Update on pediatric sepsis: a review

A tagging polymorphism in fat mass and obesity-associated (FTO) gene is associated with sepsis status in children

INTRODUCTION

Sepsis is one of the most common causes of death in patients admitted to intensive care units (ICUs). The development of sepsis is significantly influenced by genetic predisposition. In this study, we highlight a potential association between a variant of the fat mass and obesity-associated (FTO) gene and risk of sepsis in children and adolescents.

METHODS

We investigated a first-intron tagging FTO polymorphism (rs17817449) by comparing a severe condition (SC) group, comprising 598 paediatric patients (ages 0-19 years) admitted to an ICU with fever, systemic inflammatory response syndrome (SIRS), sepsis, severe sepsis, septic shock, or multiple organ dysfunction syndrome (MODS), with a control group consisting of 616 healthy young adults.

RESULTS

We observed a lower prevalence (p < 0.01; OR = 0.59, 95% CI = 0.39-0.87) of the FTO TT genotype in febrile and SIRS patients compared to patients with severe illness. There was a borderline trend towards a lower prevalence of the FTO TT genotype in the control group compared to the SC group (p < 0.09, OR = 0.81, 95% CI = 0.62-1.06).

CONCLUSIONS

Our findings suggest that rs17817449, a common FTO polymorphism, may be a predictor of sepsis in paediatric patients, and that higher body weight is protective against this clinical complication.

Extracorporeal Membrane Oxygenation for Septic Shock in Adults and Children: A Narrative Review

Refractory septic shock is associated with a high risk of death. Circulatory support in the form of veno-arterial extracorporeal membrane oxygenation (VA ECMO) may function as a bridge to recovery, allowing for the treatment of the source of the sepsis. Whilst VA ECMO has been accepted as the means of hemodynamic support for children, in adults, single center observational studies show survival rates of only 70-90% for hypodynamic septic shock. The use of VA ECMO for circulatory support in hyperdynamic septic shock with preserved cardiac output or when applied late during cardio-pulmonary resuscitation is not recommended. With unresolving septic shock and a loss of ventriculo-arterial coupling, stress cardiomyopathy often develops. If the cardiac index (CI) approaches subnormal levels (CI < 2.5 L/min m-2) that do not match low systemic vascular resistance with a resulting loss of vital systemic perfusion pressure, VA ECMO support should be considered. A further decrease to the level of cardiogenic shock (CI < 1.8 L/min m-2) should be regarded as an indication for VA ECMO insertion. For patients who maintain a normal-to-high CI as part of their refractory vasoparalysis, VA ECMO support is justified in children and possibly in patients with a low body mass index. Extracorporeal support for septic shock should be limited to high-volume ECMO centers.

Outcomes of Care-bundle Implementation for Children With Cancer and Suspected Bloodstream Infection in a Pediatric Oncology Unit in a Resource-limited Setting

Bloodstream infections (BSIs) are a major cause of mortality among pediatric oncology patients in resource-limited settings. Effective, innovative strategies are needed to improve care and survival. In a pediatric oncology unit in Mexico, we retrospectively analyzed the risk factors for mortality related to BSI and the results of using a care-bundle intervention. The care-bundle consisted of a swift clinical evaluation, initial fluid-resuscitation support, obtaining blood cultures, and administration of effective empirical antibiotic therapy for suspected BSI. The outcomes of patients who received the care-bundle during a 12-month period were compared with those of patients treated with standard care during the 12 months preceding its implementation. The primary outcomes were BSI diagnosis, choice of antibiotics, and mortality. Of the 261 suspected BSIs treated with standard care, 33 (12.6%) infections were confirmed, and of the 308 treated with the care-bundle, 67 (21.7%) BSIs were confirmed. Thus, after implementation of the care-bundle, significantly more BSIs were diagnosed ( P =0.004), and BSI-related mortality was significantly reduced by 22.2% ( P = 0.035). Surgical resection and mechanical ventilation support were independently associated with BSI-related mortality, and receiving effective initial empirical antibiotic therapy was protective against mortality (odds ratio, 0.013; 95% CI: 0.002-0.105; P =0.001), which comprising cefepime plus amikacin or meropenem in 44 (80.0%) of the cases alive. Consistent use of a care-bundle with initial fluid resuscitation, obtaining a blood culture, and administering effective antibiotics to children with cancer and suspected BSI can decrease mortality.

Pediatric sepsis profile in a tertiary-care hospital in Indonesia: a 4-year retrospective study

AIM

This study aimed to explore the factors contributing to mortality and its management among pediatric sepsis patients at a single center in Indonesia.

METHOD

We conducted a retrospective study of children admitted due to sepsis from January 2015 to December 2019 in an Indonesian tertiary hospital.

RESULTS

The mortality rate of pediatric sepsis in our study was 76.1% among 176 records with outcome identified. Mortality was significantly associated with septic shock at triage, number of organ failure, intensive care unit admission, inotropic use, septic shock and severe sepsis during hospitalization. Timing of antibiotic use did not affect mortality. Death within the first 24 h occurred in 41.8% of subjects, mostly due to septic shock.

CONCLUSION

This study illuminates the current state of pediatric sepsis management in our Indonesian hospital, revealing it as inadequate. Findings highlight the need for improved pre-hospital systems and sepsis recognition tools, and wider use of mechanical ventilators and advanced monitoring due to limited pediatric intensive care unit beds. Future research should focus on hospital-specific sepsis protocols to reduce pediatric sepsis mortality rates.

Sepsis awareness and understanding in Australian parents: A National Child Health Poll survey

AIM

The primary aim of the study was to assess parental awareness and understanding of childhood sepsis. Secondary aims included parental knowledge of the signs and symptoms of sepsis, and what parents would do if they suspected sepsis in their own child.

METHODS

An online questionnaire was administered as part of The Royal Children's Hospital National Child Health Poll. The Poll is a quarterly online survey of a sample of Australian families with at least one child aged 0-17 years old, representative by age, sex and state of residence. The questionnaire collected information on parental sepsis awareness, and for those defined as sepsis aware, information was gathered on sepsis knowledge, signs and symptoms, and how they would respond if they thought their child had sepsis. Signs and symptoms highly likely to be suggestive of sepsis were predefined based on published sepsis guidelines and awareness campaigns.

RESULTS

The questionnaire was completed by 3352 parents. Of those, 2065 (61.6%) had heard of the term sepsis and 2818 (84.1%) had heard of at least one alternate term for sepsis and were classified as 'sepsis aware'. Of the 'sepsis aware' parents, 82.9% knew that sepsis was a life-threatening condition, but only 33.8% knew that once diagnosed, sepsis may not be curable. Only 27.8% thought that they could recognise the signs of sepsis in their own child. Less than half of respondents correctly identified signs and symptoms that were highly likely to be suggestive of sepsis. Seventy-one per cent of parents said they would seek urgent care at a hospital emergency department or other facility if they thought their child had sepsis, but only 37.3% said they would consider calling an ambulance.

CONCLUSION

There are considerable knowledge gaps in parental awareness and knowledge of sepsis, particularly sepsis recognition. Parental education should target these knowledge gaps in order to improve healthcare-seeking behaviour and communication between parents and healthcare providers in order to facilitate early sepsis diagnosis and treatment.

Mortality after emergency unit fluid bolus in febrile Ugandan children

OBJECTIVES

Pediatric fluid resuscitation in sub-Saharan Africa has traditionally occurred in inpatients. The landmark Fluid Expansion as Supportive Therapy (FEAST) trial showed fluid boluses for febrile children in this inpatient setting increased mortality. As emergency care expands in sub-Saharan Africa, fluid resuscitation increasingly occurs in the emergency unit. The objective of this study was to determine the mortality impact of emergency unit fluid resuscitation on febrile pediatric patients in Uganda.

METHODS

This retrospective cohort study used data from 2012-2019 from a single emergency unit in rural Western Uganda to compare three-day mortality for febrile patients that did and did not receive fluids in the emergency unit. Propensity score matching was used to create matched cohorts. Crude and multivariable logistic regression analysis (using both complete case analysis and multiple imputation) were performed on matched and unmatched cohorts. Sensitivity analysis was done separately for patients meeting FEAST inclusion and exclusion criteria.

