Eighty-five per cent of sepsis cases and deaths occur in low- and middle-income countries, and global burden estimates increasingly fold malaria, leptospirosis, tuberculosis and severe gastroenteric illness into that total. This Personal View argues the conceptual merge has gone too far in one direction.
The case for merging is that it makes visible an enormous burden of preventable death. The case against is clinical. Standard sepsis management is built around early recognition, source control, organ support and, increasingly, host-response stratification. Endemic and emerging infections often have long, complex pre-hospital courses and need disease-specific diagnosis and disease-specific drugs — an antimalarial, an antileptospiral, antituberculous therapy — that no sepsis bundle supplies.
The authors propose keeping both: stratify endemic and emerging infections by severity, separating milder cases from those with organ dysfunction, which they label sepsis from an endemic and emerging infectious disease. The practical implication for a physician in an endemic setting is that recognising organ dysfunction and identifying the pathogen are two separate tasks, and doing the first well does not excuse deferring the second.
- Start the sepsis bundle and the pathogen-specific workup in parallel, not in sequence.
- In an endemic setting, take a travel, occupational and water-exposure history in every patient with undifferentiated febrile illness and organ dysfunction.
- Send malaria testing and leptospirosis serology early rather than after broad-spectrum antibiotics have failed.
- Remember that an antibiotic bundle does nothing for severe malaria — the disease-specific drug is the treatment.
- This framing is directly relevant to Indian practice, where monsoon-season leptospirosis, dengue, scrub typhus and severe malaria all present as undifferentiated sepsis.
Why it matters
A sepsis label can make a treatable endemic infection look like it has already been managed.
Don't overread it
This is an argument and a proposed framework, not new data or a validated stratification tool.
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