Epidemiology of sepsis in pediatric intensive care units: first Colombian multicenter study

Reporting of Social Determinants of Health in Pediatric Sepsis Studies

OBJECTIVE

Standardized, consistent reporting of social determinants of health (SDOH) in studies on children with sepsis would allow for: 1) understanding the association of SDOH with illness severity and outcomes, 2) comparing populations and extrapolating study results, and 3) identification of potentially modifiable socioeconomic factors for policy makers. We, therefore, sought to determine how frequently data on SDOH were reported, which factors were collected and how these factors were defined in studies of sepsis in children.

DATA SOURCES AND SELECTION

We reviewed 106 articles (published between 2005 and 2020) utilized in a recent systematic review on physiologic criteria for pediatric sepsis.

DATA EXTRACTION

Data were extracted by two reviewers on variables that fell within the World Health Organization's SDOH categories.

DATA SYNTHESIS

SDOH were not the primary outcome in any of the included studies. Seventeen percent of articles (18/106) did not report on any SDOH, and a further 36.8% (39/106) only reported on gender/sex. Of the remaining 46.2% of articles, the most reported SDOH categories were preadmission nutritional status (35.8%, 38/106) and race/ethnicity (18.9%, 20/106). However, no two studies used the same definition of the variables reported within each of these categories. Six studies reported on socioeconomic status (3.8%, 6/106), including two from upper-middle-income and four from lower middle-income countries. Only three studies reported on parental education levels (2.8%, 3/106). No study reported on parental job security or structural conflict.

CONCLUSIONS

We found overall low reporting of SDOH and marked variability in categorizations and definitions of SDOH variables. Consistent and standardized reporting of SDOH in pediatric sepsis studies is needed to understand the role these factors play in the development and severity of sepsis, to compare and extrapolate study results between settings and to implement policies aimed at improving socioeconomic conditions related to sepsis.

Sepsis in the Pediatric Cardiac Intensive Care Unit: An Updated Review

Sepsis remains among the most common causes of mortality in children with congenital heart disease (CHD). Extensive literature is available regarding managing sepsis in pediatric patients without CHD. Because the cardiovascular pathophysiology of children with CHD differs entirely from their typical peers, the available diagnosis and management recommendations for sepsis cannot be implemented directly in children with CHD. This review discusses the risk factors, etiopathogenesis, available diagnostic tools, resuscitation protocols, and anesthetic management of pediatric patients suffering from various congenital cardiac lesions. Further research should focus on establishing a standard guideline for managing children with CHD with sepsis and septic shock admitted to the intensive care unit.

Refining empiric subgroups of pediatric sepsis using machine-learning techniques on observational data

Sepsis contributes to 1 of every 5 deaths globally with 3 million per year occurring in children. To improve clinical outcomes in pediatric sepsis, it is critical to avoid "one-size-fits-all" approaches and to employ a precision medicine approach. To advance a precision medicine approach to pediatric sepsis treatments, this review provides a summary of two phenotyping strategies, empiric and machine-learning-based phenotyping based on multifaceted data underlying the complex pediatric sepsis pathobiology. Although empiric and machine-learning-based phenotypes help clinicians accelerate the diagnosis and treatments, neither empiric nor machine-learning-based phenotypes fully encapsulate all aspects of pediatric sepsis heterogeneity. To facilitate accurate delineations of pediatric sepsis phenotypes for precision medicine approach, methodological steps and challenges are further highlighted.

Implementation of an Automated Sepsis Screening Tool in a Children's Hospital Emergency Department: A Cost Analysis

OBJECTIVE

To determine the effect of implementation of an automated sepsis screening tool on the median cost of affected patient encounters.

STUDY DESIGN

This retrospective cohort study used propensity score-matched comparison groups to assess the difference in median cost for comparable affected patient encounters before and after the implementation of an automated sepsis screening tool in a large US children's hospital emergency department (ED) with >90 000 annual visits. All patient encounters in 2018 impacted by the automated sepsis screening tool were included and compared with a propensity score-matched comparison group drawn from patient encounters in 2012 that might have been affected by the screening tool had it been active at that time. The main outcome was the change in the median cost for comparable affected patient encounters.

RESULTS

The overall median cost for those affected by an automated sepsis screening tool decreased by 21.2%, from $6454 (IQR, $968-$21 697) to $5084 (IQR, $802-$16 618). The median cost for encounters with an associated International Classification of Diseases sepsis code decreased by 51.1%, from $58 685 (IQR, $32 224-$134 895) to $28 672 (IQR, $16 796-$60 657).

CONCLUSIONS

The median cost for comparable patient encounters decreased with implementation of an automated sepsis screening tool in the pediatric ED. Costs were decreased even more substantially for patients with sepsis. In addition to improving outcomes, an automated sepsis screening tool appears to be at least cost-effective and may be cost-saving, an incentive for more widespread use of this technology.

Sepsis in Children in Latin America: Gaps, Inequities, and Improvement Strategies

ABSTRACT

Pediatric sepsis is a worldwide public health issue because of its high mortality rate, which increases even more in low-income countries. In this article, we review the Latin American background, the burdens of pediatric sepsis in Latin America, and the Caribbean, as well as some strategies that could help improve the outcomes of sepsis in these regions from a public health view.

Intravenous Fluid Bolus Rates Associated with Outcomes in Pediatric Sepsis: A Multi-Center Analysis

Purpose

Patients and Methods

Results

Conclusion

Challenges and health-care priorities for reducing the burden of paediatric sepsis in Latin America: a call to action

Sepsis is a worldwide public health problem due to its high incidence and accompanying mortality, morbidity, and financial burden. It is a major cause of admission to paediatric intensive care units; despite advances in the diagnosis and treatment, both incidence and mortality are high in low-income and middle-income countries. There are several barriers in addressing the enormous burden of paediatric sepsis in these countries, which include: lack of data of incidence and mortality; unfamiliarity of sepsis by the lay public, leading to failure to seek care early, and by health professionals, leading to failure to treat emergently; and insufficient government funding for sepsis care programmes leading to inadequate staffing, material, and financial resources, and therefore, poor health systems. Socioeconomic inequalities, such as inequity and marked variation in income and education, high rates of malnutrition, high percentage of young population, and health systems that do not meet the population's demands also represent barriers in the care of children with sepsis in Latin America. In this Viewpoint, we draw attention to the problem of paediatric sepsis in Latin America and call for action to reduce the disease burden by proposing some solutions.

Antimicrobial Therapy in Pediatric Sepsis: What Is the Best Strategy?

Pediatric sepsis is a relevant cause of morbidity and mortality in this age group. Children are affected differently in high and low-income countries. Antibiotics are crucial for the treatment of sepsis, but indiscriminate use can increase resistance worldwide. The choice of a correct empiric therapy takes into consideration the site of infection, local epidemiology, host comorbidities and recent antibiotic exposure. Antibiotics should be administered in the first hour for patients with septic shock, and always intravenously or via intraosseous access. Culture results and clinical improvement will guide de-escalation and length of treatment. New diagnostic methods can help improve the prescription of adequate treatment. Prevention of sepsis includes vaccination and prevention of healthcare-associated infections. More research and education for awareness of sepsis is needed to improve care.

Early administration of milrinone ameliorates lung and kidney injury during sepsis in juvenile rats

BACKGROUND

A sepsis model was created, induced by cecal ligation and puncture (CLP), in juvenile rat groups. Milrinone (MIL), which is known to have a modulatory effect on pro-inflammatory cytokines, was administered to the designated rat groups in the early period before severe sepsis developed. The study was aimed at investigating the possible protective effects of milrinone on the lung and kidney tissues of rats in the late phase of sepsis.

METHODS

The rat pups were divided into seven groups with six animals in each group: (1) healthy rats who received no drug; (2) CLP-S12 (sacrificed at hour 12); (3) CLP-S24 (sacrificed at hour 24); (4) CLP-MIL1-S12 (administered with 0.5 mg/kg milrinone at hour 1 and sacrificed at hour 12); (5) CLP-MIL1-S24 (administered with 0.5 mg/kg milrinone at hour 1 and sacrificed at hour 24): (6) CLP-MIL12-S24 (administered with 0.5 mg/kg milrinone at hour 12 and sacrificed at hour 24), (7) and CLP-MIL1,12-S24 (administered with 0.5 mg/kg milrinone at hours 1 and 12 and sacrificed at hour 24).

RESULTS

Significant differences were found between the early and late administration of milrinone in terms of both molecular and histopathological results. The results showed that the tissues were significantly preserved in the groups in which milrinone had been started in the early period compared to the sepsis control groups and the groups in which milrinone had been started in the late period.

CONCLUSIONS

In addition to the positive inotropic effects of milrinone, its immunomodulatory properties that result in decreased cytokine storm can be beneficial during early period of sepsis.

Criteria for Pediatric Sepsis-A Systematic Review and Meta-Analysis by the Pediatric Sepsis Definition Taskforce

OBJECTIVE

To determine the associations of demographic, clinical, laboratory, organ dysfunction, and illness severity variable values with: 1) sepsis, severe sepsis, or septic shock in children with infection and 2) multiple organ dysfunction or death in children with sepsis, severe sepsis, or septic shock.