RESULTS

The analysis included 3087 febrile patients aged 2 months to 12 years with 1,526 patients receiving fluids and 1,561 not receiving fluids. The matched cohorts each had 1,180 patients. Overall mortality was 4.0%. No significant mortality benefit or harm was shown in the crude unmatched (Odds Ratio [95% Confidence Interval] = 0.88 [0.61-1.26] or crude matched (1.00 [0.66-1.50]) cohorts. Adjusted cohort analysis (including both complete case analysis and multiple imputation) and sensitivity analysis of patients meeting FEAST inclusion and exclusion criteria all also failed to show benefit or harm. Post-hoc power calculations showed the study was powered to detect the absolute harm seen in FEAST but not the relative risk increase.

CONCLUSIONS

This study's primary finding is that fluid resuscitation in the emergency unit did not significantly increase or decrease three-day mortality for febrile children in Uganda. Universally aggressive or fluid-sparing emergency unit protocols are unlikely to be best practices, and choices about fluid resuscitation should be individualized.

Highly multiplexed targeted sequencing strategy for infectious disease surveillance

BACKGROUND

Global efforts to characterize diseases of poverty are hampered by lack of affordable and comprehensive detection platforms, resulting in suboptimal allocation of health care resources and inefficient disease control. Next generation sequencing (NGS) can provide accurate data and high throughput. However, shotgun and metagenome-based NGS approaches are limited by low concentrations of microbial DNA in clinical samples, requirements for tailored sample and library preparations plus extensive bioinformatics analysis. Here, we adapted molecular inversion probes (MIPs) as a cost-effective target enrichment approach to characterize microbial infections from blood samples using short-read sequencing. We designed a probe panel targeting 2 bacterial genera, 21 bacterial and 6 fungi species and 7 antimicrobial resistance markers (AMRs).

RESULTS

Our approach proved to be highly specific to detect down to 1 in a 1000 pathogen DNA targets contained in host DNA. Additionally, we were able to accurately survey pathogens and AMRs in 20 out of 24 samples previously profiled with routine blood culture for sepsis.

CONCLUSIONS

Overall, our targeted assay identifies microbial pathogens and AMRs with high specificity at high throughput, without the need for extensive sample preparation or bioinformatics analysis, simplifying its application for characterization and surveillance of infectious diseases in medium- to low- resource settings.

Optimizing Recognition and Management of Patients at Risk for Infection-Related Decompensation Through Team-Based Decision Making

INTRODUCTION

Pediatric sepsis is a leading cause of death among children. Electronic alert systems may improve early recognition but do not consistently result in timely interventions given the multitude of clinical presentations, lack of treatment consensus, standardized order sets, and inadequate interdisciplinary team-based communication. We conducted a quality improvement project to improve timely critical treatment of patients at risk for infection-related decompensation (IRD) through team-based communication and standardized treatment workflow.

METHODS

We evaluated children at risk for IRD as evidenced by the activation of an electronic alert system (Children at High Risk Alert Tool [CAHR-AT]) in the emergency department. Outcomes were assessed after multiple improvements including CAHR-AT implementation, clinical coassessment, visual cues for situational awareness, huddles, and standardized order sets.

RESULTS

With visual cue activation, initial huddle compliance increased from 7.8% to 65.3% ( p < .001). Children receiving antibiotics by 3 hours postactivation increased from 37.9% pre-CAHR-AT to 50.7% posthuddle implementation ( p < .0001); patients who received a fluid bolus by 3 hours post-CAHR activation increased from 49.0% to 55.2% ( p = .001).

CONCLUSIONS

Implementing a well-validated electronic alert tool did not improve quality measures of timely treatment for high-risk patients until combined with team-based communication, standardized reassessment, and treatment workflow.

Anti-inflammatory and anti-biotic drug metronidazole loaded ZIF-90 nanoparticles as a pH responsive drug delivery system for improved pediatric sepsis management

Sepsis is a life-threatening disease caused by the dis-functioning of the immune response to pathogenic infections. Despite, the discovery of modern therapeutics and treatments of sepsis are lacking due to the resistance of pathogens. Metronidazole is an antibiotic commonly used to treat bacterial infections, but usage is limited and challenging by a short half-life period. In this research work, fabricate a pH-responsive drug delivery system for controlled release of metronidazole targeted molecules. We exemplified that, the encapsulation of hydrophilic metronidazole drug within a hydrophobic ZIF-90 framework can be enhanced the pH-responsive drug release under acidic conditions. The ZIF-90 frameworks only decompose in under acidic solutions, they are highly stable in physiological conditions. The pH-responsive protonation mechanism of ZIF-90 frameworks promotes the quick release of metronidazole within cells. The antimicrobial proficiency of zinc and metronidazole will expose a synergistic effect in ROS-mediated bacterial inhibition and auto-immunity boosting of normal cells. In vitro, antibacterial activity results revealed that the MI@ZIF-90 nano drug delivery system effectively eradicated human infectious pathogens at the lowest concentrations. In anti-fungal activity, studies show excellent growth inhibition against human pathogenic fungi Aspergillus fumigatus and Candida albicans. Finally, the PBMC cytocompatibility study concludes, that the fabricated MI@ZIF-90 drug delivery system is non-toxic to biomedical applications. The overall research findings highlight the design of a smart drug delivery system for sepsis treatment. In future it will be an efficient, low-cost, and biocompatible pharmaceutics for pediatric sepsis management processes.

Risk Factors for Pediatric Sepsis in the Emergency Department: A Machine Learning Pilot Study

OBJECTIVE

To identify underappreciated sepsis risk factors among children presenting to a pediatric emergency department (ED).

METHODS

A retrospective observational study (2017-2019) of children aged 18 years and younger presenting to a pediatric ED at a tertiary care children's hospital with fever, hypotension, or an infectious disease International Classification of Diseases (ICD)-10 diagnosis. Structured patient data including demographics, problem list, and vital signs were extracted for 35,074 qualifying ED encounters. According to the Improving Pediatric Sepsis Outcomes Classification, confirmed by expert review, 191 patients met clinical sepsis criteria. Five machine learning models were trained to predict sepsis/nonsepsis outcomes. Top features enabling model performance (N = 20) were then extracted to identify patient risk factors.

RESULTS

Machine learning methods reached a performance of up to 93% sensitivity and 84% specificity in identifying patients who received a hospital diagnosis of sepsis. A random forest classifier performed the best, followed by a classification and regression tree. Maximum documented heart rate was the top feature in these models, with importance coefficients (ICs) of 0.09 and 0.21, which represent how much an individual feature contributes to the model. Maximum mean arterial pressure was the second most important feature (IC 0.05, 0.13). Immunization status (IC 0.02), age (IC 0.03), and patient zip code (IC 0.02) were also among the top features enabling models to predict sepsis from ED visit data. Stratified analysis revealed changes in the predictive importance of risk factors by race, ethnicity, oncologic history, and insurance status.

CONCLUSIONS

Machine learning models trained to identify pediatric sepsis using ED clinical and sociodemographic variables confirmed well-established predictors, including heart rate and mean arterial pressure, and identified underappreciated relationships between sepsis and patient age, immunization status, and demographics.

Capnodynamics - noninvasive cardiac output and mixed venous oxygen saturation monitoring in children

Hemodynamic monitoring in children is challenging for many reasons. Technical limitations in combination with insufficient validation against reference methods, makes reliable monitoring systems difficult to establish. Since recent studies have highlighted perioperative cardiovascular stability as an important factor for patient outcome in pediatrics, the need for accurate hemodynamic monitoring methods in children is obvious. The development of mathematical processing of fast response mainstream capnography signals, has allowed for the development of capnodynamic hemodynamic monitoring. By inducing small changes in ventilation in intubated and mechanically ventilated patients, fluctuations in alveolar carbon dioxide are created. The subsequent changes in carbon dioxide elimination can be used to calculate the blood flow participating in gas exchange, i.e., effective pulmonary blood flow which equals the non-shunted pulmonary blood flow. Cardiac output can then be estimated and continuously monitored in a breath-by-breath fashion without the need for additional equipment, training, or calibration. In addition, the method allows for mixed venous oxygen saturation (SvO₂) monitoring, without pulmonary artery catheterization. The current review will discuss the capnodyamic method and its application and limitation as well as future potential development and functions in pediatric patients.

