The burden and contemporary epidemiology of sepsis in children

Sepsis beyond bundles: contextualising paediatric care in resource-limited settings through situational analysis

BACKGROUND

Paediatric sepsis remains a significant contributor to morbidity and mortality, particularly in low- and middle-income countries (LMICs), where healthcare resources are often limited. Paediatric sepsis bundles, which include prompt administration of antibiotics, fluid resuscitation and continuous organ function monitoring, are crucial for improving outcomes, especially when initiated within the first 'golden hour' of sepsis recognition. These bundles, adapted from adult sepsis care protocols through the Surviving Sepsis Campaign, are increasingly emphasised in global sepsis management guidelines. However, the implementation of these protocols in LMICs is challenged by resource limitations and systemic barriers.

METHODS

This situational analysis, conducted at two hospitals in Ghana-a tertiary facility and a district (secondary) facility-maps the availability of critical resources for paediatric sepsis care through a structured environmental scan using survey methodology. We assess staffing levels, access to medications, airway support and diagnostic capabilities. Methods were conceptualised through inner and outer settings of the Consolidated Framework for Implementation Research (CFIR) and reported through the Donabedian model for healthcare quality.

RESULTS

This study compared paediatric care at a tertiary hospital (Komfo Anokye Teaching Hosptial (KATH)) and a district hospital (Presbyterian Hospital, Agogo (PreHA)) in Ghana, highlighting KATH's emergency and intensive care unit (ICU) services, specialised staff and broader respiratory support. PreHA, although without a paediatric-specific ICU, leveraged research funding to enhance clinical care capacity. Both hospitals experienced regular power outages but had reliable generators, and while they offered basic medications and treatments, resource limitations, including out-of-pocket costs for families, impacted access to essential medications and laboratory tests.

CONCLUSION

Concerns around resource availability, compounded by structural determinants such as financial barriers and historical underfunding hypothesised to be rooted in colonialism, highlight the need for context-sensitive adaptations of paediatric sepsis bundles. Our findings underscore the importance of a participatory approach to guideline adaptation and resource distribution, incorporating local expertise and addressing structural inequities to improve paediatric sepsis outcomes in Ghana. Future qualitative research will explore pre- and peri-hospital barriers to care and inform more effective, contextually appropriate interventions.

Building global collaborative research networks in paediatric critical care: a roadmap

Paediatric critical care units are designed for children at a vulnerable stage of development, yet the evidence base for practice and policy in paediatric critical care remains scarce. In this Health Policy, we present a roadmap providing strategic guidance for international paediatric critical care trials. We convened a multidisciplinary group of 32 paediatric critical care experts from six continents representing paediatric critical care research networks and groups. The group identified key challenges to paediatric critical care research, including lower patient numbers than for adult critical care, heterogeneity related to cognitive development, comorbidities and illness or injury, consent challenges, disproportionately little research funding for paediatric critical care, and poor infrastructure in resource-limited settings. A seven-point roadmap was proposed: (1) formation of an international paediatric critical care research network; (2) development of a web-based toolkit library to support paediatric critical care trials; (3) establishment of a global paediatric critical care trial repository, including systematic prioritisation of topics and populations for interventional trials; (4) development of a harmonised trial minimum set of trial data elements and data dictionary; (5) building of infrastructure and capability to support platform trials; (6) funder advocacy; and (7) development of a collaborative implementation programme. Implementation of this roadmap will contribute to the successful design and conduct of trials that match the needs of globally diverse paediatric populations.

PCSK9 in metabolism and diseases

PCSK9 is a serine protease that regulates plasma levels of low-density lipoprotein (LDL) and cholesterol by mediating the endolysosomal degradation of LDL receptor (LDLR) in the liver. When PCSK9 functions unchecked, it leads to increased degradation of LDLR, resulting in elevated circulatory levels of LDL and cholesterol. This dysregulation contributes to lipid and cholesterol metabolism abnormalities, foam cell formation, and the development of various diseases, including cardiovascular disease (CVD), viral infections, cancer, and sepsis. Emerging clinical and experimental evidence highlights an imperative role for PCSK9 in metabolic anomalies such as hypercholesterolemia and hyperlipidemia, as well as inflammation, and disturbances in mitochondrial homeostasis. Moreover, metabolic hormones - including insulin, glucagon, adipokines, natriuretic peptides, and sex steroids - regulate the expression and circulatory levels of PCSK9, thus influencing cardiovascular and metabolic functions. In this comprehensive review, we aim to elucidate the regulatory role of PCSK9 in lipid and cholesterol metabolism, pathophysiology of diseases such as CVD, infections, cancer, and sepsis, as well as its pharmaceutical and non-pharmaceutical targeting for therapeutic management of these conditions.

