda and admission KPS. Numbers in bars represent numbers of patients. Reprinted from reference .

Citation: Moore C, Jacob S, Banura P, Scheld W. 2010. Sepsis in Sub-Saharan Africa, p 223-239. In Scheld W, Grayson M, Hughes J (ed), Emerging Infections 9. ASM Press, Washington, DC. doi: 10.1128/9781555816803.ch11
Permissions and Reprints Request Permissions
Download as Powerpoint


1. Altaweel, L.,, D. Sweeney,, X. Cui,, A. Barochia,, C. Natanson, and, P. Q. Eichacker. 2009. Growing insights into the potential benefits and risks of activated protein C administration in sepsis: a review of preclinical and clinical studies. Biologics 3: 391406.
2. Amexo, M.,, R. Tolhurst,, G. Barnish, and, I. Bates. 2004. Malaria misdiagnosis: effects on the poor and vulnerable. Lancet 364: 18961898.
3. Archampong, E. Q. 1992. Getting oxygen into our hospital theatres and wards. West Afr. J. Med. 11: 233.
4. Archibald, L. K.,, L. C. McDonald,, O. Nwanyanwu,, P. Kazembe,, H. Dobbie,, J. Tokars,, L. B. Reller, and, W. R. Jarvis. 2000. A hospital-based prevalence survey of bloodstream infections in febrile patients in Malawi: implications for diagnosis and therapy. J. Infect. Dis. 181: 14141420.
5. Arthur, G.,, V. N. Nduba,, S. M. Kariuki,, J. Kimari,, S. M. Bhatt, and, C. F. Gilks. 2001. Trends in bloodstream infections among human immunodeficiency virus-infected adults admitted to a hospital in Nairobi, Kenya, during the last decade. Clin. Infect. Dis. 33: 248256.
6. Bates, I.,, V. Bekoe, and, A. Asamoa-Adu. 2004. Improving the accuracy of malaria-related laboratory tests in Ghana. Malar. J. 3: 38.
7. Berkley, J. A.,, B. S. Lowe,, I. Mwangi,, T. Williams,, E. Bauni,, S. Mwarumba,, C. Ngetsa,, M. P. Slack,, S. Njenga,, C. A. Hart,, K. Maitland,, M. English,, K. Marsh, and, J. A. Scott. 2005. Bacteremia among children admitted to a rural hospital in Kenya. N. Engl. J. Med. 352: 3947.
8. Berkley, J. A.,, K. Maitland,, I. Mwangi,, C. Ngetsa,, S. Mwarumba,, B. S. Lowe,, C. R. Newton,, K. Marsh,, J. A. Scott, and, M. English. 2005. Use of clinical syndromes to target antibiotic prescribing in seriously ill children in malaria endemic area: observational study. BMJ 330: 995.
9. Bernard, G. R.,, J. L. Vincent,, P. F. Laterre,, S. P. LaRosa,, J. F. Dhainaut,, A. Lopez-Rodriguez,, J. S. Steingrub,, G. E. Garber,, J. D. Helterbrand,, E. W. Ely, and, C. J. Fisher, Jr. 2001. Efficacy and safety of recombinant human activated protein C for severe sepsis. N. Engl. J. Med. 344: 699709.
10. Bimenya, G. S.,, G. R. Nzarubara,, J. Kiconco,, S. Sabuni, and, W. Byarugaba. 2003. The accuracy of self monitoring blood glucose meter systems in Kampala Uganda. Afr. Health Sci. 3: 2332.
11. Blomberg, B.,, R. Jureen,, K. P. Manji,, B. S. Tamim,, D. S. Mwakagile,, W. K. Urassa,, M. Fataki,, V. Msangi,, M. G. Tellevik,, S. Y. Maselle, and, N. Langeland. 2005. High rate of fatal cases of pediatric septicemia caused by gram-negative bacteria with extended-spectrum beta-lactamases in Dar es Salaam, Tanzania. J. Clin. Microbiol. 43: 745749.