Pediatric Sepsis: The Importance of Understanding Criteria for Diagnosis

Pediatric sepsis is a very significant issue for the pediatric population. Sepsis can be defined in relation to systemic inflammatory response syndrome. It can be further characterized based on the severity, including severe sepsis, septic shock, multiorgan failure, and refractory septic shock, in the setting of proven infection or suspected infection. In the pediatric population, sepsis is a complicated and dangerous event with no one specific criteria or definition in the systemic inflammatory response syndrome criteria applicable to every child who is suffering from the condition. The goal of this paper is to enhance awareness of the various forms and severities of sepsis in the pediatric population so that swift diagnosis can be made and treatment can be initiated. An electronic literature review search was performed, and relevant data were collected from peer-reviewed articles from January 2005 to May 2020. The nonspecific nature of this condition can manifest as cardiovascular dysfunction, and hematologic abnormalities to neurologic symptoms, resulting in a late diagnosis, which ultimately leads to an increase in mortality and morbidity. The implications of sepsis in the pediatric population needs to be addressed. It is imperative for all medical professionals, including medical students, to understand the criteria and to raise a high level of suspicion when presented with a child exhibiting symptoms that may indicate sepsis. By increasing awareness of pediatric sepsis, complications, including death, that arise as a result of late diagnosis and treatment would be substantially decreased. [Pediatr Ann. 2022;51(10):e405-e408.].

A case report: septic shock due to (tropical) pyomyositis and multiple metastatic embolisms caused by Panton Valentine Leukocidin-positive methicillin-sensitive staphylococcus aureus in a 12-year-old boy

CASE REPORT

A 12-year-old boy, of Congolese roots and without medical history, first presented to our Emergency Department 3 days after blunt trauma of the left ankle. The boy represented on two more occasions in the next 3 days due to ongoing pain. On the last occasion he presented with severe hypoglycaemia. He was diagnosed with severe septic shock, secondary to subperiosteal abscess formation / osteomyelitis of the ankle. The patient was transferred to the paediatric intensive care unit where appropriate medical care was provided, including broad-spectrum antibiotic therapy, high dose vasopressor / inotropic support, surgical debridement of abscesses and below-knee amputation.

PANTON VALENTINE LEUKOCIDIN TOXIN AND PYOMYOSITIS TROPICALIS

The causative organism was a methicillin-susceptible S. aureus, which upon further identification was a carrier of the PVL (Panton Valentine leukocidin) toxin. This pathogen is responsible for severe musculoskeletal infections. In children these infections are often associated with more severe clinical course requiring a higher need for surgical intervention and longer hospital stay.Tropical pyomyositis is a disease caused by Staphylococcus aureus, often seen in tropical countries, and classically presented with muscle abscesses. Young males between the ages of 10-40 years old are the most susceptible, and often present with a history of blunt trauma. Treatment generally requires a combination of an anti-staphylococcal agent, and an anti-toxic agent blocking bacterial protein-synthesis of PVL. Source control by surgical debridement also plays a major role in the treatment of PVL-infection. Despite agressive treatment, mortality still varies from 0.5% to 2%.

Association of PAI-1 4G/5G and ACE I/D Polymorphisms with Susceptibility to Pediatric Sepsis: Evidence from a Meta-Analysis

BackgroundSeveral studies have investigated the role of PAI-1 4G/5G and ACE I/D polymorphisms in the etiology of pediatric sepsis, but the results are inconsistent. We performed a meta-analysis to assess for any associations. Methods: A comprehensive literature search on PubMed, web of science, and CNKI database was conducted up to April 15, 2020. Results: There were twelve case-control studies involving seven studies with 860 cases and 1144 controls on PA-1 4G/5G and five studies with 1602 cases and 1585 controls on ACE I/D. PAI-1 4G/5G and ACE I/D polymorphisms were associated with an increased risk of pediatric sepsis in the global population. Stratified analysis by ethnicity showed a significant association in the Caucasians children. Conclusions: The meta-analysis suggests that the PAI-1 4G/5G and ACE I/D polymorphisms may be risk factors for development of pediatric sepsis in the global population.

Extracorporeal Membrane Oxygenation for Septic Shock in Children

Extracorporeal membrane oxygenation (ECMO) is a rescue treatment used in children and adults with reversible cardiorespiratory failure. The role of ECMO is not fully established in pediatric sepsis. In this retrospective single-center study, we aimed to investigate risk factors and survival in pediatric septic shock supported with peripheral cannulation ECMO. All patients aged 30 days to 18 years treated between 2007 and 2016 with ECMO for septic shock were included. Of 158 screened patients, 31 were enrolled in the study. The P/F ratio was 48 ± 22 mm Hg, b-lactate 8.5 ± 6.6 mmol/L, p-procalcitonin 214 (IQR 19-294) μg/L, and 2 (1-2) vasoactive drugs were infused. The number of organ failures were 3 (3-4). Ten patients were commenced on venovenous and 21 on venoarterial ECMO. Survival from ECMO was 71%, and 68% survived to hospital discharge. Hospital survival was 80% for venovenous ECMO and 62% in venoarterial support (p = 0.43). Factors associated with in-hospital mortality were high b-lactate (p = 0.015) and high creatinine (p = 0.019) at admission. Conversion between modalities was not a risk factor. Sixty percent were alive at long-term follow-up (median 6.5 years). Peripheral cannulation ECMO is feasible in pediatric septic shock. Treatment should be performed at high-volume ECMO centers experienced in sepsis, and central or peripheral type and ECMO modality according to center preference and patient's need.

Update on Pediatric Sepsis in Mexico

The main objective of this work was to determine and update the causal agents’ antibiotic sensitivity and resistance patterns on pediatric sepsis in a population of northeast Mexico. It is a cross-sectional study showing the results of blood cultures of pediatric patients with a presumptive diagnosis of sepsis were reviewed according to the SOFA criteria during 2020 in a public hospital in Mexico. A total of 207 blood cultures were performed and analyzed. The main isolated microorganisms were Staphylococcus, followed by Klebsiella and Escherichia. Several microorganisms showed 100% of sensitivity to different antibiotics or antifungals, some of them include Vancomycin, Voriconazole, Meropenem, Ciprofloxacin, and Cefotaxime. Bacteria of genre Staphylococcus showed its highest sensitivity rate to Tigecycline with 63.3%. Too Staphylococcus showed the highest resistance rate to Oxacillin with 50%. Although the patterns of sepsis-causing germs are similar to those previously reported, the development of new drugs with greater efficacy is the main contribution.

All-cause mortality in a pediatric intensive care unit at a teaching hospital in Amman, Jordan

BACKGROUND

The aim of this study was to describe the main causes of admission to a general pediatric intensive care unit (PICU), and examine the main causes of mortality in this patient population. In addition, we describe the percentage of patients who died following a failed cardiopulmonary resuscitation (CPR) versus do not resuscitate (DNR) orders.

METHODS

This was a retrospective, cohort study with a chart review of admissions and mortality cases that occurred in the PICU. Mortality rates in pediatric admissions are reported with a description of demographics, diagnosis, length of stay, use of mechanical ventilation, use of vasoactive agents, preexisting comorbidities, the presence of a DNR order, and final cause of mortality. Modes of mortality were described as failed CPR or a DNR order.

RESULTS

During the study period there were 1,523 admissions to the PICU. Of those, 102 patients died with an overall mortality rate of 6.7%. Patients who died tended to be younger, and the majority (85%) had a preexisting comorbidity, with neuromuscular disease being the most common. The majority of the patients who died (69%) required invasive ventilation. The most common immediate cause of mortality was respiratory disease and the highest case fatality was among those with cardiac disease. Of those patients who died, 90% had failed CPR and 10% had a DNR order. Care was not withdrawn from any patient.

CONCLUSION

This study describes the diagnostic categories of children admitted to the PICU, with respiratory disease being the most common cause of admission and mortality. The majority of children who died had an existing comorbidity and did not have a DNR order at the time of their death.

Association of IL-6 -174G > C Polymorphism with Susceptibility to Childhood Sepsis: A Systematic Review and Meta-Analysis

BackgroundThis meta-analysis evaluates the correlation between the IL-6 -174 G > C polymorphism and susceptibility of childhood sepsis. Methods: We searched PubMed, ISI Web of Knowledge, Scopus, CNKI, SID, SciELO databases until December 30, 2019 to identify all eligible studies. Results: A total of 17 studies with 1,287 cases and 2,482 controls were identified. Pooled data revealed that there was no significant association between the IL-6 -174 G > C polymorphism and risk childhood sepsis in the overall population. When stratified analysis was carried out by age group of cases, no associations were found in neonates and pediatrics. However, in ethnicity-based subgroups, a significant association was found in Caucasians and Africans. Conclusions: There was no significant association of the IL-6 -174G > C polymorphism with susceptibility to sepsis in childhood overall, but there was an association with the Caucasian and African ethnic subgroups.