DATA SOURCES

MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were searched from January 1, 2004, and November 16, 2020.

STUDY SELECTION

Case-control studies, cohort studies, and randomized controlled trials in children greater than or equal to 37-week-old postconception to 18 years with suspected or confirmed infection, which included the terms "sepsis," "septicemia," or "septic shock" in the title or abstract.

DATA EXTRACTION

Study characteristics, patient demographics, clinical signs or interventions, laboratory values, organ dysfunction measures, and illness severity scores were extracted from eligible articles. Random-effects meta-analysis was performed.

DATA SYNTHESIS

One hundred and six studies met eligibility criteria of which 81 were included in the meta-analysis. Sixteen studies (9,629 patients) provided data for the sepsis, severe sepsis, or septic shock outcome and 71 studies (154,674 patients) for the mortality outcome. In children with infection, decreased level of consciousness and higher Pediatric Risk of Mortality scores were associated with sepsis/severe sepsis. In children with sepsis/severe sepsis/septic shock, chronic conditions, oncologic diagnosis, use of vasoactive/inotropic agents, mechanical ventilation, serum lactate, platelet count, fibrinogen, procalcitonin, multi-organ dysfunction syndrome, Pediatric Logistic Organ Dysfunction score, Pediatric Index of Mortality-3, and Pediatric Risk of Mortality score each demonstrated significant and consistent associations with mortality. Pooled mortality rates varied among high-, upper middle-, and lower middle-income countries for patients with sepsis, severe sepsis, and septic shock (p < 0.0001).

CONCLUSIONS

Strong associations of several markers of organ dysfunction with the outcomes of interest among infected and septic children support their inclusion in the data validation phase of the Pediatric Sepsis Definition Taskforce.

Latin American Consensus on the Management of Sepsis in Children: Sociedad Latinoamericana de Cuidados Intensivos Pediátricos [Latin American Pediatric Intensive Care Society] (SLACIP) Task Force: Executive Summary

OBJECTIVE

The aim of this study was to develop evidence-based recommendations for the diagnosis and treatment of sepsis in children in low- and middle-income countries (LMICs), more specifically in Latin America. Design: A panel was formed consisting of 27 experts with experience in the treatment of pediatric sepsis and two methodologists working in Latin American countries. The experts were organized into 10 nominal groups, each coordinated by a member. Methods: A formal consensus was formed based on the modified Delphi method, combining the opinions of nominal groups of experts with the interpretation of available scientific evidence, in a systematic process of consolidating a body of recommendations. The systematic search was performed by a specialized librarian and included specific algorithms for the Cochrane Specialized Register, PubMed, Lilacs, and Scopus, as well as for OpenGrey databases for grey literature. The GRADEpro GDT guide was used to classify each of the selected articles. Special emphasis was placed on search engines that included original research conducted in LMICs. Studies in English, Spanish, and Portuguese were covered. Through virtual meetings held between February 2020 and February 2021, the entire group of experts reviewed the recommendations and suggestions. Result: At the end of the 12 months of work, the consensus provided 62 recommendations for the diagnosis and treatment of pediatric sepsis in LMICs. Overall, 60 were strong recommendations, although 56 of these had a low level of evidence. Conclusions: These are the first consensus recommendations for the diagnosis and management of pediatric sepsis focused on LMICs, more specifically in Latin American countries. The consensus shows that, in these regions, where the burden of pediatric sepsis is greater than in high-income countries, there is little high-level evidence. Despite the limitations, this consensus is an important step forward for the diagnosis and treatment of pediatric sepsis in Latin America.

The epidemiology of sepsis in paediatric intensive care units in Brazil (the Sepsis PREvalence Assessment Database in Pediatric population, SPREAD PED): an observational study

BACKGROUND

Data on the prevalence and mortality of paediatric sepsis in resource-poor settings are scarce. We aimed to assess the prevalence and in-hospital mortality of severe sepsis and septic shock treated in paediatric intensive care units (PICUs) in Brazil, and risk factors for mortality.

METHODS

We performed a nationwide, 1-day, prospective point prevalence study with follow-up of patients with severe sepsis and septic shock, using a stratified random sample of all PICUs in Brazil. Patients were enrolled at each participating PICU on a single day between March 25 and 29, 2019. All patients occupying a bed at the PICU on the study day (either admitted previously or on that day) were included if they were aged 28 days to 18 years and met the criteria for severe sepsis or septic shock at any time during hospitalisation. Patients were followed up until hospital discharge or death, censored at 60 days. Risk factors for mortality were assessed using a Poisson regression model. We used prevalence to generate national estimates.

FINDINGS

Of 241 PICUs invited to participate, 144 PICUs (capacity of 1242 beds) included patients in the study. On the day of the study, 1122 children were admitted to the participating PICUs, of whom 280 met the criteria for severe sepsis or septic shock during hospitalisation, resulting in a prevalence of 25·0% (95% CI 21·6-28·8), with a mortality rate of 19·8% (15·4-25·2; 50 of 252 patients with complete clinical data). Increased risk of mortality was associated with higher Pediatric Sequential Organ Failure Assessment score (relative risk per point increase 1·21, 95% CI 1·14-1·29, p<0·0001), unknown vaccination status (2·57, 1·26-5·24; p=0·011), incomplete vaccination status (2·16, 1·19-3·92; p=0·012), health care-associated infection (2·12, 1·23-3·64, p=0·0073), and compliance with antibiotics (2·38, 1·46-3·86, p=0·0007). The estimated incidence of PICU-treated sepsis was 74·6 cases per 100 000 paediatric population (95% CI 61·5-90·5), which translates to 42 374 cases per year (34 940-51 443) in Brazil, with an estimated mortality of 8305 (6848-10 083).

INTERPRETATION

In this representative sample of PICUs in a middle-income country, the prevalences of severe sepsis or septic shock and in-hospital mortality were high. Modifiable factors, such as incomplete vaccination and health care-associated infections, were associated with greater risk of in-hospital mortality.

FUNDING

Fundação de Amparo à Pesquisa do Estado de São Paulo and Conselho Nacional de Desenvolvimento Científico e Tecnológico.

TRANSLATION

For the Portuguese translation of the abstract see Supplementary Materials section.

How Are Clinicians Treating Children With Sepsis in Emergency Departments in Latin America?: An International Multicenter Survey

OBJECTIVE

Guidelines adherence in emergency departments (EDs) relies partly on the availability of resources to improve sepsis care and outcomes. Our objective was to assess the management of pediatric septic shock (PSS) in Latin America's EDs and to determine the impact of treatment coordinated by a pediatric emergency specialist (PEMS) versus nonpediatric emergency specialists (NPEMS) on guidelines adherence.

METHODS

Prospective, descriptive, and multicenter study using an electronic survey administered to PEMS and NPEMS who treat PSS in EDs in 14 Latin American countries.

RESULTS

We distributed 2164 surveys with a response rate of 41.5%, of which 22.5% were PEMS. Overall American College of Critical Care Medicine reported guidelines adherence was as follows: vascular access obtained in 5 minutes, 76%; fluid infusion technique, 60%; administering 40 to 60 mL/kg within 30 minutes, 32%; inotropic infusion by peripheral route, 61%; dopamine or epinephrine in cold shock, 80%; norepinephrine in warm shock, 57%; and antibiotics within 60 minutes, 82%. Between PEMS and NPEMS, the following differences were found: vascular access in 5 minutes, 87.1% versus 72.7% (P < 0.01); fluid infusion technique, 72.3% versus 55.9% (P < 0.01); administering 40 to 60 mL/kg within 30 minutes, 42% versus 29% (P < 0.01); inotropic infusion by peripheral route, 75.7% versus 56.3% (P < 0.01); dopamine or epinephrine in cold shock, 87.1% versus 77.3% (P < 0.05); norepinephrine in warm shock, 67.8% versus 54% (P < 0.01); and antibiotic administration within first 60 minutes, 90.1% versus 79.3% (P < 0.01), respectively. Good adherence criteria were followed by 24%. The main referred barrier for sepsis care was a failure in its recognition, including the lack of triage tools.

CONCLUSIONS

In some Latin American countries, there is variability in self-reported adherence to the evidence-based recommendations for the treatment of PSS during the first hour. The coordination by PEMS support greater adherence to these recommendations.