Integration of Mendelian Randomization to explore the genetic influences of pediatric sepsis: a focus on RGL4, ATP9A, MAP3K7CL, and DDX11L2

OBJECTIVE

This study aims to explore the genetic characteristics of pediatric sepsis through a combined analysis of multiple methods, including Mendelian Randomization (MR), differential gene expression analysis, and immune cell infiltration assessment. It explores their potential as biomarkers for sepsis risk and their involvement in immune-related pathways.

METHODS

Differential expression analysis was performed using public datasets to identify genes with significant expression changes between pediatric sepsis patients and healthy controls. MR analysis utilized genome-wide significant SNPs as instrumental variables to assess causal relationships between gene expression and sepsis risk. Bi-directional MR was conducted to assess both forward and reverse causality. FDR correction was applied to adjust for multiple comparisons in MR results. Immune cell infiltration analysis was performed to investigate the genes' roles in immune responses, and findings were validated with independent datasets. ROC curves were constructed to assess predictive performance.

RESULTS

Differential expression analysis identified significant changes in RGL4,ATP9A,MAP3K7CL, and DDX11L2. MR analysis revealed causal associations between these genes and sepsis risk, with RGL4 and ATP9A upregulated (inflammatory roles), and MAP3K7CL and DDX11L2 downregulated (protective roles). Bi-directional MR found no significant reverse causality. Immune cell analysis showed associations with key immune cell types, and ROC analysis demonstrated strong predictive potential.

CONCLUSION

RGL4,ATP9A,MAP3K7CL, and DDX11L2 play important roles in pediatric sepsis risk and immune response regulation, offering insights into genetic and immune mechanisms that may inform future sepsis research and treatment.

The injury effect of osteopontin in sepsis-associated lung injury

BACKGROUND

Sepsis is a severe condition causing organ failure due to an abnormal immune reaction to infection, characterized by ongoing excessive inflammation and immune system issues. Osteopontin (OPN) is secreted by various cells and plays a crucial role in inflammatory responses and immune regulation. Nonetheless, the precise function of OPN in sepsis remains to be elucidated.

METHODS

In the present study, we evaluated the levels of OPN in paediatric patients with sepsis and healthy individuals. We examined the impact of OPN on survival rates, systemic inflammation, and lung injury within an experimental sepsis model using cecal ligation and puncture (CLP). Furthermore, the pro-inflammatory effects and potential mechanisms of OPN in sepsis were investigated through Mouse Hemophagocytic Synuclein (MH-S) cells.

RESULTS

The OPN level was found to be elevated in patients with sepsis (368.5 ± 249.4 ng/ml) compared to children with infections (73.78 ± 40.46 ng/ml) (p < 0.0001) and healthy individuals (44.03 ± 20.76 ng/ml) (p < 0.0001). The serum concentration of OPN was elevated in pediatric patients with septic shock compared to those with sepsis (504 ± 266.3 ng/ml vs. 238.6 ± 143.8 ng/ml, p < 0.001). Intravenous administration of OPN inhibitor into the tail vein decreased the mortality rate (HR = 0.2695, p = 0.0015), suppressed systemic inflammatory responses and mitigated lung tissue damage. The concentration of tumour necrosis factor (TNF)-α, IL-6 and IL-1β in serum of CLP mice treated with OPN inhibitor decreased compared with CLP mice. Within the sepsis mouse model, there was a marked increase in OPN expression in the lung's tissues compared to the sham group mice. This surge was accompanied by a significant accumulation of alveolar macrophages and an upregulation of inflammasome expression. Mechanistic investigations in MH-s cells revealed that OPN-siRNA suppressed the LPS-induced macrophage inflammatory response by inhibiting caspase1-dependent classical pyroptosis signaling pathway. However, recombinant OPN was supplemented after OPN silencing, the protective effects in MH-s cells treated with LPS were reversed.

CONCLUSION

This study reveals that OPN has an adverse impact on the host's immune response to sepsis. Suppressing OPN expression holds potential therapeutic value for the treatment of sepsis.

TRIAL REGISTRATION

Study on the diagnostic value of osteopontin in children with sepsis. MR5024001771. Registered 22 January 2024. https//www.medicalresearch.org.cn.

Epidemiology and outcomes of septic shock in Thai children: a nationwide retrospective study from 2015 to 2022

BACKGROUND

Paediatric septic shock is a formidable challenge worldwide that significantly impacts health care systems. This nationwide retrospective study analyses the prevalence and mortality rates of paediatric septic shock across Thailand from 2015 to 2022, focusing on hospital burdens, including mechanical ventilation and renal replacement therapy.