Factors associated with mortality of pediatric sepsis patients at the pediatric intensive care unit in a low-resource setting

Background

Sepsis is the leading cause of death worldwide in pediatric populations. Studies in low-resource settings showed that the majority of pediatric patients with sepsis still have a high mortality rate.

Methods

We retrospectively collected records from 2014 to 2019 of patients who had been diagnosed with sepsis and admitted to PICU in our tertiary hospital. Cox proportional hazard regression modeling was used to evaluate associations between patient characteristics and mortality.

Results

Overall, 665 patients were enrolled in this study, with 364 (54.7%) boys and 301 (46.3%) girls. As many as 385 patients (57.9%) died during the study period. The median age of patients admitted to PICU were 1.8 years old with interquartile range (IQR) ±8.36 years and the median length of stay was 144 h (1–1896 h). More than half 391 patients (58.8%) had a good nutritional status. Higher risk of mortality in PICU was associated fluid overload percentage of > 10% (HR 9.6, 95% CI: 7.4–12.6), the need of mechanical ventilation support (HR 2.7, 95% CI: 1.6–4.6), vasoactive drugs (HR 1.5, 95% CI: 1.2–2.0) and the presence of congenital anomaly (HR 1.4, 95% CI: 1.0–1.9). On the contrary, cerebral palsy (HR 0.3, 95% CI: 0.1–0.5) and post-operative patients (HR 0.4, 95% CI: 0.3–0.6) had lower mortality.

Conclusion

PICU mortality in pediatric patients with sepsis is associated with fluid overload percentage of > 10%, the need for mechanical ventilation support, the need of vasoactive drugs, and the presence of congenital anomaly. In septic patients in PICU, those with cerebral palsy and admitted for post-operative care had better survival.

Hemodynamic monitoring and management of pediatric septic shock

Sepsis remains a major cause of morbidity and mortality among children worldwide. Furthermore, refractory septic shock and multiple organ dysfunction syndrome are the most critical groups which account for a high mortality rate in pediatric sepsis, and their clinical course often deteriorates rapidly. Resuscitation based on hemodynamics can provide objective values for identifying the severity of sepsis and monitoring the treatment response. Hemodynamics in sepsis can be divided into two groups: basic and advanced hemodynamic parameters. Previous therapeutic guidance of early-goal directed therapy (EGDT), which resuscitated based on the basic hemodynamics (central venous pressure and central venous oxygen saturation (ScvO2)) has lost its advantage compared with “usual care”. Optimization of advanced hemodynamics, such as cardiac output and systemic vascular resistance, has now been endorsed as better therapeutic guidance for sepsis. Despite this, there are still some important hemodynamics associated with prognosis. In this article, we summarize the common techniques for hemodynamic monitoring, list important hemodynamic parameters related to outcomes, and update evidence-based therapeutic recommendations for optimizing resuscitation in pediatric septic shock.

Prediction of Impending Septic Shock in Children With Sepsis

Objectives

Sepsis and septic shock are leading causes of in-hospital mortality. Timely treatment is crucial in improving patient outcome, yet treatment delays remain common. Early prediction of those patients with sepsis who will progress to its most severe form, septic shock, can increase the actionable window for interventions. We aim to extend a time-evolving risk score, previously developed in adult patients, to predict pediatric sepsis patients who are likely to develop septic shock before its onset, and to determine whether or not these risk scores stratify into groups with distinct temporal evolution once this prediction is made.

Design

Retrospective cohort study.

Setting

Academic medical center from July 1, 2016, to December 11, 2020.

Patients

Six-thousand one-hundred sixty-one patients under 18 admitted to the Johns Hopkins Hospital PICU.

Interventions

None.

Measurements and Main Results

We trained risk models to predict impending transition into septic shock and compute time-evolving risk scores representative of a patient's probability of developing septic shock. We obtain early prediction performance of 0.90 area under the receiver operating curve, 43% overall positive predictive value, patient-specific positive predictive value as high as 62%, and an 8.9-hour median early warning time using Sepsis-3 labels based on age-adjusted Sequential Organ Failure Assessment score. Using spectral clustering, we stratified pediatric sepsis patients into two clusters differing in septic shock prevalence, mortality, and proportion of patients adequately fluid resuscitated.

CONCLUSIONS

We demonstrate the applicability of our methodology for early prediction and stratification for risk of septic shock in pediatric sepsis patients. Through analyses of risk score evolution over time, we corroborate our past finding of an abrupt transition preceding onset of septic shock in children and are able to stratify pediatric sepsis patients using their risk score trajectories into low and high-risk categories.

An evaluation of sepsis in dentistry

Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection. It is a major health concern and causes substantial morbidity and mortality. It is imperative that the signs of sepsis are identified early in both adult and paediatric patients and appropriately escalated to initiate early treatment and improve prognosis. This paper aims to discuss the change in classification from the previous systemic inflammatory response syndrome (SIRS) criteria to the current definition in adults and also the unchanged definition in children. The hallmark signs of sepsis (both red and amber flags) are discussed in relation to their underlying cellular mechanisms to provide a comprehensive overview for clinicians in primary care, hospital and community settings. The rise of antimicrobial resistance is also an increasing global health concern with resistant bacteria from common infections likely to result in greater patient morbidity and worse outcomes.A literature search identified reported sepsis cases in dentistry through searches in Ovid Medline and Embase from January 1990 to December 2019. Only primary studies were included with no restrictions on languages. Four articles were identified which reported sepsis associated with tooth extractions, dental abscess and submental/submandibular cellulitis. It is well known that locoregional infections of dental origin have the potential to cause sepsis. Therefore, dental healthcare professionals need to be vigilant and understand the specific signs and escalation protocols to ensure patient safety.

Integrating Focused Cardiac Ultrasound Into Pediatric Septic Shock Assessment

OBJECTIVES

To assess focused cardiac ultrasound impact on clinician hemodynamic characterization of patients with suspected septic shock as well as expert-generated focused cardiac ultrasound algorithm performance.

DESIGN

Retrospective, observational study.

SETTING

Single-center, noncardiac PICU.

PATIENTS

Less than 18 years old receiving focused cardiac ultrasound study within 72 hours of sepsis pathway initiation from January 2014 to December 2016.

INTERVENTIONS

Hemodynamics of patients with suspected septic shock were characterized as fluid responsive, myocardial dysfunction, obstructive physiology, and/or reduced systemic vascular resistance by a bedside clinician before and immediately following focused cardiac ultrasound performance. The clinician's post-focused cardiac ultrasound hemodynamic assessments were compared with an expert-derived focused cardiac ultrasound algorithmic hemodynamic interpretation. Subsequent clinical management was assessed for alignment with focused cardiac ultrasound characterization and association with patient outcomes.

MEASUREMENTS AND MAIN RESULTS

Seventy-one patients with suspected septic shock (median, 4.7 yr; interquartile range, 1.6-8.1) received clinician performed focused cardiac ultrasound study within 72 hours of sepsis pathway initiation (median, 2.1 hr; interquartile range, -1.5 to 11.8 hr). Two patients did not have pre-focused cardiac ultrasound and 23 patients did not have post-focused cardiac ultrasound hemodynamic characterization by clinicians resulting in exclusion from related analyses. Post-focused cardiac ultrasound clinician hemodynamic characterization differed from pre-focused cardiac ultrasound characterization in 67% of patients (31/46). There was substantial concordance between clinician's post-focused cardiac ultrasound and algorithm hemodynamic characterization (33/48; κ = 0.66; CI, 0.51-0.80). Fluid responsive (κ = 0.62; CI, 0.40-0.84), obstructive physiology (к = 0.87; CI, 0.64-1.00), and myocardial dysfunction (1.00; CI, 1.00-1.00) demonstrated substantial to perfect concordance. Management within 4 hours of focused cardiac ultrasound aligned with algorithm characterization in 53 of 71 patients (75%). Patients with aligned management were less likely to have a complicated course (14/52, 27%) compared with misaligned management (8/19, 42%; p = 0.25).