Early Prediction of Multiple Organ Dysfunction in the Pediatric Intensive Care Unit

Objective: The objective of the study is to build models for early prediction of risk for developing multiple organ dysfunction (MOD) in pediatric intensive care unit (PICU) patients. Design: The design of the study is a retrospective observational cohort study. Setting: The setting of the study is at a single academic PICU at the Johns Hopkins Hospital, Baltimore, MD. Patients: The patients included in the study were <18 years of age admitted to the PICU between July 2014 and October 2015. Measurements and main results: Organ dysfunction labels were generated every minute from preceding 24-h time windows using the International Pediatric Sepsis Consensus Conference (IPSCC) and Proulx et al. MOD criteria. Early MOD prediction models were built using four machine learning methods: random forest, XGBoost, GLMBoost, and Lasso-GLM. An optimal threshold learned from training data was used to detect high-risk alert events (HRAs). The early prediction models from all methods achieved an area under the receiver operating characteristics curve ≥0.91 for both IPSCC and Proulx criteria. The best performance in terms of maximum F1-score was achieved with random forest (sensitivity: 0.72, positive predictive value: 0.70, F1-score: 0.71) and XGBoost (sensitivity: 0.8, positive predictive value: 0.81, F1-score: 0.81) for IPSCC and Proulx criteria, respectively. The median early warning time was 22.7 h for random forest and 37 h for XGBoost models for IPSCC and Proulx criteria, respectively. Applying spectral clustering on risk-score trajectories over 24 h following early warning provided a high-risk group with ≥0.93 positive predictive value. Conclusions: Early predictions from risk-based patient monitoring could provide more than 22 h of lead time for MOD onset, with ≥0.93 positive predictive value for a high-risk group identified pre-MOD.

Effect of obesity on mortality among hospitalized paediatric patients with severe sepsis

INTRODUCTION

Severe sepsis is one of the leading causes of mortality among children. Studies in adults have suggested a protective effect of obesity on mortality among patients hospitalized with sepsis. Paediatric studies evaluating similar relationship is lacking.

METHODS

We analysed non-overlapping years of the Kids Inpatient Database (KID) and National Inpatient Sample (NIS) database between 2003 and 2014 of all paediatric patients with severe sepsis (PSS) up to 20 years of age. PSS was defined using specific International Classification of Diseases (ICD) codes and modified Angus criteria. Using ICD-9 diagnosis codes, patients were divided into three mutually exclusive groups (obesity, morbid obesity and control groups), and these groups were compared for outcomes measures including in-hospital mortality and healthcare resource utilization using the length of stay and inflation-adjusted hospitalization charges.

RESULTS

We analysed 109 026 hospitalizations due to PSS. The prevalence rate of obesity was 1.5% (n = 1643), and morbid obesity was 1.05% (n = 1147). Multivariate regression models showed obesity was associated with 63% (OR 0.37, CI: 0.29-0.47, p < 0.001) and 54% reduction in mortality among PSS patients and patients with septic shock respectively. Contrastingly, morbid obesity was not associated with mortality among PSS patients and but was associated with 1.37 times (CI: 1.06-1.78, p = 0.01) increased risk of mortality among paediatric patients with septic shock.

CONCLUSIONS

Paediatric obesity is associated with reduced mortality among patients with PSS, with the exception of morbid obesity. Further prospective studies are needed to better understand the relationship between obesity and outcomes in PSS.

Prevalence and outcomes of sepsis in children admitted to public and private hospitals in Latin America: a multicenter observational study

OBJECTIVE

To report the prevalence and outcomes of sepsis in children admitted to public and private hospitals.

METHODS

Post hoc analysis of the Latin American Pediatric Sepsis Study (LAPSES) data, a cohort study that analyzed the prevalence and outcomes of sepsis in critically ill children with sepsis on admission at 21 pediatric intensive care units in five Latin American countries.

RESULTS

Of the 464 sepsis patients, 369 (79.5%) were admitted to public hospitals and 95 (20.5%) to private hospitals. Compared to those admitted to private hospitals, sepsis patients admitted to public hospitals did not differ in age, sex, immunization status, hospital length of stay or type of admission but had higher rates of septic shock, higher Pediatric Risk of Mortality (PRISM), Pediatric Index of Mortality 2 (PIM 2), and Pediatric Logistic Organ Dysfunction (PELOD) scores, and higher rates of underlying diseases and maternal illiteracy. The proportion of patients admitted from pediatric wards and sepsis-related mortality were higher in public hospitals. Multivariate analysis did not show any correlation between mortality and the type of hospital, but mortality was associated with greater severity on pediatric intensive care unit admission in patients from public hospitals.

CONCLUSION

In this sample of critically ill children from five countries in Latin America, the prevalence of septic shock within the first 24 hours at admission and sepsis-related mortality were higher in public hospitals than in private hospitals. Higher sepsis-related mortality in children admitted to public pediatric intensive care units was associated with greater severity on pediatric intensive care unit admission but not with the type of hospital. New studies will be necessary to elucidate the causes of the higher prevalence and mortality of pediatric sepsis in public hospitals.

Comparison of Intermittent versus Continuous Superior Venal Caval Oxygen Saturation Monitoring in Early Goal Directed Therapy in Septic Shock: A Systematic Review

Early goal directed therapy (EGDT) is a bundle of care (monitoring ScvO2 and lactate along with clinical parameters and instituting therapy) that has shown to improve outcomes in patients with septic shock. We conducted a systematic review of clinical trials and observational studies to compare intermittent versus continuous monitoring of ScvO2. We did major database searches till August 2020. Hospitalized children (>2 months age) and adults with septic shock were included. The intervention was “intermittent ScvO2 monitoring,” and the comparator was “continuous ScvO2 monitoring.” The primary outcome is “all-cause mortality.” Of 564 citations, 3 studies (n = 541) including both children and adults were included in the analysis. There was no significant difference in the “overall/all-cause mortality” (two randomized controlled trials; 258 participants) between the “intermittent” and “continuous” ScvO2 monitoring groups (relative risk [RR]: 1.00; 95% confidence interval [CI]: 0.8–1.24). However, a single observational study (283 participants) showed a significant increase in mortality in the intermittent group (RR: 1.46; 95% CI: 1.03–2.05). The GRADE evidence generated for “overall/all-cause mortality” was of “moderate certainty.” To conclude, the present meta-analysis did not find any significant difference between “intermittent” and “continuous” ScvO2 monitoring in patients with septic shock.

Comparison of a new predictive model with other critical scores for predicting in-hospital mortality among children with pneumonia-related bacteremia

Prediction of mortality in children with pneumonia-related bacteremia is necessary for providing timely care and treatment. This study aims to develop and validate a nomogram and compare it with Pediatric Risk of Mortality III (PRISM III), Brighton Pediatric Early Warning Score (Brighton PEWS) and Pediatric Critical Illness Score (PCIS), which are widely used in predicting in-hospital mortality in children with pneumonia-related bacteremia. This retrospective study collected clinical data of hospitalized children with pneumonia-related bacteremia in Chongqing, China (January 2013-May 2019). The nomogram was built using multivariate logistic regression analysis. The nomogram was compared with PRISM III, PEWS and PCIS in accuracy and clinical benefits in predicting in-hospital mortality in children with pneumonia-related bacteremia. A total of 242 children were included. The nomogram including time to first positivity of blood cultures (TTFP), serum albumin (ALB) and lactate dehydrogenase (LDH) was established. The area under the receiver operating characteristic curve of the nomogram was 0.84 (95% CI 0.77 to 0.91) in the training set and 0.82 (95% CI 0.71 to 0.93) in the validating set. Good consistency was observed between the predictions and the actual observations, and the decision curve analysis showed that the nomogram was clinically useful. The results showed that the nomogram significantly performed better than the three critical scores. In conclusion, a nomogram-illustrated model incorporating TTFP, ALB and LDH for predicting in-hospital mortality in children with pneumonia-related bacteremia at the early stage was established and validated. It performed better than PRISM III, PEWS and PCIS.

Association of early hypotension in pediatric sepsis with development of new or persistent acute kidney injury

OBJECTIVE

To determine how hypotension in the first 48 h of sepsis management impacts acute kidney injury (AKI) development and persistence.

STUDY DESIGN

Retrospective study of patients > 1 month to < 20 years old with sepsis in a pediatric ICU between November 2012 and January 2015 (n = 217). All systolic blood pressure (SBP) data documented within 48 h after sepsis recognition were collected and converted to percentiles for age, sex, and height. Time below SBP percentiles and below pediatric advanced life support (PALS) targets was calculated by summing elapsed time under SBP thresholds during the first 48 h. The primary outcome was new or persistent AKI, defined as stage 2 or 3 AKI present between sepsis day 3-7 using Kidney Disease: Improving Global Outcomes creatinine definitions. Secondary outcomes included AKI-free days (days alive and free of AKI) and time to kidney recovery.

RESULTS

Fifty of 217 sepsis patients (23%) had new or persistent AKI. Patients with AKI spent a median of 35 min under the first SBP percentile, versus 4 min in those without AKI. After adjustment for potential confounders, the odds of AKI increased by 9% with each doubling of minutes spent under this threshold (p = 0.03). Time under the first SBP percentile was also associated with fewer AKI-free days (p = 0.02). Time spent under PALS targets was not associated with AKI.

CONCLUSIONS

The duration of severe systolic hypotension in the first 48 h of pediatric sepsis management is associated with AKI incidence and duration when defined by age, sex, and height norms, but not by PALS definitions. Graphical abstract.