METHODS

The study included paediatric patients ranging from infants to individuals under 18 years of age who were admitted to hospitals due to septic shock across Thailand. Data were retrospectively gathered from the Thai National Health Security Office for the years 2015-2022. The data included demographic data, clinical outcomes, and hospital burden indicators such as mechanical ventilation and renal replacement therapy.

RESULTS

From 2015 to 2022, there were 30,718 paediatric admissions for septic shock, with a peak in 2019. The highest incidence was observed in infants, accounting for 44.7% of the cases. The prevalence rate increased from 190 per 100,000 population in 2015 to a peak of 280 per 100,000 population in 2020. Mortality rates decreased from 30.7% in 2015 to 20.2% in 2022, with a peak of 40.5% observed in the central region in 2015. The study highlighted a substantial health care burden, with 34.9% of patients requiring prolonged mechanical ventilation and 23.4% needing renal replacement therapy.

CONCLUSIONS

Despite a decrease in mortality, paediatric septic shock remains a significant burden on the health care system in Thailand. Urgent improvements in resources and adherence to clinical guidelines, especially in under-resourced areas, are necessary. Addressing disparities in mortality and resource usage across hospital levels is vital for improving outcomes and reducing the health care burden of paediatric patients with septic shock.

Digital solutions in paediatric sepsis: current state, challenges, and opportunities to improve care around the world

The digitisation of health care is offering the promise of transforming the management of paediatric sepsis, which is a major source of morbidity and mortality in children worldwide. Digital technology is already making an impact in paediatric sepsis, but is almost exclusively benefiting patients in high-resource health-care settings. However, digital tools can be highly scalable and cost-effective, and-with the right planning-have the potential to reduce global health disparities. Novel digital solutions, from wearable devices and mobile apps, to electronic health record-embedded decision support tools, have an unprecedented opportunity to transform paediatric sepsis research and care. In this Series paper, we describe the current state of digital solutions in paediatric sepsis around the world, the advances in digital technology that are enabling the development of novel applications, and the potential effect of advances in artificial intelligence in paediatric sepsis research and clinical care.

Susceptibility to childhood sepsis, contemporary management, and future directions

Sepsis disproportionally affects children across all health-care settings and is one of the leading causes of morbidity and mortality in neonatal and paediatric age groups. As shown in the first paper in this Series, the age-specific incidence of sepsis is highest during the first years of life, before approaching adult incidence rates during adolescence. In the second paper in this Series, we focus on the unique susceptibility of paediatric patients to sepsis and how the underlying dysregulated host response relates to developmental aspects of children's immune system, genetic, perinatal, and environmental factors, and comorbidities and socioeconomic determinants of health, which often differ between children and adults. State-of-the-art clinical management of paediatric sepsis is organised around three treatment pillars-diagnosis, early resuscitation, and titration of advanced care-and we examine available treatment guidelines and the limitations of their supporting evidence. Serious evidence gaps remain in key areas of paediatric sepsis care, especially surrounding recognition, common interventions, and survivor support, and to this end we offer a research roadmap for the next decade that could accelerate targeted diagnostics and personalised use of immunomodulation. However, improving outcomes for children with sepsis relies fundamentally on systematic quality improvement in both recognition and treatment, which is the theme of the third paper in this Series. Digital health, as shown in the fourth and final paper of this Series, holds promising potential in breaking down the barriers that hinder progress in paediatric sepsis care and, ultimately, global child health.

Quality improvement programmes in paediatric sepsis from a global perspective

Sepsis is a major contributor to poor child health outcomes around the world. The high morbidity, mortality, and societal cost associated with paediatric sepsis render it a global health priority, as summarised in Paper 1 of this Series. Sepsis is characterised by a dysregulated host response to infection that manifests as organ failure, and children are uniquely susceptible to sepsis, as discussed in Paper 2. The focus of this third Series paper is quality improvement in paediatric sepsis. The 2017 WHO resolution on sepsis outlined key aims to reduce the burden of sepsis. As of 2024, only a small number of countries have implemented systematic, paediatric-focused quality improvement programmes to raise sepsis awareness, enhance recognition of sepsis, promote timely treatment, and provide long-term support for paediatric sepsis survivors. We examine programme successes and systematic barriers to quality improvement targeting paediatric sepsis. We highlight the need for programme design to consider the entire patient journey, starting with prevention, caregiver awareness, recognition at home, education of the health-care workforce, development of health-care systems, and establishment of long-term family and survivor support extending beyond the intensive care unit. Building on lessons learnt from existing quality improvement programmes, we outline implementation strategies and measures to enable benchmarking. Ultimately, quality improvement on a global scale can only be accelerated through a global learning platform focusing on paediatric sepsis.