12. Bronzan, R. N.,, T. E. Taylor,, J. Mwenechanya,, M. Tembo,, K. Kayira,, L. Bwanaisa,, A. Njobvu,, W. Kondowe,, C. Chalira,, A. L. Walsh,, A. Phiri,, L. K. Wilson,, M. E. Molyneux, and, S. M. Graham. 2007. Bacteremia in Malawian children with severe malaria: prevalence, etiology, HIV coinfection, and outcome. J. Infect. Dis. 195: 895904.
13. Brun-Buisson, C. 2000. The epidemiology of the systemic inflammatory response. Intensive Care Med. 26( Suppl. 1): 6474.
14. Brunkhorst, F. M.,, C. Engel,, F. Bloos,, A. Meier-Hellmann,, M. Ragaller,, N. Weiler,, O. Moerer,, M. Gruend-ling,, M. Oppert,, S. Grond,, D. Olthoff,, U. Jaschinski,, S. John,, R. Rossaint,, T. Welte,, M. Schaefer,, P. Kern,, E. Kuhnt,, M. Kiehntopf,, C. Hartog,, C. Natanson,, M. Loeffler, and, K. Reinhart. 2008. Intensive insulin therapy and pentastarch resuscitation in severe sepsis. N. Engl. J. Med. 358: 125139.
15. Buor, D. 2003. Analysing the primacy of distance in the utilization of health services in the Ahafo-Ano South district, Ghana. Int. J. Health Plann. Manag. 18: 293311.
16. Carrol, E. D.,, L. A. Mankhambo,, G. Jeffers,, D. Parker,, M. Guiver,, P. Newland,, D. L. Banda,, E. M. Molyneux,, R. S. Heyderman,, M. E. Molyneux, and, C. A. Hart. 2009. The diagnostic and prognostic accuracy of five markers of serious bacterial infection in Malawian children with signs of severe infection. PLoS One 4: e6621.
17. Cheng, A. C.,, T. E. West,, D. Limmathurotsakul, and, S. J. Peacock. 2008. Strategies to reduce mortality from bacterial sepsis in adults in developing countries. PLoS Med. 5: e175.
18. Dellinger, R. P.,, M. M. Levy,, J. M. Carlet,, J. Bion,, M. M. Parker,, R. Jaeschke,, K. Reinhart,, D. C. Angus,, C. Brun-Buisson,, R. Beale,, T. Calandra,, J. F. Dhainaut,, H. Gerlach,, M. Harvey,, J. J. Marini,, J. Marshall,, M. Ranieri,, G. Ramsay,, J. Sevransky,, B. T. Thompson,, S. Townsend,, J. S. Vender,, J. L. Zimmerman,, J. L. Vincent, et al. 2008. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008. Crit. Care Med. 36: 296327.
19. Dunser, M. W.,, I. Baelani, and, L. Ganbold. 2006. A review and analysis of intensive care medicine in the least developed countries. Crit. Care Med. 34: 12341242.
20. English, M.,, F. Esamai,, A. Wasunna,, F. Were,, B. Ogutu,, A. Wamae,, R. W. Snow, and, N. Peshu. 2004. Assessment of inpatient paediatric care in first referral level hospitals in 13 districts in Kenya. Lancet 363: 19481953.
21. English, M.,, F. Esamai,, A. Wasunna,, F. Were,, B. Ogutu,, A. Wamae,, R. W. Snow, and, N. Peshu. 2004. Delivery of paediatric care at the first-referral level in Kenya. Lancet 364: 16221629.
22. Ghebremedhin, B.,, M. O. Olugbosi,, A. M. Raji,, F. Layer,, R. A. Bakare,, B. Konig, and, W. Konig. 2009. Emergence of a community-associated methicillin-resistant Staphylococcus aureus strain with a unique resistance profile in southwest Nigeria. J. Clin. Microbiol. 47: 29752980.