A Pediatric Sepsis Protocol Reduced Mortality and Dysfunctions in a Brazilian Public Hospital

Introduction: Few studies in the literature discuss the benefits of compliance with sepsis bundles in hospitals in low- and middle-income countries, where resources are limited and mortality is high. Methods: This is a retrospective cohort study conducted at a public hospital in a low-income region in Brazil. We evaluated whether completion of a sepsis bundle is associated with reduced in-hospital mortality for sepsis, severe sepsis, and septic shock, as well as prevention of septic shock and organ dysfunction. Bundle compliance required the completion of three items: (1) obtaining blood count and culture, arterial or venous blood gases, and arterial or venous lactate levels; (2) antibiotic infusion within the first hour of diagnosis; and (3) infusion of 10-20 ml/kg saline solution within the first hour of diagnosis. Results: A total of 548 children with sepsis, severe sepsis, or septic shock who were treated at the emergency room from February 2008 to August of 2016 were included in the study. Of those, 371 patients were included in the protocol group and had a lower median length of stay (3 days vs. 11 days; p < 0.001), fewer organ dysfunctions during hospitalization (0 vs. 2, p < 0.001), and a lower probability of developing septic shock. According to a propensity score analysis, mortality was lower during the post-implementation period [2.75 vs. 15.4% (RR 95%IC 0.13 (0.06, 0.27); p < 0.001)]. Conclusions: A simple and low-cost protocol was feasible and yielded good results at a general hospital in a low-income region in Brazil. Protocol use resulted in decreased mortality and progression of dysfunctions and was associated with a reduced probability of developing septic shock.

Myocardial Dysfunction Is Independently Associated With Mortality in Pediatric Septic Shock

Supplemental Digital Content is available in the text.

Objectives:

Circulatory dysfunction has been associated with mortality in children with septic shock. However, the mortality risk attributable to myocardial dysfunction per se has not been established, and the association between myocardial dysfunction and mortality is confounded by illness severity. The objective was to determine if sepsis-associated myocardial dysfunction defined by low left ventricular ejection fraction or global longitudinal strain is associated with mortality in pediatric septic shock after adjusting for baseline mortality probability.

Design:

Retrospective, observational study.

Setting:

Single-center, quaternary-care PICU.

Patients:

Children less than 18 years old admitted to the PICU from 2003 to 2018 who had an echocardiogram performed within 48 hours of septic shock identification and Pediatric Sepsis Biomarker Risk Model II data available.

Interventions:

None.

Measurements and Main Results:

All echocardiograms were reread by a cardiologist blinded to patient data for left ventricular ejection fraction and global longitudinal strain. Low left ventricular ejection fraction was defined as less than 45%, and low global longitudinal strain was defined as greater than z score of –2 for body surface area. Multivariable logistic regression separately analyzed the associations of low left ventricular ejection fraction and low global longitudinal strain with mortality, adjusting for Pediatric Sepsis Biomarker Risk Model II mortality risk. A post hoc logistic regression analyzed the association of left ventricular ejection fraction as a continuous variable with mortality, where linearity was maintained for left ventricular ejection fraction less than 65%. Eighteen percent of 181 children had low left ventricular ejection fraction. After adjusting for baseline mortality risk, low left ventricular ejection fraction remained independently associated with mortality (odds ratio, 4.4 [1.0–19.8]; p = 0.0497). Likewise, left ventricular ejection fraction was associated with mortality (odds ratio, 0.96 [0.93–0.99]; p = 0.037) on multivariable analysis for left ventricular ejection fraction less than 65%. Thirty-six percent of 169 children had low global longitudinal strain, and low global longitudinal strain was also independently associated with mortality (odds ratio, 4.6 [1.2–18.0]; p = 0.027).

Conclusions:

Sepsis-associated myocardial dysfunction, whether defined by low left ventricular ejection fraction or low global longitudinal strain, is an independent risk factor for mortality in pediatric septic shock after accounting for the confounding effects of septic shock severity.

Epidemiology, Clinical and Microbiologic Profile and Risk Factors for Inpatient Mortality in Pediatric Severe Sepsis in the United States From 2003 to 2014: A Large Population Analysis

OBJECTIVE

To evaluate the national trends in pediatric severe sepsis in the United States from 2003 to 2014.

STUDY DESIGN

For this study, we included nonoverlapping years of Kids Inpatient database and National Inpatient Sample database while including hospitalizations of children between 1 and 20 years of age from more than 4200 hospitals across the United States. We identified patient hospitalizations with severe sepsis using specific ICD codes and modified Angus Criteria. Trend analysis of various factors associated with severe sepsis was calculated using the Cochrane-Armitage test. Associated foci of infection and comorbid conditions were identified using specific ICD codes, and a multivariate regression analysis with death as outcome variable was done to evaluate for in hospital predictors of mortality.

RESULTS

Totally, 109,026 episodes of severe sepsis were identified during the study period between 2003 and 2014. Incidence of severe sepsis hospitalizations increased by 2.5 times (0.64-1.57 per 10,000 population) over the study period with notable concurrent significant decrease in mortality by more than 50%. Lower age, African American, Hispanic ethnicity, complex neurologic conditions, infective endocarditis, immunodeficient states including primary immunodeficiency disorder, HIV, burns, malignancy and transplant status are associated with mortality. There is a significant increase in use of healthcare resources (P < 0.001) with mean charges of 94,966$ despite a notable decrease in mean length of stay (22 vs. 16 days, P < 0.001) over the study period.

CONCLUSION

Incidence of pediatric severe sepsis is high leading to a significant use of healthcare resources. This study provides a detailed analysis of associated inpatient factors and comorbidities associated with mortality.

Epidemiology of Pediatric Severe Sepsis in Main PICU Centers in Southwest China

OBJECTIVES

To estimate the prevalence, management, and outcomes of pediatric severe sepsis in the main PICUs in Southwest China.

DESIGN

A prospective, observational, and multicenter study.

SETTING

Eight PICUs in Southwest China with 19 (13-24) beds and 1,322 (1,066-1,452) annual admissions each.

PATIENTS

A total of 10,598 patients (29 d to 18 yr old) were consecutively admitted between September 1, 2016, and August 31, 2017. All patients were screened and evaluated for severe sepsis or septic shock. Of them, 10,353 patients were excluded due to incomplete data or not meeting the consensus criteria for severe sepsis or septic shock; 245 patients were included with complete data.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Finally, 245 patients who were diagnosed with severe sepsis or septic shock were included in the study, with an incidence rate of 2.3%. Of them, 64.0% of the enrolled patients were male with 80.8% being less than 5 years old and 60.8% being from rural areas. The respiratory system was the most common organ system in which dysfunction was observed (76.7%) as well as the most frequently infected site (37.6%). The primary therapies were antibiotics (99.0%), immunoglobulin (88.3%), mechanical ventilation (78.4%), vasoactive infusions (59.6%), and corticosteroids (46.1%). Among the 188 patients who had respiratory dysfunction, 173(92%) required mechanical ventilation and 39 (20.7%) met the criteria for pediatric acute respiratory distress syndrome. Seven of the patients with pediatric acute respiratory distress syndrome died (7/39, 17.9%). The median durations for mechanical ventilation and vasoactive medications were 123.5 hours (35.25-226.00 hr) and 2 days (1-5 d), respectively. Eighty-six percent of patients had multiple organ dysfunction syndrome at the point at which severe sepsis was recognized, and 31% had underlying conditions. The hospital mortality rate was 18.8%.

CONCLUSIONS

This report is the first to present the prevalence, treatment, and outcomes of pediatric severe sepsis in the main PICU centers in Southwest China. The mortality rate remains high; therefore, improved clinical management and implementation of large-scale clinical trials are necessary to improve early diagnoses and treatment.

'Intermittent' versus 'continuous' ScvO2 monitoring in children with septic shock: a randomised, non-inferiority trial

PURPOSE

To compare the effect of 'intermittent' central venous oxygen saturation (ScvO₂) monitoring with 'continuous' ScvO₂ monitoring on shock resolution and mortality in children with septic shock.

METHODS

Primary outcome was the achievement of therapeutic goals or shock resolution in the first 6 h. We randomly assigned children < 17 years' age with septic shock to 'intermittent ScvO₂' or 'continuous ScvO₂' groups. All children were subjected to subclavian/internal jugular line insertion and managed as per Surviving Sepsis Campaign Guidelines. To guide resuscitation, we used ScvO₂ estimated at other clinical and laboratory parameters were monitored similarly in both groups.

RESULTS

We enrolled 75 and 77 children [median (IQR) age: 6 (1.5-10) years] in the 'intermittent' and 'continuous' groups, respectively. Baseline characteristics were comparable between the groups. When compared to the 'continuous' group, fewer children in the 'intermittent' group achieved shock resolution within first 6 h [19% vs. 36%; relative risk (RR) 0.51; 95% CI 0.29-0.89; risk difference - 18.0%; 95% CI - 32.0 to - 4.0]. The lower bound of confidence interval, however, crossed the pre-specified non-inferiority margin. There was no difference in the proportion of children attaining shock resolution within 24 h (63% vs. 69%; RR 0.86; 95% CI 0.68-1.08) or risk of mortality between the groups (47% vs. 43%; RR 1.06; 95% CI 0.74-1.51).

