www.thelancet.com/infection Published online August 17, 2017 http://dx.doi.org/10.1016/S1473-3099(17)30322-5 1 Articles The epidemiology of sepsis in Brazilian intensive care units (the Sepsis PREvalence Assessment Database, SPREAD): an observational study Flavia R Machado, Alexandre Biasi Cavalcanti, Fernando Augusto Bozza, Elaine M Ferreira, Fernanda Sousa Angotti Carrara, Juliana Lubarino Sousa, Noemi Caixeta, Reinaldo Salomao, Derek C Angus, Luciano Cesar Pontes Azevedo, on behalf of the SPREAD Investigators and the Latin American Sepsis Institute Network* Summary Background The sepsis burden on acute care services in middle-income countries is a cause for concern. We estimated incidence, prevalence, and mortality of sepsis in adult Brazilian intensive care units (ICUs) and association of ICU organisational factors with outcome. Methods We did a 1-day point prevalence study with follow-up of patients in ICU with sepsis in a nationally representative pseudo-random sample. We produced a sampling frame initially stratifed by geographical region. Each stratum was then stratifed by hospitals’ main source of income (serving general public vs privately insured individuals) and ICU size (ten or fewer beds vs more than ten beds), fnally generating 40 strata. In each stratum we selected a random sample of ICUs so as to enrol the total required beds in 1690 Brazilian adult ICUs. We followed up patients until hospital discharge censored at 60 days, estimated incidence from prevalence and length of stay, and generated national estimates. We assessed mortality prognostic factors using random-efects logistic regression models. Findings On Feb 27, 2014, 227 (72%) of 317 ICUs that were randomly selected provided data on 2632 patients, of whom 794 had sepsis (30·2 septic patients per 100 ICU beds, 95% CI 28·4–31·9). The ICU sepsis incidence was 36·3 per 1000 patient-days (95% CI 29·8–44·0) and mortality was observed in 439 (55·7%) of 788 patients (95% CI 52·2–59·2). Low availability of resources (odds ratio [OR] 1·67, 95% CI 1·02–2·75, p=0·045) and adequacy of treatment (OR 0·56, 0·37–0·84, p=0·006) were independently associated with mortality. The projected incidence rate is 290 per 100 000 population (95% CI 237·9–351·2) of adult cases of ICU-treated sepsis per year, which yields about 420 000 cases annually, of whom 230 000 die in hospital. Interpretation The incidence, prevalence, and mortality of ICU-treated sepsis is high in Brazil. Outcome varies considerably, and is associated with access to adequate resources and treatment. Our results show the burden of sepsis in resource-limited settings, highlighting the need to establish programmes aiming for sepsis prevention, early diagnosis, and adequate treatment. Funding Fundação de Apoio a Pesquisa do Estado de São Paulo (FAPESP). Introduction Middle-income countries have better basic health care and socioeconomic conditions than do low-income countries and have been able to invest in considerably better hospital care. In particular, the number of intensive- care units (ICUs) in middle-income countries are growing. 1 However, concerns persist regarding both the adequacy of ICU resources and the quality of ICU care delivery in these settings. 2 Sepsis is one of the most frequent conditions worldwide for which ICU care is required. 3 Although there is no estimate of sepsis incidence from low-income and middle-income countries, 3 extrapolation based on results from studies in high-income countries suggest that low-income and middle-income countries comprise 85% of the global burden of sepsis. 4 Outcomes of sepsis, such as mortality, have improved in high-income countries, 5 with a case- fatality rate of hospital-treated cases of 26% in the past decade. 3 However, the scarce data suggest higher case- fatality in low-income and middle-income countries than in high-income countries. 6,7 Most observational studies of sepsis in low-income and middle-income countries, including previous studies in Brazil, 8–10 have enrolled small convenience cohorts that neither allowed robust inference of national or regional burden nor interrogation of the associations between resource availability, quality of treatment, and outcome. 11–13 Thus, we have completed a nationwide, 1-day, point- prevalence study with follow-up to assess the national incidence, prevalence, and in-hospital mortality of sepsis in a stratifed pseudo-random sample of Brazilian adult ICUs. We also assessed the association of select hospital and ICU organisational factors (eg, hospital ownership and public or private missions), availability of ICU resources for sepsis management, and compliance with international treatment guidelines with outcome. 14 Lancet Infect Dis 2017 Published Online August 17, 2017 http://dx.doi.org/10.1016/ S1473-3099(17)30322-5 See Online/Comment http://dx.doi.org/10.1016/ S1473-3099(17)30480-2 *A complete list of the investigators of the trial is included at the end of the Article Anesthesiology, Pain, and Intensive Care Department (Prof F R Machado PhD) and Infectious Disease Department (Prof R Salomao PhD), Universidade Federal de São Paulo, São Paulo, Brazil; Latin America Sepsis Institute, São Paulo, Brazil (Prof F R Machado, A B Cavalcanti PhD, F A Bozza PhD, E M Ferreira MsH, F S Angotti Carrara MsH, J L Sousa RN, N Caixeta, Prof R Salomao, Prof L C Pontes Azevedo PhD); Brazilian Research in Intensive Care Network (BRICNet), São Paulo, Brazil (Prof F R Machado, A B Cavalcanti, F A Bozza, Prof L C Pontes Azevedo); Research Institute, Hospital do Coração (HCor), São Paulo, Brazil (A B Cavalcanti); Oswaldo Cruz Foundation (FIOCRUZ), Rio de Janeiro, Brazil (F A Bozza); Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA (Prof D C Angus MD); and Hospital Sírio Libanes, São Paulo, Brazil (Prof L C Pontes Azevedo) Correspondence to: Prof Flavia R Machado, Latin America Sepsis Institute, Universidade Federal de São Paulo, 04039-002 São Paulo, Brazil frmachado@unifesp.br