23. Gilks, C. F.,, R. J. Brindle,, L. S. Otieno,, P. M. Simani,, R. S. Newnham,, S. M. Bhatt,, G. N. Lule,, G. B. Okelo,, W. M. Watkins,, P. G. Waiyaki, et al. 1990. Life-threatening bacteraemia in HIV-1 seropositive adults admitted to hospital in Nairobi, Kenya. Lancet 336: 545549.
24. Gordon, M. A.,, H. T. Banda,, M. Gondwe,, S. B. Gordon,, M. J. Boeree,, A. L. Walsh,, J. E. Corkill,, C. A. Hart,, C. F. Gilks, and, M. E. Molyneux. 2002. Non-typhoidal salmonella bacteraemia among HIV-infected Malawian adults: high mortality and frequent recrudescence. AIDS 16: 16331641.
25. Gove, S.,, G. Tamburlini,, E. Molyneux,, P. Whitesell, and, H. Campbell. 1999. Development and technical basis of simplified guidelines for emergency triage assessment and treatment in developing countries. WHO Integrated Management of Childhood Illness (IMCI) Referral Care Project. Arch. Dis. Child. 81: 473477.
26. Granja, A. C.,, F. Machungo, and, S. Bergstrom. 2000. Avoidability of maternal death in Mozambique: audit and retrospective risk assessment in 106 consecutive cases. Afr. J. Health Sci. 7: 8387.
27. Hill, P. C.,, C. O. Onyeama,, U. N. Ikumapayi,, O. Secka,, S. Ameyaw,, N. Simmonds,, S. A. Donkor,, S. R. Howie,, M. Tapgun,, T. Corrah, and, R. A. Adegbola. 2007. Bacteraemia in patients admitted to an urban hospital in West Africa. BMC Infect. Dis. 7: 2.
28. Hodges, S. C.,, C. Mijumbi,, M. Okello,, B. A. McCormick,, I. A. Walker, and, I. H. Wilson. 2007. Anaesthesia services in developing countries: defining the problems. Anaesthesia 62: 411.
29. Jacob, S. T.,, C. C. Moore,, P. Banura,, R. Pinkerton,, D. Meya,, P. Opendi,, S. J. Reynolds,, N. Kenya-Mugisha,, H. Mayanja-Kizza, and, W. M. Scheld. 2009. Severe sepsis in two Ugandan hospitals: a prospective observational study of management and outcomes in a predominantly HIV-1 infected population. PLoS One 4: e7782.
30. Jochberger, S.,, F. Ismailova,, W. Lederer,, V. D. Mayr,, G. Luckner,, V. Wenzel,, H. Ulmer,, W. R. Hasi-beder, and, M. W. Dunser. 2008. Anesthesia and its allied disciplines in the developing world: a nationwide survey of the Republic of Zambia. Anesth. Analg. 106: 942948.
31. Ka, S. B.,, O. Kane,, E. Diouf, and, M. D. Beye. 2002. Emergencies at a hospital center and university in a tropical area. An anesthesiologist’s point of view. Med. Trop. (Marseilles) 62: 247250.
32. Kumar, A.,, P. Ellis,, Y. Arabi,, D. Roberts,, B. Light,, J. E. Parrillo,, P. Dodek,, G. Wood,, A. Kumar,, D. Simon,, C. Peters,, M. Ahsan, and, D. Chateau. 2009. Initiation of inappropriate antimicrobial therapy results in a fivefold reduction of survival in human septic shock. Chest 136: 12371248.
33. Kumar, A.,, D. Roberts,, K. E. Wood,, B. Light,, J. E. Parrillo,, S. Sharma,, R. Suppes,, D. Feinstein,, S. Zanotti,, L. Taiberg,, D. Gurka,, A. Kumar, and, M. Cheang. 2006. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit. Care Med. 34: 15891596.