CONCLUSIONS

Incorporation of focused cardiac ultrasound in the evaluation of patients with suspected septic shock frequently changed a clinician's characterization of hemodynamics. An expert-developed algorithm had substantial concordance with a clinician's post-focused cardiac ultrasound hemodynamic characterization. Management aligned with algorithm characterization may improve outcomes in children with suspected septic shock.

Acute kidney injury and mortality in pediatric Lassa fever versus question of access to dialysis

OBJECTIVES

To assess the prevalence of acute kidney injury (AKI), and its impact on outcome in hospitalized pediatric patients with Lassa fever (LF).

METHODS

We reviewed the presenting clinical and laboratory features and outcomes of 40 successive hospitalized children with PCR-confirmed LF. The diagnosis and staging of AKI was based on KDIGO criteria. We compared groups of patients using t- or χ2 tests as necessary, and took p-values <0.05 as indicative of the presence of significant differences.

RESULTS

Sixteen (40%) children had AKI. Case fatality rate (CFR) was 9/16 (56%) in children with and 1/24 (4%) in those without AKI (OR [95% CI] of CFR associated with AKI = 29.57 [3.17, 275.7]). Presentation with abnormal bleeding (p = 0.008), encephalopathy (p = 0.004), hematuria plus proteinuria (p = 0.013), and elevated serum transaminase levels (p <0.02) were significantly associated with an increased prevalence of AKI.

CONCLUSION

AKI prevalence in hospitalized pediatric patients with Lassa fever is high, and correlated with illness severity/CFR. The high prevalence underscores the need for access to hemodialysis, and clinical presentation and/or presence of hematuria plus proteinuria could serve as a ready prompt for referral for such specialized care.

Diagnostic potential of a gradient boosting-based model for detecting pediatric sepsis

Pediatric sepsis is a major cause of mortality of children worldwide. However, there is still a lack of easy-to-use predictive tools that can accurately diagnose sepsis in children. This study aimed to develop an optimal gene model for the diagnosis of pediatric sepsis using statistics and machine learning approaches. Combining gene expression profiles from a training cohort of 364 pediatric samples with a Least Absolute Shrinkage and Selection Operator analysis produced eighteen genes as diagnostic markers. With the implementation of a Gradient Boosting algorithm, a model designated PEDSEPS-GBM, that aggregated these markers was developed with optimal performance for the diagnosis of pediatric samples in the validation and two independent cohorts. Moreover, a web calculator with a user-friendly interface was established for PEDSEPS-GBM. This study presents a diagnostic model that holds great potential for the detection of pediatric sepsis, and demonstrates the biologic and clinical relevance of this model.

Recent Developments in Infectious Disease Chemotherapy: Review for Emergency Department Practitioners 2020

Purpose of Review

We discuss and review new antimicrobials for treatment of bacterial, viral, fungal, and parasitic infections with indications, contraindications, and side effects for each. We will also review new information and indications on older agents that are relevant to clinical practice. Many of them may be unfamiliar to Emergency Physicians given their newness and at times hospital restrictions on their use. We also review some new promising agents that are not yet in the clinical pipeline.

Recent Findings

As new antibiotics become available for clinicians to use, new information becomes available with respect to the drugs' indications, efficacy, pathogen resistance, drug-drug interactions, and side effects.

Summary

This article provides Emergency Department clinicians with a useful summary with new information on antibiotic use and recent research into agents which may become available.

Appropriateness of antibiotic prescribing in the Emergency Department

Background

Antibiotics are some of the most commonly prescribed drugs in the Emergency Department (ED) and yet data describing the overall appropriateness of antibiotic prescribing in the ED is scarce.

Objectives

To describe the appropriateness of antibiotic prescribing in the ED.

Methods

A retrospective, observational study of current practice. All patients who presented to the ED during the study period and were prescribed at least one antibiotic were included. Specialists from Infectious Disease, Microbiology and Emergency Medicine and a Senior Pharmacist assessed antibiotic appropriateness against evidence-based guidelines.

Results

A total of 1019 (13.6%) of patient presentations involved the prescription of at least one antibiotic. Of these, 640 (62.8%) antibiotic prescriptions were assessed as appropriate, 333 (32.7%) were assessed as inappropriate and 46 (4.5%) were deemed to be not assessable. Adults were more likely to receive an inappropriate antibiotic prescription than children (36.9% versus 22.9%; difference 14.1%, 95% CI 7.2%–21.0%). Patients who met quick Sepsis-related Organ Failure Assessment (qSOFA) criteria were more likely to be prescribed inappropriate antibiotics (56.7% versus 36.1%; difference 20.5%, 95% CI, 2.4%–38.7%). There was no difference in the incidence of appropriate antibiotic prescribing based on patient gender, disposition (admitted/discharged), reason for antibiotic administration (treatment/prophylaxis) or time of shift (day/night).

Conclusions

Inappropriate administration of antibiotics can lead to unnecessary adverse events, treatment failure and antimicrobial resistance. With over one in three antibiotic prescriptions in the ED being assessed as inappropriate, there is a pressing need to develop initiatives to improve antibiotic prescribing to prevent antibiotic-associated patient and community harms.

Copper and selenium status as biomarkers of neonatal infections

Neonatal infections are a major risk factor for neonatal mortality. A reliable diagnosis of early-onset sepsis (EOS) is hampered by the variable clinical presentations of the children. We hypothesized that changes in the Se or Cu status, or the biomarkers selenoprotein P (SELENOP) or ceruloplasmin (CP) alone or in combination may be informative of EOS. We generated a new human CP-specific non-competitive immunoassay (ELISA) suitable of analysing small sample volumes and validated the method with a commercial CP source. Using this novel CP assay, we analysed a case-control study of EOS (n = 19 control newborns, n = 18 suspected cases). Concentrations of Se, Cu, SELENOP, CP, interleukin-6 (IL-6), and C-reactive protein (CRP) along with the Cu/Se and CP/SELENOP ratios were evaluated by correlation analyses as biomarkers for EOS. Diagnostic value was estimated by receiver operating characteristic (ROC) curve analyses. The new CP-ELISA displayed a wide working range (0.10-6.78 mg CP/L) and low sample requirement (2 μL of serum, EDTA-, heparin- or citrate-plasma). Plasma CP correlated positively with Cu concentrations in the set of all samples (Pearson r = 0.8355, p < 0.0001). Three of the infected neonates displayed particularly high ratios of Cu/Se and CP/SELENOP, i.e., 3.8- to 6.9-fold higher than controls. Both the Cu/Se and the CP/SELENOP ratios correlated poorly with the early infection marker IL-6, but strongly and positively with the acute-phase protein CRP (Cu/Se-CRP: Spearman ϱ = 0.583, p = 0.011; CP/SELENOP-CRP: ϱ = 0.571, p = 0.013). The ROC curve analyses indicate that a combination of biomarkers for the Se and Cu status do not improve the early identification of EOS considerably. This study established a robust, highly precise, partly validated and scalable novel CP sandwich ELISA suitable for basic and clinical research, requiring minute amounts of sample. The ratio of circulating CP/SELENOP constitutes a promising new composite biomarker for detection of EOS, at least in a subset of severely diseased children.

Clinical, laboratory features and prognosis of children receiving IgM-enriched immunoglobulin (3 days vs. 5 days) as adjuvant treatment for serious infectious disease in pediatric intensive care unit: a retrospective single-center experience (PIGMENT study)

Introduction

Although there are studies about sepsis treatment in different age groups, data on immunoglobulin-M (IgM)-enriched intravenous immunoglobulin use in pediatric intensive care units (PICUs) are limited. The aim of this study was to evaluate the clinical features and prognoses of children receiving IgM-enriched intravenous immunoglobulin to treat sepsis, septic shock, and multi-organ failure.

Method

We extracted data from the medical records of 254 children who received IgM-enriched intravenous immunoglobulin infusion (104 children for 3 days, 150 children for 5 days) in addition to standard treatment between 2010 and 2017.

Results

When the 5-day vs. 3-day IgM-enriched immunoglobulin treatments were compared, the mortality rate was shown to be lower in patients who received the longer duration of treatment (p < .001). Better outcomes were observed among children with septic shock (p < .01).

Conclusion

Our clinical work with 5-days IgM-enriched intravenous immunoglobulin may reveal a survival benefit of this treatment for children with septic shock.