CONCLUSIONS

Given that a greater proportion of children attained therapeutic end points in the first 6 h, continuous monitoring of ScvO₂ should preferably be used to titrate therapy in the first few hours in children with septic shock. In the absence of such facility, intermittent monitoring of ScvO₂ can be used to titrate therapy in these children, given the lack of difference in the proportion of patients achieving shock resolution at 24 h or in risk of mortality between the intermittent and continuous groups.

Clinical Update in Pediatric Sepsis: Focus on Children With Pre-Existing Heart Disease

SEPSIS REMAINS one of the most common causes of childhood morbidity, mortality, and higher healthcare costs, with over 75,000 hospital admissions in the United States and an estimated 4 million cases worldwide per year. While standardized criteria to define sepsis are in flux, the general concept of sepsis is a severe infection that results in organ dysfunction. Although sepsis can affect previously healthy children, those with certain pre-existing comorbid conditions, including congenital and acquired heart disease, are at higher risk for both developing sepsis and having a poor outcome after sepsis. Multiple specialists including intensivists, cardiologists, surgeons, and anesthesiologists commonly contribute to the management and outcome of sepsis in children. In this article, the authors examine the evolving epidemiology of pediatric sepsis, including the subset of patients with underlying heart disease; contrast pediatric and adult sepsis; review the latest hemodynamic guidelines for management of pediatric septic shock and their application to children with heart disease; discuss the role of mechanical circulatory support; and review key aspects of anesthetic management for children with sepsis.

Relationship Between Resistin Levels and Sepsis Among Children Under 12 Years of Age: A Case Control Study

Objective: The aim of this study was to investigate the level of resistin in children with and without sepsis hospitalized in the pediatric intensive care unit (PICU) and compare them to levels in healthy subjects in order to determine the trend of resistin levels in children in PICUs and also to identify the cut-off values for positive sepsis. Methods: This was a case-control study conducted in 2014 at a children's hospital in Tabriz, Iran. Three groups were investigated, a case group comprised of patients with sepsis admitted to PICU and two control groups; one made up of patients admitted to PICU without sepsis and the other of healthy children. Variables included demographic, anthropometric (growth metric percentile), and clinical factors. Results: Patients were randomized into control group A (n = 12, 48%), control group B (n = 11, 44%), and the sepsis group (n = 24, 47.1%). The difference in the means of resistin levels was significant on the first, fourth, and seventh days (P < 0.0001) in the case and control group A. Means comparisons in the case and control group B revealed significant differences on the fourth and seventh day (P = 0.005 and P < 0.0001, respectively) but not on the first day (P = 0.246). The trend of resistin levels increased in the septic group (F Huynh-Feldt = 37.83, P < 0.0001). The diagnostic accuracy of resistin level was high for discriminating sepsis (area under the receiver operating characteristic curve [AUC] 0.864 [SE = 0.41]). The sensitivity was 0.824 and specificity 0.72 with a cut-off point of 5.2 ng/ml on the first day. Conclusion: In the present study, resistin level can be used as an indicator of sepsis in children admitted to PICU. However, the cut-off point based upon when a prediction could be made is different and is dependent on a variety of factors, such as control group and number of days since the first signs of sepsis.

Impact of inappropriate empiric antimicrobial therapy on mortality in pediatric patients with bloodstream infection: a retrospective observational study

Inappropriate empiric antibiotic therapy for bloodstream infection could be associated with mortality in adults. However, data for pediatric patients have been scarce. The purpose of this study was to investigate the impact of an inappropriate empiric antibiotic therapy on mortality in pediatric patients with bloodstream infection. We retrospectively analyzed the data of pediatric patients with consecutive positive blood culture in the university hospital between 2007 and 2016. The association between the use of inappropriate empiric therapy and mortality was investigated. A total of 247 bacteremia events in 223 pediatric patients were analyzed. Overall, 208 (84%) events were hospital acquired and 16 (6%) patients died within 28 days. The most frequent causative microorganisms were Gram-positive bacteria (150 events, 61%), followed by Gram-negative bacteria (90 events, 36%) and Candida spp. (7 events, 3%). Inappropriate empiric antibiotic therapy was prescribed within 48 h in 34 (16%) events. Significantly better 28-day survival rates were obtained in patients that received appropriate empiric antibiotic therapy compared with those who received inappropriate therapy (p = 0.004). Multivariate Cox regression analysis showed that inappropriate empiric antibiotic therapy was an independent prognostic factor of 28-day mortality (hazard ratio, 4.39; 95% confidence interval, 1.48-11.94; p = 0.01), after adjusting for age and McCabe score. Inappropriate empiric antibiotic therapy was associated with poor 28-day mortality in pediatric patients with bloodstream infection. Strategies to increase appropriate selection of empiric antibiotic therapy might be an option for improving survival in pediatric patients with bloodstream infection.

Global Case-Fatality Rates in Pediatric Severe Sepsis and Septic Shock: A Systematic Review and Meta-analysis

IMPORTANCE

The global patterns and distribution of case-fatality rates (CFRs) in pediatric severe sepsis and septic shock remain poorly described.

OBJECTIVE

We performed a systematic review and meta-analysis of studies of children with severe sepsis and septic shock to elucidate the patterns of CFRs in developing and developed countries over time. We also described factors associated with CFRs.

DATA SOURCES

We searched PubMed, Web of Science, Excerpta Medica database, Cumulative Index of Nursing and Allied Health Literature (CINAHL), and Cochrane Central systematically for randomized clinical trials and prospective observational studies from earliest publication until January 2017, using the keywords "pediatric," "sepsis," "septic shock," and "mortality."

STUDY SELECTION

Studies involving children with severe sepsis and septic shock that reported CFRs were included. Retrospective studies and studies including only neonates were excluded.

DATA EXTRACTION AND SYNTHESIS

We conducted our systematic review and meta-analysis in close accordance to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Pooled case-fatality estimates were obtained using random-effects meta-analysis. The associations of study period, study design, sepsis severity, age, and continents in which studies occurred were assessed with meta-regression.

MAIN OUTCOMES AND MEASURES

Meta-analyses to provide pooled estimates of CFR of pediatric severe sepsis and septic shock over time.

RESULTS

Ninety-four studies that included 7561 patients were included. Pooled CFRs were higher in developing countries (31.7% [95% CI, 27.3%-36.4%]) than in developed countries (19.3% [95% CI, 16.4%-22.7%]; P < .001). Meta-analysis of CFRs also showed significant heterogeneity across studies. Continents that include mainly developing countries reported higher CFRs (adjusted odds ratios: Africa, 7.89 [95% CI, 6.02-10.32]; P < .001; Asia, 3.81 [95% CI, 3.60-4.03]; P < .001; South America, 2.91 [95% CI, 2.71-3.12]; P < .001) than North America. Septic shock was associated with higher CFRs than severe sepsis (adjusted odds ratios, 1.47 [95% CI, 1.41-1.54]). Younger age was also a risk factor (adjusted odds ratio, 0.95 [95% CI, 0.94-0.96] per year of increase in age). Earlier study eras were associated with higher CFRs (adjusted odds ratios for 1991-2000, 1.24 [95% CI, 1.13-1.37]; P < .001) compared with 2011 to 2016. Time-trend analysis showed higher CFRs over time in developing countries than developed countries.

CONCLUSIONS AND RELEVANCE

Despite the declining trend of pediatric severe sepsis and septic shock CFRs, the disparity between developing and developed countries persists. Further characterizations of vulnerable populations and collaborations between developed and developing countries are warranted to reduce the burden of pediatric sepsis globally.

Epidemiology of Pediatric Septic Shock

Sepsis, or dysregulated host response to infection, is considered a worldwide public health problem. It is a major childhood disease both in terms of frequency and severity, and severe sepsis is still considered the main cause of death from infection in childhood. This review provides an overview of the epidemiology of pediatric septic shock. The prevalence of severe sepsis and septic shock among hospitalized children ranges from 1 to 26%. Mortality is high, ranging from 5% in developed countries to up to 35% in developing countries. However, 10 years after the publication of pediatric sepsis definitions, a global perspective on the burden of this disease in childhood is still missing. Major obstacles to a better knowledge of sepsis epidemiology in children are the absence of an adequate disease definition and not having sepsis as a cause of death in the World Health Organization Global Burden of Disease Report, which is one of the most important sources of information for health policies decision-making in the world. Several studies performed in both developed and developing countries have shown that mortality from septic shock is high and is associated with delayed diagnosis, late treatment, and nonadherence to the treatment guidelines. Reducing mortality from sepsis in childhood is a worldwide challenge, especially in developing countries, where the highest number of cases and deaths are recorded and where financial resources are scarce. Many specialists consider that prevention, education, and organization are key to achieve a reduction in the burden of sepsis.

Risk factors and inpatient outcomes associated with acute kidney injury at pediatric severe sepsis presentation

BACKGROUND

Little data exist on acute kidney injury (AKI) risk factors in pediatric sepsis. We identified risk factors and inpatient outcomes associated with AKI at sepsis recognition in children with severe sepsis.