34. Levy, M. M.,, M. P. Fink,, J. C. Marshall,, E. Abraham,, D. Angus,, D. Cook,, J. Cohen,, S. M. Opal,, J. L. Vincent, and, G. Ramsay. 2003. 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Crit. Care Med. 31: 12501256.
35. Li, B.,, J. Li,, X. Pan,, G. Ding,, H. Cao,, W. Jiang,, J. Zheng, and, H. Zhou. 11 December 2009. Artesunate protects sepsis model mice challenged with Staphylococcus aureus by decreasing TNF-alpha release via inhibition TLR2 and Nod2 mRNA expressions and transcription factor NF-kappaB activation. Int. Immunopharmacol. 10: 344350. [Epub ahead of print.]
36. Lockman, S.,, N. Hone,, T. A. Kenyon,, M. Mwasekaga,, M. Villauthapillai,, T. Creek,, E. Zell,, A. Kirby,, W. L. Thacker,, D. Talkington,, I. N. Moura,, N. J. Binkin,, L. Clay, and, J. W. Tappero. 2003. Etiology of pulmonary infections in predominantly HIV-infected adults with suspected tuberculosis, Botswana. Int. J. Tuberc. Lung Dis. 7: 714723.
37. Lyons, R. A.,, K. Wareham,, H. A. Hutchings,, E. Major, and, B. Ferguson. 2000. Population requirement for adult critical–care beds: a prospective quantitative and qualitative study. Lancet 355: 595598.
38. Mackenzie, A. F. 2005. Activated protein C: do more survive? Intensive Care Med. 31: 16241626.
39. Meya, D. B.,, E. Katabira,, M. Otim,, A. Ronald,, R. Colebunders,, D. Njama,, H. Mayanja-Kizza,, C. C. Whalen, and, M. Sande. 2007. Functional adrenal insufficiency among critically ill patients with human immunodeficiency virus in a resource-limited setting. Afr. Health Sci. 7: 101107.
40. Moore, C. C.,, S. T. Jacob,, R. Pinkerton,, P. Banura,, D. B. Meya,, S. J. Reynolds,, N. Kenya–Mugisha,, H. Mayanja-Kizza, and, W. M. Scheld. 2009. Treatment of severe sepsis with artemether-lumefantrine is associated with decreased mortality in Ugandan patients without malaria. Am. J. Trop. Med. Hyg. 80: 723728.
41. Moore, C. C.,, S. T. Jacob,, R. Pinkerton,, D. B. Meya,, H. Mayanja-Kizza,, S. J. Reynolds, and, W. M. Scheld. 2008. Point-of-care lactate testing predicts mortality of severe sepsis in a predominantly HIV type 1-infected patient population in Uganda. Clin. Infect. Dis. 46: 215222.
42. Mshana, S. E.,, E. Kamugisha,, M. Mirambo,, T. Chakraborty, and, E. F. Lyamuya. 2009. Prevalence of multiresistant gram-negative organisms in a tertiary hospital in Mwanza, Tanzania. BMC Res. Notes 2: 49.
43. Mullan, F. 2005. The metrics of the physician brain drain. N. Engl. J. Med. 353: 18101818.
44. Mundy, C.,, M. Ngwira,, G. Kadewele,, I. Bates,, S. B. Squire, and, C. F. Gilks. 2000. Evaluation of microscope condition in Malawi. Trans. R. Soc. Trop. Med. Hyg. 94: 583584.
45. Ngwu, B. A.,, and J. A. Agbo. 2003. Typhoid fever: clinical diagnosis versus laboratory confirmation. Niger. J. Med. 12: 187192.
46. O’Dempsey, T. J.,, T. F. McArdle,, N. Lloyd-Evans,, I. Baldeh,, B. E. Laurence,, O. Secka, and, B. M. Greenwood. 1994. Importance of enteric bacteria as a cause of pneumonia, meningitis and septicemia among children in a rural community in The Gambia, West Africa. Pediatr. Infect. Dis. J. 13: 122128.