How to Treat Sepsis in the Background of Resistance?: Role of Pharmacodynamics / Pharmacokinetics in Treating Sepsis

Though a decline has been seen in child mortality and morbidity over the last decades, sepsis in neonates and infants remains a major cause of death. Optimal use of antibiotics in sepsis management is a key factor which can further reduce the number of poor clinical outcomes. Selecting the right antibiotic to which the offending bacteria is susceptible and administrating the antibiotic within the first hour can save many lives. However, the pharmacokinetic profile of an antibiotic is affected by developmental changes such as capacity of drug metabolizing enzymes and maturation of organ function. This can affect antibiotic exposure and response in neonates and infants. While suspecting sepsis, the primary focus of empiric treatment during the initial phase is to assure efficacy and it must be broad based to cover all suspected pathogens. Once the bacterial etiology is confirmed as a cause of sepsis and the in vitro antibiotic susceptibility is established, targeted treatment can be started which ensures optimal balance between efficacy and safety.

Bundle Adherence of Intravenous Antibiotic Fluid Resuscitation and Vasopressor in Children with Severe Sepsis or Septic Shock

Objective

The aim of this study was to measure the effects of a bundle of interventions in children admitted with severe sepsis or septic shock in the first hour after diagnosis on mortality.

Materials and methods

A retrospective study was conducted at a pediatric intensive care unit (PICU) between January 2014 and January 2016. Three interventions (intravenous [IV] antibiotic, fluid boluses, and vasopressor administration) applied in the first hour of severe sepsis or septic shock diagnosis were analyzed according to their adherence rates. The main outcome was mortality. Odds ratios were calculated.

Results

Of a total of 530 PICU admissions, 105 patients met the criteria for sepsis, 53 (50.5%) with severe sepsis and 52 (49.5%) with septic shock. Seventy-two (68.6%) patients received IV antibiotic within the first hour, 65 (61.9%) received IV fluid bolus, and 55 (53.3%) received a vasopressor drug. Fifty-two (49.5%) patients received concomitant IV antibiotics and fluid bolus. Blood cultures were collected before IV antibiotic administration in 87 (82.9%) out of 105 patients. Thirteen (12.4%) patients died, 1 with severe sepsis and 12 with septic shock. In a univariate analysis, the odds ratios for death and IV antibiotic were 6.39 (p value = 0.081, 95% CI = 0.795-51.465), 4.77 for fluid bolus between 21 and 40 mL/kg (p value = 0.013, 95% CI = 1.395-16.336), and 3.23 for vasopressor administration (p value < 0.0001, 95% CI = 1.734-6.018). In a multivariate analysis, the odds ratio of fluid bolus between 21 and 40 mL/kg was 42.66 (p value = 0.005, 95% CI = 3.117-583.841) and noradrenaline use was 23.93 (p value = 0.010, 95% CI = 2.124-269.750).

Conclusion

Adherence was observed for more than half of the single interventions as IV antibiotic, fluid resuscitation, and vasopressor administration in the first hour. The antibiotic administration alone was not associated with high mortality. Vasopressor administration was related to higher mortality but moderate fluid bolus was a protective factor associated with lower mortality.

How to cite this article

Barboza CL, Valete COS, da Silva ARA. Bundle Adherence of Intravenous Antibiotic Fluid Resuscitation and Vasopressor in Children with Severe Sepsis or Septic Shock. Indian J Crit Care Med 2020;24(2):128-132.

Characteristics of Febrile Children Admitted to the ICU Following an Unscheduled ED Revisit Within 72 h, a Case-Control Study

Objective: The purpose of this article was to demonstrate related characteristics of intensive care unit (ICU) admission after an unscheduled revisit by febrile children visiting the emergency department (ED). Method: We performed a retrospective study in a tertiary medical center from 2010 to 2016. Patients whose chief complaint was fever and who were admitted to the ICU following a 72-h return visit to the ED were included, and we selected patients who were discharged from the same emergency department for comparison. Results: During the study period, 54 (0.03%) patients met the inclusion criteria, and 216 patients were selected for the matched control group. Regarding clinical variables on initial ED visit, visiting during the night shift (66.7 vs. 46.8%, p = 0.010), shorter length of 1st ED stay (2.5 ± 2.63 vs. 3.5 ± 3.44 h, p = 0.017), and higher shock index (SI) (1.6 ± 0.07 vs. 1.4 ± 0.02, p = 0.008) were associated with ICU admission following a return visit. On the return ED visit, we found that clinical variables such as elevated heart rate, SI, white blood cell count, and C-reactive protein level were all associated with ICU admission. Furthermore, elevated SI and pediatric age-adjusted (SIPA) values were observed in the study group in both the initial (42.2 vs. 20.1%, OR:2.3 (1.37-4.31), p = 0.002) and return ED visits (29.7 vs. 6.9%, OR: 4.6 (2.42-8.26), p < 0.001). Conclusion: For children who visited the emergency department with a febrile complaint, elevated SIPA values on the initial ED visit were associated with ICU admission following an unscheduled ED revisit within 72 h.

Early Recognition of Pediatric Sepsis Simulation Checklist - An Exploratory Study

PURPOSE

To report on the modification and exploration of a 21-item Early Detection of Pediatric Sepsis Assessment Checklist aimed at improving nursing students' recognition of key factors that contribute to early detection of sepsis in pediatric patients through clinical simulation.

DESIGN AND METHODS

One hundred and thirty-one undergraduate, pre-licensure nursing students were evaluated using the adapted 21-item Early Detection of Pediatric Sepsis Assessment Checklist in simulation using high-fidelity manikins. Categorical Principle Component Analysis was used to evaluate for factor structure, with items accounting for <0.20 of the variance were dropped from the loadings.

RESULTS

Two factors emerged from the analysis: assessment and deterioration, accounting for 68% of the variance. Factor one, assessment, contained nine items (α = 0.77; λ = 3.36). Factor two, deterioration, contained seven items (α = 0.72; λ = 2.85). Five items did not load and were dropped from the factor structure, resulting in a 16-item checklist.

CONCLUSIONS

Two factors emerged from the analysis which is key to improving the early detection of pediatric sepsis. Assessment, factor one, accounted for the nursing students' central skills of recognizing baseline vital signs and timely medication administration. Deterioration, factor two, contained items reflecting the recognition of changes from baseline that require action. Conceptually, these factors reflect the most central points in the early detection of signs in pediatric patients at risk for sepsis.

PRACTICE IMPLICATIONS

This checklist forms a valuable tool to assess the knowledge of pre-licensure students and may possibly be extended as a tool to assess the clinical readiness and performance of new graduates through the safety and supervision allotted by simulation.

Comparison of procalcitonin and C-reactive protein as early diagnostic marker for the identification of transplant-related adverse events after allogeneic hematopoietic stem cell transplantation in pediatric patients

PURPOSE

To evaluate serum procalcitonin (PCT) and C-reactive protein (CRP) as diagnostic biomarkers of transplant-related adverse events (TRAE) in pediatric patients undergoing hematopoietic stem cell transplantation (HSCT).

METHODS

This study analyzed PCT and CRP levels of 214 pediatric patients with a median age of 8.5 years (0.4-17.8 years) undergoing allogeneic HSCT with respect to major TRAE.

RESULTS

26 patients (12.1%) did not experience TRAE (control group), and 188 (87.9%) experienced median 2 (range 1-4) TRAE. Median CRP and PCT were highly and significantly increased during sepsis/SIRS and bacteremia (17.24 mg/dl | 6.30 ng/ml; p < 0.0001 vs. prior values), graft rejection (14.73 mg/dl | 3.20 ng/ml; p < 0.0001), and liver GvHD (6.88 mg/dl | 2.29 ng/ml; p < 0.01). Strong CRP increases and slight/minimal/no PCT increases occurred during fungemia (8.85 mg/dl | 0.72 ng/ml; p < 0.001), intestinal GvHD (8.73 mg/dl | 1.06 ng/ml; p < 0.0001), VOD (10.84 mg/dl | 0.59 ng/ml; p < 0.01), mucositis (8.84 mg/dl | 0.81 ng/ml; p < 0.0001), and viremia (3.62 mg/dl; p < 0.0001 | 0.43 ng/ml; below normal limit). During skin GvHD, CRP and PCT were slightly increased (2.03 mg/dl | 0.93 ng/ml; p < 0.0001).

CONCLUSIONS

CRP and PCT did not show congruent changes during TRAE. PCT was a clinically relevant marker for the early detection and differentiation of severe mucositis and sepsis/SIRS and bacteremia during the critical neutropenic period after HSCT. PCT helped to discriminate acute intestinal GvHD from adenovirus viremia and liver GvHD from hepatic VOD. Thus, PCT may be a valuable parameter to enable a prompt and appropriate treatment during these complications, improving patient outcomes.