METHODS

Retrospective, cross-sectional study with inpatient outcome description of 315 patients > 1 month to < 20 years old with severe sepsis in a pediatric intensive care unit over 3 years. Exposures included demographics, vitals, and laboratory data. The primary outcome was kidney disease: Improving Global Outcomes creatinine-defined AKI within 24 h of sepsis recognition. Factors associated with AKI and AKI severity were identified using multivariable Poisson and multinomial logistic regression, respectively.

RESULTS

AKI was present in 42% (133/315) of severe sepsis patients, and 26% (83/315) had severe (stage 2/3) AKI. In multivariable-adjusted analysis, hematologic/immunologic comorbidities, malignancies, chronic kidney disease (CKD), abdominal infection, admission illness severity, and minimum systolic blood pressure (SBP) ≤ 5th percentile for age and sex within 24 h of sepsis recognition were associated with AKI. Factors associated with mild AKI were CKD and abdominal infection, while factors associated with severe AKI were younger age, hematologic/immunologic comorbidities, malignancy, abdominal infection, and minimum SBP ≤ 5th percentile. Patients with AKI had increased hospital mortality (17 vs. 8%, P = 0.02) and length of stay [median 20 (IQR 10-47) vs. 16 days (IQR 7-37), P = 0.03].

CONCLUSIONS

In pediatric severe sepsis, AKI is associated with age, comorbidities, infection characteristics, and hypotension. Future evaluation of risk factors for AKI progression during sepsis is warranted to minimize AKI progression in this high-risk population.

Viral Sepsis in Children

Sepsis in children is typically presumed to be bacterial in origin until proven otherwise, but frequently bacterial cultures ultimately return negative. Although viruses may be important causative agents of culture-negative sepsis worldwide, the incidence, disease burden and mortality of viral-induced sepsis is poorly elucidated. Consideration of viral sepsis is critical as its recognition carries implications on appropriate use of antibacterial agents, infection control measures, and, in some cases, specific, time-sensitive antiviral therapies. This review outlines our current understanding of viral sepsis in children and addresses its epidemiology and pathophysiology, including pathogen-host interaction during active infection. Clinical manifestation, diagnostic testing, and management options unique to viral infections will be outlined.

Effect of a Sepsis Educational Intervention on Hospital Stay

OBJECTIVES

To evaluate adherence to the sepsis bundle before and after an educational strategy and its impact on hospital stay.

DESIGN

A prospective, analytic, before-and-after study of children with severe sepsis and septic shock who presented to the emergency department.

SETTING

Carried out from January to December 2014 in the emergency department of a quaternary care hospital.

PATIENTS

Of a total of 19,836 children who presented to the emergency department, 4,383 had an infectious pathology, with 203 of these showing severe sepsis and septic shock (124 pre intervention, and 79 post intervention).

INTERVENTIONS

The healthcare providers caring for the patients in pediatric emergency received an educational intervention and an update on the bundle concepts proposed in 2010 by the Pediatric Advanced Life Support program of the American Heart Association and adapted by this study's investigators.

MEASUREMENTS AND MAIN RESULTS

The main cause of sepsis in both groups was respiratory (59 vs 33; p = 0.72), without differences in the Pediatric Index of Mortality 2 score (7.23 vs 8.1; p = 0.23). The postintervention group showed a reduced hospital stay (11.6 vs 7.9 d; p = 0.01), a shorter time before ordering fluid boluses (247 vs 5 min; p = 0.001), the application of the first dose of antibiotic (343 vs 271 min; p = 0.03), and a decreased need for mechanical ventilation (20.1% vs 7.5%; p = 0.01). Postintervention adherence to the complete bundle was 19.2%, compared with the preintervention group, which was 27.7% (p = 0.17).

CONCLUSIONS

Adherence to a bundle strategy is low following an educational intervention. However, when patients are managed after instruction in guideline recommendations, hospital stay may be significantly reduced.

Association of Delayed Antimicrobial Therapy with One-Year Mortality in Pediatric Sepsis

OBJECTIVE

Delayed antimicrobial therapy in sepsis is associated with increased hospital mortality, but the impact of antimicrobial timing on long-term outcomes is unknown. We tested the hypothesis that hourly delays to antimicrobial therapy are associated with 1-year mortality in pediatric severe sepsis.

DESIGN

Retrospective observational study.

SETTING

Quaternary academic pediatric intensive care unit (PICU) from February 1, 2012 to June 30, 2013.

PATIENTS

One hundred sixty patients aged ≤21 years treated for severe sepsis.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We tested the association of hourly delays from sepsis recognition to antimicrobial administration with 1-year mortality using multivariable Cox and logistic regression. Overall 1-year mortality was 24% (39 patients), of whom 46% died after index PICU discharge. Median time from sepsis recognition to antimicrobial therapy was 137 min (IQR 65-287). After adjusting for severity of illness and comorbid conditions, hourly delays up to 3 h were not associated with 1-year mortality. However, increased 1-year mortality was evident in patients who received antimicrobials ≤1 h (aOR 3.8, 95% CI 1.2, 11.7) or >3 h (aOR 3.5, 95% CI 1.3, 9.8) compared with patients who received antimicrobials within 1 to 3 h from sepsis recognition. For the subset of patients who survived index PICU admission, antimicrobial therapy ≤1 h was also associated with increased 1-year mortality (aOR 5.5, 95% CI 1.1, 27.4), while antimicrobial therapy >3 h was not associated with 1-year mortality (aOR 2.2, 95% CI 0.5, 11.0).

CONCLUSIONS

Hourly delays to antimicrobial therapy, up to 3 h, were not associated with 1-year mortality in pediatric severe sepsis in this study. The finding that antimicrobial therapy ≤1 h from sepsis recognition was associated with increased 1-year mortality should be regarded as hypothesis-generating for future studies.

High Levels of Morbidity and Mortality Among Pediatric Hematopoietic Cell Transplant Recipients With Severe Sepsis: Insights From the Sepsis PRevalence, OUtcomes, and Therapies International Point Prevalence Study

OBJECTIVES

Pediatric severe sepsis is a major cause of morbidity and mortality worldwide, and hematopoietic cell transplant patients represent a high-risk population. We assessed the epidemiology of severe sepsis in hematopoietic cell transplant patients, describing patient outcomes compared with children with no history of hematopoietic cell transplant.

DESIGN

Secondary analysis of the Sepsis PRevalence, OUtcomes, and Therapies point prevalence study, comparing demographics, sepsis etiology, illness severity, organ dysfunction, and sepsis-related treatments in patients with and without hematopoietic cell transplant. The primary outcome was hospital mortality. Multivariable logistic regression models were used to determine adjusted differences in mortality.

SETTING

International; 128 PICUs in 26 countries.

PATIENTS

Pediatric patients with severe sepsis prospectively identified over a 1-year period.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

In patients with severe sepsis, 37/567 (6.5%) had a history of hematopoietic cell transplant. Compared with patients without hematopoietic cell transplant, hematopoietic cell transplant patients had significantly higher hospital mortality (68% vs 23%; p < 0.001). Hematopoietic cell transplant patients were more likely to have hospital acquired sepsis and had more preexisting renal and hepatic dysfunction than non-hematopoietic cell transplant patients with severe sepsis. History of hematopoietic cell transplant, renal replacement therapy, admission from inpatient floor, and number of organ dysfunctions at severe sepsis recognition were independently associated with hospital mortality in multivariable analysis; hematopoietic cell transplant conferred the highest odds of mortality (odds ratio, 4.00; 95% CI, 1.78-8.98). In secondary analysis of hematopoietic cell transplant patients compared with other immunocompromised patients with severe sepsis, history of hematopoietic cell transplant remained independently associated with hospital mortality (odds ratio, 3.03; 95% CI, 1.11-8.27).

CONCLUSIONS

In an international study of pediatric severe sepsis, history of hematopoietic cell transplant is associated with a four-fold increased odds of hospital mortality after adjustment for potential measured confounders. Hematopoietic cell transplant patients more often originated from within the hospital compared to children with severe sepsis without hematopoietic cell transplant, possibly providing an earlier opportunity for sepsis recognition and intervention in this high-risk population.

Clinical Benefits of High-Volume Hemofiltration in Critically Ill Pediatric Patients with Severe Sepsis: A Retrospective Cohort Study

AIMS

The study aimed to assess the clinical benefits of high-volume hemofiltration (HVHF) in pediatric patients with severe sepsis compared with standard-volume continuous veno-venous hemofiltration (CVVH).

METHODS

We retrospectively analyzed the medical records of 155 pediatric patients with severe sepsis admitted to the pediatric intensive care unit of Shanghai Children's Hospital from January 2010 to June 2016. A total of 93 patients were treated with HVHF and 62 patients were treated with CVVH.

RESULTS

HVHF treatment did not significantly reduce 28-day mortality. Moreover, there was no significant difference in reducing the plasma level of inflammatory mediators and improving hemodynamic variables between HVHF and CVVH group. However, the incidence of hyperglycemia was significantly higher in HVHF group than in CVVH group.

