Unraveling Sepsis Epidemiology in a Low- and Middle-Income Intensive Care Setting Reveals the Alarming Burden of Tropical Infections and Antimicrobial Resistance: A Prospective Observational Study (MARS-India)

Our study addresses the sepsis research gap in lower- and middle-income countries, notably India. Here, we investigate community-acquired sepsis comprehensively and explore the impact of tropical microbiology on etiology and outcomes. MARS-India was a prospective observational study from December 2018 to September 2022 in a tertiary-care hospital in South India. Adult patients within 24 hours of intensive care unit (ICU) admission meeting the Sepsis-3 definition were enrolled, with 6 months of follow-up. More than 4000 patients were screened on ICU admission, with 1000 unique patients meeting the inclusion criteria. Median age was 55 (interquartile range, 44-65) years, with a male preponderance (66%). Almost half the cohort resided in villages (46.5%) and 74.6% worked in the primary sector. Mortality in-hospital was 24.1%. Overall, about 54% had confirmed microbiological diagnosis and >18% had a viral cause of sepsis. Surprisingly, we identified leptospirosis (10.6%), scrub typhus (4.1%), dengue (3.7%), and Kyasanur forest disease (1.6%) as notable causes of sepsis. All of these infections showed seasonal variation around the monsoon. In community-acquired infections, we observed substantial resistance to third-generation cephalosporins and carbapenems. In India, sepsis disproportionally affects a younger and lower-socioeconomic demographic, yielding high mortality. Tropical and viral sepsis carry a significant burden. Analyzing local data, we pinpoint priorities for public health and resources, offering valuable insights for global sepsis research. Clinical Trials Registration. NCT03727243.