Presepsin as a diagnostic marker of sepsis in children and adolescents: a systemic review and meta-analysis

Background

Early diagnosis of sepsis in pediatric patients is vital but remains a major challenge. Previous studies showed that presepsin is potentially a reliable diagnostic biomarker for sepsis in adult and neonates. However, there is no pooled analysis of its efficacy as a diagnostic biomarker for sepsis in children. The aims of the present meta-analysis were to assess the overall diagnostic accuracy of presepsin in pediatric sepsis and compare it to those for C-reactive protein (CRP) and procalcitonin (PCT).

Methods

A systematic literature search was performed in Medline/Pubmed, Embase, the Cochrane Library, and ISI Web of Science to identify relevant studies reporting the diagnostic accuracy of presepsin in patients with pediatric sepsis. Sensitivities and specificities were pooled by bivariate meta-analysis. Heterogeneity was evaluated by χ² test.

Results

We identified 129 studies in total. Most were disqualified on the basis of their titles/abstracts and duplication. Four studies were included in the final analysis. They comprised 308 patients aged between 1 mo and 18 y. The pooled diagnostic sensitivity and specificity of presepsin were 0.94 (95% confidence interval [CI]: 0.74–0.99) and 0.71 (95% CI: 0.35–0.92), respectively. The pooled diagnostic odds ratio, positive likelihood ratio (LR), and negative LR of presepsin were 32.87 (95% CI: 2.12–510.09), 3.24 (95% CI, 1.14–12.38), and 0.08 (95% CI, 0.01–0.74), respectively. Heterogeneity was found in both sensitivity (χ² = 11.17; P = 0.011) and specificity (χ² = 65.78; P < 0.001). No threshold effect was identified among the studies (r = − 0.938). The pooled sensitivity of presepsin (0.94) was higher than that of CRP (0.51) and PCT (0.76), whereas the overall specificity of presepsin (0.71) was lower than that of CRP (0.81) and PCT (0.76). The AUC of presepsin (0.925) was higher than that of CRP (0.715) and PCT (0.820).

Conclusion

Currently available evidence indicates that presepsin has higher sensitivity and diagnostic accuracy, but lower specificity, than PCT or CRP in detecting sepsis in children. However, these results must be carefully interpreted as the number of studies included was small and the studies were statistically heterogeneous.

Electronic supplementary material

The online version of this article (10.1186/s12879-019-4397-1) contains supplementary material, which is available to authorized users.

Dialyzable Leukocyte Extract (Transferon™) Administration in Sepsis: Experience from a Single Referral Pediatric Intensive Care Unit

Immunomodulatory agents have been proposed as therapeutic candidates to improve outcomes in sepsis. Transferon™, a dialyzable leukocyte extract (DLE), has been supported in Mexico as an immunomodulatory adjuvant in anti-infectious therapy. Here we present a retrospective study describing the experience of a referral pediatric intensive care unit (PICU) with Transferon™ in sepsis. We studied clinical and laboratory data from 123 patients with sepsis (15 in the DLE group and 108 in the control group) that were admitted to PICU during the period between January 2010 and December 2016. Transferon™ DLE use was associated with lower C reactive protein (CRP), increase in total lymphocyte counts (TLC), and decrease in total neutrophil count (TNC) 72 hours after Transferon™ DLE administration. The control group did not present any significant difference in CRP values and had lower TLC after 72 hours of admission. There was no difference in PICU length of stay between control and Transferon™ DLE group. Transferon™ DLE administration was associated with a higher survival rate at the end of PICU stay. This study shows a possible immunomodulatory effect of Transferon™ on pediatric sepsis patients.

Characteristics and Outcomes of Pediatric Septic Patients With Cancer: A Retrospective Cohort Study

BACKGROUND

Pediatric oncology patients may be at a higher risk of complications and mortality from sepsis compared with their nononcology counterpart.

OBJECTIVES

The aim of this study is to compare characteristics, treatment, and sepsis-related mortality between oncology and nononcology patients presenting to the emergency department (ED).

METHODS

This is a retrospective single-center cohort study including patients <18 years old with a diagnosis of sepsis, severe sepsis, septic shock, or bacteremia presenting to an academic ED between January 2009 and January 2015. A total of 158 patients were included with 53.8% having an underlying malignancy. The primary outcome of the study was in-hospital mortality. Secondary outcomes included ED vital signs, resuscitation parameters, laboratory work, infection site, general practitioner unit, intensive care unit length of stay, and hospital length of stay.

RESULTS

Oncology patients had a higher in-hospital mortality (5.9% vs. 2.7%), however, it did not meet statistical significance (p = 0.45). On presentation, oncology patients had a lower respiratory rate (24.33 ± 9.48 vs. 27.45 ± 7.88; p = 0.04). There was a significant increase in the white blood count in oncology patients (4.011 ± 4.965 vs. 17.092 ± 12.806; p < 0.001) with this cohort receiving more intravenous fluids. In the first 6 hours (33.0 ± 27.7 mL/kg vs. 24.9 ± 16.1 mL/kg; p = 0.029) as well as having a higher percentage of vasopressor administration (15.3% vs. 1.4%; p = 0.002). Antibiotics were initiated at an earlier stage in the oncology cohort (1.25 ± 1.95 vs. 3.33 ± 1.97 hours; p < 0.0001). Cancer-free patients had a significantly higher rate of lung infections compared with cancer patients (68.5% vs. 32.9%; p < 0.0001). In terms of infection characteristics, cancer patients had a higher percentage of bacteremia (27.1% vs. 4.1%; p < 0.001).

CONCLUSION

There was no statistical significance regarding mortality between the 2 cohorts. Pediatric cancer patients were found to have a higher incidence of bacteremia and received more aggressive treatment.

Decreasing Time to Antibiotics for Patients with Sepsis in the Emergency Department

Background:

Sepsis is a significant cause of morbidity and mortality. Patients may present in a spectrum, from nonsevere sepsis through septic shock. Literature supports improvement in patient outcomes with timely care. This project describes an effort to improve delays in antibiotic administration in patients with sepsis spectrum disease presenting to a pediatric emergency department (PED).

Objective:

This project aimed to decrease time to antibiotics for patients with sepsis in the PED from 154 to <120 minutes within 2 years.

Methods:

Following the collection of baseline data, we assembled a multidisciplinary team. Specific interventions included staff education, the institution of a best practice alert with order set and standardized huddle response, and local stocking of antibiotics. We included all patients with orders for intravenous antibiotics and blood culture.

Results:

From April 2015 to April 2017, the PED demonstrated reduction in time to antibiotics from 154 to 114 minutes. The time from emergency department (ED) arrival to antibiotic order also improved, from 87 to 59 minutes.

Conclusions:

This initiative improved prioritization and efficiency of care of sepsis, and overall time to antibiotics in this population. The results of this project demonstrate the effectiveness of a multidisciplinary team working to improve an essential time-driven process.

Use of extracorporeal membrane oxygenation and associated outcomes in children hospitalized for sepsis in the United States: A large population-based study

Objective

The American College of Critical Care Medicine recommends that children with persistent fluid, catecholamine, and hormone-resistant septic shock be considered for extracorporeal membrane oxygenation (ECMO) support. Current national estimates of ECMO use in hospitalized children with sepsis are unknown. We sought to examine the use of ECMO in these children and to examine the overall outcomes such as in-hospital mortality, length of stay (LOS), and hospitalization charges (HC).

Methods

A retrospective analysis of the National Inpatient Sample, which approximates a 20% stratified sample of all discharges from United States community hospitals, was performed. All children (≤ 17 years) who were hospitalized for sepsis between 2012 and 2014 were included. The associations between ECMO and outcomes were examined by multivariable linear and logistic regression models.

Results

A total of 62,310 children were included in the study. The mean age was 4.2 years. ECMO was provided to 415 of the children (0.67% of the cohort with sepsis). Comparative outcomes of sepsis in children who received ECMO versus those who did not included in-hospital mortality rate (41% vs 2.8%), mean HC ($749,370 vs $90,568) and mean LOS (28.8 vs 9.1 days). After adjusting for confounding factors, children receiving ECMO had higher odds of mortality (OR 11.15, 95% CI 6.57–18.92, p < 0.001), longer LOS (6.6 days longer, p = 0.0004), and higher HC ($510,523 higher, p < 0.0001).