CONCLUSIONS

There is no evidence to indicate that HVHF is superior to CVVH in reducing 28-day mortality as an adjunct to the treatment of severe sepsis in pediatric patients.

New or Progressive Multiple Organ Dysfunction Syndrome in Pediatric Severe Sepsis: A Sepsis Phenotype With Higher Morbidity and Mortality

OBJECTIVES

To describe the epidemiology, morbidity, and mortality of new or progressive multiple organ dysfunction syndrome in children with severe sepsis.

DESIGN

Secondary analysis of a prospective, cross-sectional, point prevalence study.

SETTING

International, multicenter PICUs.

PATIENTS

Pediatric patients with severe sepsis identified on five separate days over a 1-year period.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of 567 patients from 128 PICUs in 26 countries enrolled, 384 (68%) developed multiple organ dysfunction syndrome within 7 days of severe sepsis recognition. Three hundred twenty-seven had multiple organ dysfunction syndrome on the day of sepsis recognition. Ninety-one of these patients developed progressive multiple organ dysfunction syndrome, whereas an additional 57 patients subsequently developed new multiple organ dysfunction syndrome, yielding a total proportion with severe sepsis-associated new or progressive multiple organ dysfunction syndrome of 26%. Hospital mortality in patients with progressive multiple organ dysfunction syndrome was 51% compared with patients with new multiple organ dysfunction syndrome (28%) and those with single-organ dysfunction without multiple organ dysfunction syndrome (10%) (p < 0.001). Survivors of new or progressive multiple organ dysfunction syndrome also had a higher frequency of moderate to severe disability defined as a Pediatric Overall Performance Category score of greater than or equal to 3 and an increase of greater than or equal to 1 from baseline: 22% versus 29% versus 11% for progressive, new, and no multiple organ dysfunction syndrome, respectively (p < 0.001).

CONCLUSIONS

Development of new or progressive multiple organ dysfunction syndrome is common (26%) in severe sepsis and is associated with a higher risk of morbidity and mortality than severe sepsis without new or progressive multiple organ dysfunction syndrome. Our data support the use of new or progressive multiple organ dysfunction syndrome as an important outcome in trials of pediatric severe sepsis although efforts are needed to validate whether reducing new or progressive multiple organ dysfunction syndrome leads to improvements in more definitive morbidity and mortality endpoints.

The Epidemiology of Sepsis in Childhood

BACKGROUND

Sepsis, or systemic inflammatory response to infection, is a major childhood disease and a common cause of death in children. Despite its importance, a global perspective on the epidemiology and mortality of pediatric sepsis across the world is still lacking.

METHODS

A non-systematic review of the medical articles published in Medline from 2005 to 2015.

RESULTS

Studies suggest that there has been a rise in the number of pediatric sepsis cases along the last two decades, which may relate to the increased survival of preterm and low birth-weight infants and children with severe chronic conditions. Children living in low-income countries represent a vulnerable population for sepsis. Despite several initiatives to improve the diagnosis and early treatment of pediatric sepsis, the mortality resulting from pediatric sepsis remains high, ranging from 5% to 40%. Poor outcomes, however, do not seem to be related to the limitation of resources but to the delay in the recognition and early treatment of sepsis.

CONCLUSIONS

Educational efforts aiming to increase the awareness on sepsis by the general public and the adherence to the treatment guidelines by healthcare providers may result in significant improvements in sepsis survival. The global attention to pediatric sepsis, however, can only be achieved with the standardization of the definitions and the use of simple and sensitive diagnostic criteria that incorporate the differences in the necessities among different settings and the availability of local resources.

Epidemiology of Sepsis in Children Admitted to PICUs in South America

OBJECTIVES

To report the prevalence of sepsis within the first 24 hours at admission and the PICU sepsis-related mortality among critically ill children admitted to PICU in South America.

DESIGN

A prospective multicenter cohort study.

SETTING

Twenty-one PICU, located in five South America countries.

PATIENTS

All children from 29 days to 17 years old admitted to the participating PICU between June 2011 and September 2011. Clinical, demographic, and laboratory data were registered within the first 24 hours at admission. Outcomes were registered upon PICU discharge or death.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of the 1,090 patients included in this study, 464 had sepsis. The prevalence of sepsis, severe sepsis, and septic shock were 42.6%, 25.9%, and 19.8%, respectively. The median age of sepsis patients was 11.6 months (interquartile range, 3.2-48.7) and 43% had one or more prior chronic condition. The prevalence of sepsis was higher in infants (50.4%) and lower in adolescents (1.9%). Sepsis-related mortality was 14.2% and was consistently higher with increased disease severity: 4.4% for sepsis, 12.3% for severe sepsis, and 23.1% for septic shock. Twenty-five percent of deaths occurred within the first 24 hours at PICU admission. Multivariate analysis showed that higher Pediatric Risk of Mortality and Pediatric Logistic Organ Dysfunction scores, the presence of two or more chronic conditions, and admission from pediatric wards were independently associated with death.

CONCLUSIONS

We observed high prevalence of sepsis and sepsis-related mortality among this sample of children admitted to PICU in South America. Mortality was associated with greater severity of illness at admission and potentially associated with late PICU referral.

An observational study using ultrasound to assess physiological changes following fluid bolus administration in paediatric sepsis in the emergency department

Background

Fluid bolus administration is widely recommended as part of the initial treatment of paediatric sepsis, though the physiological benefits and harms are unclear. The primary aim of this study is to determine the effect of fluid bolus administration on cardiac index (CI). Secondary aims are to determine the effect of fluid bolus administration on extra-vascular lung water (EVLW), whether fluid responsiveness can be predicted by inferior vena cava (IVC) collapsibility, and whether fluid responsiveness correlates with changes in vital signs.

Methods/design

A prospective observational study of children presenting to the Emergency Department of The Royal Children’s Hospital with clinically diagnosed sepsis requiring fluid bolus administration. Prior to fluid bolus administration, an echocardiogram, lung ultrasound, and IVC ultrasound will be performed, and vital signs recorded. These will be repeated 5 min after and 60 min after fluid bolus administration. Recorded echocardiograms and lung/IVC ultrasound will be evaluated independently by a paediatric cardiologist and paediatric emergency physician, respectively, blinded to the patient identity and time of examination relative to time of fluid bolus administration. Fifty patients will be enrolled in the study based on a precision based sample size calculation. Results will be analysed for change in CI and change in EVLW 5 min after and 60 min after fluid bolus administration compared to baseline, IVC collapsibility as a predictor of fluid responsiveness, and the relationship between fluid responsiveness and changes in vital signs.

Discussion

This study will explore assumptions about the effect of fluid boluses on CI in children with sepsis, and will provide evidence for secondary effects on other organ systems. This may lead to novel methods for assessment and decision making in the initial resuscitation of paediatric sepsis in clinical and research settings, and will likely influence the design of future interventional studies in this arena.

Trial registration

The study is registered with the Australian and New Zealand Clinical Trials Registry (ACTRN12614000824662; 04 August 2014).

Association between the lactate/albumin ratio and mortality in pediatric septic shock patients with underlying chronic disease: retrospective pilot study

BACKGROUND

We aimed to evaluate the ability of the lactate/albumin ratio to predict mortality in pediatric septic shock patients.

METHODS

Retrospective analysis of the medical records of a pediatric intensive care unit. The study cohort comprised 90 pediatric septic shock patients admitted from February 2012 to May 2015.

RESULTS

The serum lactate and albumin levels and lactate/albumin ratio were compared between survivors and non-survivors. We assessed whether the lactate/albumin ratio could be used to predict mortality. The 28-day hospital mortality was 26.7% (24/90). The lactate level was higher (2.5±2.2 vs. 8.1±5.1 mmol/L, P<0.001) and the albumin level was lower (2.9±0.5 vs. 2.7±0.5 mg/dL, P=0.063) in non-survivors than in survivors. The lactate/albumin ratio was 0.9±0.8 in survivors and 3.2±2.4 in non-survivors (P<0.001). According to the area under the receiver operating characteristic curve (AUC), the lactate/albumin ratio showed good discriminatory power for predicting mortality (AUC=0.867). A lactate/albumin ratio exceeding 1.016 led to a 7.636-fold increase in mortality.

CONCLUSIONS

The lactate/albumin ratio is a useful predictor of mortality in pediatric septic shock patients.

Comparison of Pediatric Severe Sepsis Managed in U.S. and European ICUs

OBJECTIVES

Pediatric severe sepsis remains a significant global health problem without new therapies despite many multicenter clinical trials. We compared children managed with severe sepsis in European and U.S. PICUs to identify geographic variation, which may improve the design of future international studies.

DESIGN

We conducted a secondary analysis of the Sepsis PRevalence, OUtcomes, and Therapies study. Data about PICU characteristics, patient demographics, therapies, and outcomes were compared. Multivariable regression models were used to determine adjusted differences in morbidity and mortality.

SETTING

European and U.S. PICUs.