47. Oji, A. 1986. Intensive care in a developing country: a review of the first 100 cases. Ann. R. Coll. Surg. Engl. 68: 122124.
48. Otu, A. A. 1989. Tropical surgical abdominal emergencies: acute appendicitis. Trop. Geogr. Med. 41: 118122.
49. Petti, C. A.,, C. R. Polage,, T. C. Quinn,, A. R. Ronald, and, M. A. Sande. 2006. Laboratory medicine in Africa: a barrier to effective health care. Clin. Infect. Dis. 42: 377382.
50. Razzak, J. A.,, and A. L. Kellermann. 2002. Emergency medical care in developing countries: is it worth-while? Bull. W. H. O. 80: 900905.
51. Reddy, E. A.,, A. V. Shaw, and, J. A. Crump. 2010. Community-acquired bloodstream infections in Africa: a systematic review and meta-analysis. Lancet Infect. Dis. 10: 417432.
52. Reyburn, H.,, R. Mbatia,, C. Drakeley,, I. Carneiro,, E. Mwakasungula,, O. Mwerinde,, K. Saganda,, J. Shao,, A. Kitua,, R. Olomi,, B. M. Greenwood, and, C. J. Whitty. 2004. Overdiagnosis of malaria in patients with severe febrile illness in Tanzania: a prospective study. BMJ 329: 1212.
53. Robson, W.,, T. Nutbeam, and, R. Daniels. 2009. Sepsis: a need for prehospital intervention? Emerg. Med. J. 26: 535538.
54. Scarborough, M.,, S. B. Gordon,, C. J. Whitty,, N. French,, Y. Njalale,, A. Chitani,, T. E. Peto,, D. G. Lalloo, and, E. E. Zijlstra. 2007. Corticosteroids for bacterial meningitis in adults in sub-Saharan Africa. N. Engl. J. Med. 357: 24412450.
55. Scott, J. A.,, A. J. Hall,, C. Muyodi,, B. Lowe,, M. Ross,, B. Chohan,, K. Mandaliya,, E. Getambu,, F. Gleeson,, F. Drobniewski, and, K. Marsh. 2000. Aetiology, outcome, and risk factors for mortality among adults with acute pneumonia in Kenya. Lancet 355: 12251230.
56. Shapiro, N.,, M. D. Howell,, D. W. Bates,, D. C. Angus,, L. Ngo, and, D. Talmor. 2006. The association of sepsis syndrome and organ dysfunction with mortality in emergency department patients with suspected infection. Ann. Emerg. Med. 48: 583590.
57. Reference deleted.
58. Sinclair, J. R.,, D. A. Watters, and, M. Davison. 1988. Outcome of mechanical ventilation in Central Africa. Ann. R. Coll. Surg. Engl. 70: 7679.
59. Sprung, C. L.,, D. Annane,, D. Keh,, R. Moreno,, M. Singer,, K. Freivogel,, Y. G. Weiss,, J. Benbenishty,, A. Kalenka,, H. Forst,, P. F. Laterre,, K. Reinhart,, B. H. Cuthbertson,, D. Payen,, J. Briegel, and CORTICUS Study Group. 2008. Hydrocortisone therapy for patients with septic shock. N. Engl. J. Med. 358: 111124.
60. Ssali, F. N.,, M. R. Kamya,, F. Wabwire-Mangen,, S. Kasasa,, M. Joloba,, D. Williams,, R. D. Mugerwa,, J. J. Ellner, and, J. L. Johnson. 1998. A prospective study of community-acquired bloodstream infections among febrile adults admitted to Mulago Hospital in Kampala, Uganda. J. Acquir. Immune Defic. Syndr. Hum. Retrovirol. 19: 484489.
61. Sweeney, D. A.,, R. L. Danner,, P. Q. Eichacker, and, C. Natanson. 2008. Once is not enough: clinical trials in sepsis. Intensive Care Med. 34: 19551960.