PATIENTS

Children with severe sepsis managed in European and U.S. PICUs enrolled in the Sepsis PRevalence, OUtcomes, and Therapies study.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

European PICUs had fewer beds (median, 11 vs 24; p < 0.001). European patients were younger (median, 1 vs 6 yr; p < 0.001), had higher severity of illness (median Pediatric Index of Mortality-3, 5.0 vs 3.8; p = 0.02), and were more often admitted from the ward (37% vs 24%). Invasive mechanical ventilation, central venous access, and vasoactive infusions were used more frequently in European patients (85% vs 68%, p = 0.002; 91% vs 82%, p = 0.05; and 71% vs 50%; p < 0.001, respectively). Raw morbidity and mortality outcomes were worse for European compared with U.S. patients, but after adjusting for patient characteristics, there were no significant differences in mortality, multiple organ dysfunction, disability at discharge, length of stay, or ventilator/vasoactive-free days.

CONCLUSIONS

Children with severe sepsis admitted to European PICUs have higher severity of illness, are more likely to be admitted from hospital wards, and receive more intensive care therapies than in the United States. The lack of significant differences in morbidity and mortality after adjusting for patient characteristics suggests that the approach to care between regions, perhaps related to PICU bed availability, needs to be considered in the design of future international clinical trials in pediatric severe sepsis.

Etiology and prognostic factors of sepsis among children and adolescents admitted to the intensive care unit

Objective

To determine the etiology and clinical disease progression variables of sepsis associated with the prognosis of patients admitted to a pediatric intensive care unit.

Methods

Prospective and retrospective case series. Data were collected from the medical records of patients diagnosed with sepsis who were admitted to the pediatric intensive care unit of a general hospital from January 2011 to December 2013. Bacteria were identified in blood and fluid cultures. Age, sex, vaccination schedule, comorbidities, prior antibiotic use, clinical data on admission, and complications during disease progression were compared in the survival and death groups at a 5% significance level.

Results

A total of 115 patients, with a mean age of 30.5 months, were included in the study. Bacterial etiology was identified in 40 patients. Altered peripheral perfusion on admission and diagnosis of severe sepsis were associated with complications. A greater number of complications occurred in the group of patients older than 36 months (p = 0.003; odds ratio = 4.94). The presence of complications during hospitalization was associated with death (odds ratio = 27.7). The main etiological agents were Gram-negative bacteria (15/40), Staphylococcus aureus (11/40) and Neisseria meningitidis (5/40).

Conclusion

Gram-negative bacteria and Staphylococcus aureus predominated in the etiology of sepsis among children and adolescents admitted to an intensive care unit. The severity of sepsis and the presence of altered peripheral perfusion on admission were associated with complications. Moreover, the presence of complications was a factor associated with death.

Clinical Validation of Therapeutic Drug Monitoring of Imipenem in Spent Effluent in Critically Ill Patients Receiving Continuous Renal Replacement Therapy: A Pilot Study

Objectives

The primary objective of this pilot study was to investigate whether the therapeutic drug monitoring of imipenem could be performed with spent effluent instead of blood sampling collected from critically ill patients under continuous renal replacement therapy.

Methods

A prospective open-label study was conducted in a real clinical setting. Both blood and effluent samples were collected pairwise before imipenem administration and 0.5, 1, 1.5, 2, 3, 4, 6, and 8 h after imipenem administration. Plasma and effluent imipenem concentrations were determined by reversed-phase high-performance liquid chromatography with ultraviolet detection. Pharmacokinetic and pharmacodynamic parameters of blood and effluent samples were calculated.

Results

Eighty-three paired plasma and effluent samples were obtained from 10 patients. The Pearson correlation coefficient of the imipenem concentrations in plasma and effluent was 0.950 (P<0.0001). The average plasma-to-effluent imipenem concentration ratio was 1.044 (95% confidence interval, 0.975 to 1.114) with Bland-Altman analysis. No statistically significant difference was found in the pharmacokinetic and pharmacodynamic parameters tested in paired plasma and effluent samples with Wilcoxon test.

Conclusion

Spent effluent of continuous renal replacement therapy could be used for therapeutic drug monitoring of imipenem instead of blood sampling in critically ill patients.

Discordant identification of pediatric severe sepsis by research and clinical definitions in the SPROUT international point prevalence study

INTRODUCTION

Consensus criteria for pediatric severe sepsis have standardized enrollment for research studies. However, the extent to which critically ill children identified by consensus criteria reflect physician diagnosis of severe sepsis, which underlies external validity for pediatric sepsis research, is not known. We sought to determine the agreement between physician diagnosis and consensus criteria to identify pediatric patients with severe sepsis across a network of international pediatric intensive care units (PICUs).

METHODS

We conducted a point prevalence study involving 128 PICUs in 26 countries across 6 continents. Over the course of 5 study days, 6925 PICU patients <18 years of age were screened, and 706 with severe sepsis defined either by physician diagnosis or on the basis of 2005 International Pediatric Sepsis Consensus Conference consensus criteria were enrolled. The primary endpoint was agreement of pediatric severe sepsis between physician diagnosis and consensus criteria as measured using Cohen's κ. Secondary endpoints included characteristics and clinical outcomes for patients identified using physician diagnosis versus consensus criteria.

RESULTS

Of the 706 patients, 301 (42.6%) met both definitions. The inter-rater agreement (κ ± SE) between physician diagnosis and consensus criteria was 0.57 ± 0.02. Of the 438 patients with a physician's diagnosis of severe sepsis, only 69% (301 of 438) would have been eligible to participate in a clinical trial of pediatric severe sepsis that enrolled patients based on consensus criteria. Patients with physician-diagnosed severe sepsis who did not meet consensus criteria were younger and had lower severity of illness and lower PICU mortality than those meeting consensus criteria or both definitions. After controlling for age, severity of illness, number of comorbid conditions, and treatment in developed versus resource-limited regions, patients identified with severe sepsis by physician diagnosis alone or by consensus criteria alone did not have PICU mortality significantly different from that of patients identified by both physician diagnosis and consensus criteria.

CONCLUSIONS

Physician diagnosis of pediatric severe sepsis achieved only moderate agreement with consensus criteria, with physicians diagnosing severe sepsis more broadly. Consequently, the results of a research study based on consensus criteria may have limited generalizability to nearly one-third of PICU patients diagnosed with severe sepsis.

Clinical management for patients admitted to a critical care unit with severe sepsis or septic shock

BACKGROUND

The Surviving Sepsis Campaign promotes the use of norepinephrine as the first-line inotropic support for patients presenting with severe sepsis or septic shock in cases of persistent hypotension, despite adequate fluid resuscitation. However, there is little published evidence on how much noradrenaline is administered to such patients when admitted to the intensive care unit (ICU). The authors report the clinical management of this group of patients, with a special focus on the total amount and duration of norepinephrine infusion required.

METHODS

A chart review of the admission records of an ICU in Hong Kong was carried out in 2013. A total of 5000 patients were screened by their diagnosis of severe sepsis or septic shock (in the admissions book) between 1 January 2011 and 31 December 2013. A total of 150 of these were identified and 100 included in the study after simultaneous in-depth reviews of their case notes by two of the investigators. The analysis covers those with severe sepsis or septic shock who required ICU admission for further care. Clinical management and outcomes were analysed.

RESULTS

100 patients (median age 61.6; M/F ratio 2:1) met the inclusion criteria. The mean ICU stay was 13.4 days (range=1-371). 14 patients (14%) died in the ICU, with a 28-day mortality rate of 22%. The mean period of mechanical ventilation was 6.1 days (range=0-137). 91.5% (n=43) of patients had been operated on immediately before admission to the ICU, and the majority of these operations had been of the emergency type (97.7%, n=43). The mean total volumes of crystalloid and colloid administered were 3420ml and 478ml, respectively. The mean wean-off period for norepinephrine infusion was 4234minutes (70.5hours). All patients were prescribed norepinephrine for persistent hypotension despite adequate fluid resuscitation, and the mean total amount administered was 87,211mg. Final multiple linear and logistic regression analysis showed different clinical outcomes associated with different covariates, which included: (1) total amount of crystalloid given, positively associated with the total amount and duration of norepinephrine infusion; (2) duration of mechanical ventilation, positively associated with the type of operation the patient had undergone; (3) 28-day mortality rate, positively associated with the INR.

CONCLUSIONS

What this study adds to knowledge about patients suffering from severe sepsis or septic shock: (1) the mean duration of norepinephrine infusion for septic shock patients in an ICU is almost three days; (2) the more crystalloid is required to correct hypoperfusion, the higher the dosage and longer the duration of norepinephrine infusion will be necessary; (3) the longer the patient's INR, the higher the chances of death within 28 days. Since not all patients have their body weight measured on or after admission to the ICU, we suggest further research into indirect estimation of body weight by other means, such as anthropometric measures, to guide the use of drugs and nutritional support in the ICU. In addition, APACHE scores should be included in further studies to compare the severity of the patient's condition in other research. Furthermore, since this study does not cover university hospital ICUs, we suggest that further research concerning such patients should compare and reflect similarities and differences between public and university hospitals in the territory.