62. Tamburlini, G.,, M. S. Di,, R. S. Maggi,, J. N. Vilarim, and, S. Gove. 1999. Evaluation of guidelines for emergency triage assessment and treatment in developing countries. Arch. Dis. Child. 81: 478482.
63. Thomson, N. 2005. Emergency medical services in Zimbabwe. Resuscitation 65: 1519.
64. Towey, R. M.,, and S. Ojara. 2007. Intensive care in the developing world. Anaesthesia 62( Suppl. 1): 3237.
65. Towey, R. M.,, and S. Ojara. 2008. Practice of intensive care in rural Africa: an assessment of data from Northern Uganda. Afr. Health Sci. 8: 6164.
66. Trachtenberg, J. D.,, A. D. Kambugu,, M. McKellar,, F. Semitala,, H. Mayanja-Kizza,, M. H. Samore,, A. Ronald, and, M. A. Sande. 2007. The medical management of central nervous system infections in Uganda and the potential impact of an algorithm-based approach to improve outcomes. Int. J. Infect. Dis. 11: 524530.
67. Van den Berghe, G.,, A. Wilmer,, G. Hermans,, W. Meersseman,, P. J. Wouters,, I. Milants,, W. E. Van,, H. Bobbaers, and, R. Bouillon. 2006. Intensive insulin therapy in the medical ICU. N. Engl. J. Med. 354: 449461.
68. Van den Berghe, G.,, P. Wouters,, F. Weekers,, C. Verwaest,, F. Bruyninckx,, M. Schetz,, D. Vlasselaers,, P. Ferdinande,, P. Lauwers, and, R. Bouillon. 2001. Intensive insulin therapy in the critically ill patients. N. Engl. J. Med. 345: 13591367.
69. Vray, M.,, Y. Germani,, S. Chan,, N. H. Duc,, B. Sar,, F. D. Sarr,, R. Bercion,, L. Rahalison,, M. Maynard,, P. L’Her,, L. Chartier, and, C. Mayaud. 2008. Clinical features and etiology of pneumonia in acid-fast bacillus sputum smear-negative HIV-infected patients hospitalized in Asia and Africa. AIDS 22: 13231332.
70. Wang, H. E.,, M. D. Weaver,, N. I. Shapiro, and, D. M. Yealy. 2010. Opportunities for Emergency Medical Services care of sepsis. Resuscitation 81: 193197.
71. Wang, J.,, H. Zhou,, J. Zheng,, J. Cheng,, W. Liu,, G. Ding,, L. Wang,, P. Luo,, Y. Lu,, H. Cao,, S. Yu,, B. Li, and, L. Zhang. 2006. The antimalarial artemisinin synergizes with antibiotics to protect against lethal live Escherichia coli challenge by decreasing proinflammatory cytokine release. Antimicrob. Agents Chemother. 50: 24202427.
72. Wang, J. X.,, L. F. Hou,, Y. Yang,, W. Tang,, Y. Li, and, J. P. Zuo. 2009. SM905, an artemisinin derivative, inhibited NO and pro-inflammatory cytokine production by suppressing MAPK and NF-kappaB pathways in RAW 264.7 macrophages. Acta Pharmacol. Sin. 30: 14281435.
73. Wood, S. M.,, S. S. Shah,, M. Bafana,, A. J. Ratner,, P. A. Meaney,, K. C. Malefho, and, A. P. Steenhoff. 2009. Epidemiology of methicillin-resistant Staphylococcus aureus bacteremia in Gaborone, Botswana. Infect. Control Hosp. Epidemiol. 30: 782785.
74. Yager, P.,, T. Edwards,, E. Fu,, K. Helton,, K. Nelson,, M. R. Tam, and, B. H. Weigl. 2006. Microfluidic diagnostic technologies for global public health. Nature 442: 412418.

This is a required field
Please enter a valid email address
Please check the format of the address you have entered.
Approval was a Success
Invalid data
An Error Occurred
Approval was partially successful, following selected items could not be processed due to error