Conclusions

Use of ECMO in children with sepsis is associated with considerable resource utilization but has 59% survival to discharge. Further studies are needed to examine the post discharge and neurocognitive outcomes in survivors.

Evidence-Based Strategies and Recommendations for Preservation of Central Venous Access in Children

Children with chronic illness often require prolonged or repeated venous access. They remain at high risk for venous catheter-related complications (high-risk patients), which largely derive from elective decisions during catheter insertion and continuing care. These complications result in progressive loss of the venous capital (patent and compliant venous pathways) necessary for delivery of life-preserving therapies. A nonstandardized, episodic, isolated approach to venous care in these high-need, high-cost patients is too often the norm, imposing a disproportionate burden on affected persons and escalating costs. This state-of-the-art review identifies known failure points in the current systems of venous care, details the elements of an individualized plan of care, and emphasizes a patient-centered, multidisciplinary, collaborative, and evidence-based approach to care in these vulnerable populations. These guidelines are intended to enable every practitioner in every practice to deliver better care and better outcomes to these patients through awareness of critical issues, anticipatory attention to meaningful components of care, and appropriate consultation or referral when necessary.

Assessment of early goal-directed therapy guideline adherence: Balancing clinical importance and feasibility

BACKGROUND

Assessing adherence to Early goal-directed therapy (EGDT) is challenging and might account for the negative findings and generalisability of the major trials to a real-life setting. This study was aimed (1) to extract key components of pediatric EGDT guidelines potentially becoming adherence criteria; (2) to classify adherence criteria into complete, clinically important, and feasible; and (3) to compare percent adherence to selected guidelines using the three approaches.

METHODS

This study started with review of existing evidence to extract key components of pediatric EGDT guidelines. Modified Delphi method was then conducted in two rounds among national experts to identify feasible and/or clinically important criteria. Data from the national prospective multicenter study "Clinical Effectiveness of the Utilization of Bundled Care for Severe Sepsis and Septicemia Children" at King Chulalongkorn Memorial Hospital (KCMH) during 1 June 2012 and 28 February 2014 was used to compare percentage of adherence across the three approaches.

RESULTS

Of 28 components extracted from the review, 10 were identified by the national experts through the Modified Delphi as feasible whereas 8 were identified as clinically important. Thirty-one severe sepsis patients (48.39% male, median age 3.4 years) were reviewed. Sepsis mortality was 9.7%, a significant reduction from 19% and 42% in 2010 and 2007, respectively. Based on the complete adherence criteria, the percent adherence varied from 60.71% to 89.29% (overall mean 76.84%), with lower adherence in the dead than the survived cases (73.81% vs 77.17%; p = 0.55). The percent adherence varied by criteria used: 69.35%, 76.84%, and 84.52% for clinical importance, complete, and feasibility criteria, respectively.

CONCLUSION

Adherence determination based on selected clinical importance alone might result in an incorrectly estimated clinical benefit of EGDT guidelines, especially in a resource-limited setting. Both clinical importance and feasibility should be integrated into the development of adherence assessment criteria.

Comparison of International Pediatric Sepsis Consensus Conference Versus Sepsis-3 Definitions for Children Presenting With Septic Shock to a Tertiary Care Center in India: A Retrospective Study

OBJECTIVES

To evaluate the proportion of children fulfilling "Sepsis-3" definition and International Pediatric Sepsis Consensus Conference definition among children diagnosed to have septic shock and compare the mortality risk between the two groups.

DESIGN

Retrospective chart review.

SETTING

PICU of a tertiary care teaching hospital from 2014 to 2017.

PATIENTS

Children (≤ 17 yr old) with a diagnosis of septic shock at admission or during PICU stay.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We applied both International Pediatric Sepsis Consensus Conference and the new "Sepsis-3" definition (sepsis with hypotension requiring vasopressors and a lactate value of ≥ 2 mmol/L) to identify cases of septic shock by these definitions. Key outcomes such as mortality, proportion attaining shock reversal at 24 hours and organ dysfunction were compared between those fulfilling "Sepsis-3" definitions ("Sepsis-3" group) and those fulfilling "International Pediatric Sepsis Consensus Conference" definition ("International Pediatric Sepsis Consensus Conference" group). A total of 216 patients fulfilled International Pediatric Sepsis Consensus Conference definitions of septic shock. Of these, only 104 (48%; 95% CI, 42-55) fulfilled "Sepsis-3" definition. Children fulfilling "Sepsis-3 plus International Pediatric Sepsis Consensus Conference definitions" ("Sepsis-3 and International Pediatric Sepsis Consensus Conference" group) had lower proportion with shock resolution (61% vs 82%; relative risk, 0.73; 95% CI, 0.62-0.88) and higher risk of multiple organ dysfunction (85% vs 68%; 1.24; 1.07-1.45) at 24 hours. The mortality was 48.5% in "Sepsis-3 and International Pediatric Sepsis Consensus Conference" group as compared with 37.5% in the "International Pediatric Sepsis Consensus Conference only" group (relative risk, 1.3; 95% CI, 0.94-1.75).

CONCLUSIONS

Less than half of children with septic shock identified by International Pediatric Sepsis Consensus Conference definitions were observed to fulfill the criteria for shock as per "Sepsis-3" definitions. Lack of difference in the risk of mortality between children who fulfilled "Sepsis-3" definition and those who did not fulfill the definition raises questions on the appropriateness of using this definition for diagnosis of septic shock in children.

Evaluation of disseminated intravascular coagulation scores in critically ill pediatric patients with septic shock

PURPOSE

To evaluated the outcome predictability of DIC scores in critically ill children with septic shock.

MATERIALS AND METHODS

Pediatric patients with septic shock who were admitted to the pediatric intensive care unit of a tertiary care children's hospital between January 2013 and December 2017 were enrolled. We analyzed the association between DIC and clinical outcomes. DIC was diagnosed based on the International Society on Thrombosis and Hemostasis (ISTH), Japanese Association for Acute Medicine (JAAM), and modified JAAM DIC criteria.

RESULTS

Among the 89 patients, DIC was diagnosed in 66.3%, 61.8%, and 41.6% of patients using the JAAM, modified JAAM, and ISTH DIC criteria, respectively. Overall 28-day mortality was 14.6%. DIC patients had worse outcomes, including a higher 28-day mortality and multiorgan dysfunction syndrome (MODS) than those without DIC. The DIC scores were well correlated with the MODS scores. The JAAM and modified JAAM DIC scores showed good outcome predictability (p < 0.05) with areas under the receiver operating characteristic curve of 0.765 and 0.741, respectively.

CONCLUSIONS

Critically ill children with septic shock frequently experience DIC. Patients with DIC had worse outcomes than those without DIC. JAAM and modified JAAM DIC scores could be promising outcome predictors in these patients.

Sepsis: Changing Definitions, Unchanging Treatment

The recently revised Sepsis-3 definitions were based on criteria that were derived and validated in adult patient databases from high income countries. Both sepsis and septic shock continue to account for a substantial proportion of mortality globally, especially amongst children in low-and-middle income country settings. It is therefore urgent to develop and validate standardized criteria for sepsis that can be applied to pediatric populations in different settings, including in- and outside intensive care, both in high- and low/middle- income countries. This will be a pre-requisite to evaluate the impact of sepsis treatment strategies to improve clinical outcomes.

Oxygen Delivery and Oxygen Consumption in Pediatric Fluid Refractory Septic Shock During the First 42 h of Therapy and Their Relationship to 28-Day Outcome

Background: In septic shock, both oxygen delivery (DO₂) and oxygen consumption (VO₂) are dysfunctional. The current therapeutic regimens are geared to normalize global oxygen delivery (DO₂) to tissues via goal directed therapies but mortality remains high at 10-20%. Methods: We studied cardiac index (CI), systemic vascular resistance index (SVRI), central venous oxygen saturation (ScvO2), central venous pressure (CVP), peripheral oxygen saturation (SpO2), mean blood pressure (MBP), body temperature, blood lactate, base excess and hemoglobin concentration (Hb) in a cohort of children admitted in "fluid-refractory" severe septic shock to pediatric intensive care, over 4.5-years. We calculated their 6 h global oxygen delivery (DO2) and global oxygen consumption (VO2) over the first 42 h and looked at factors associated with VO2/DO2 ratio (i.e., global oxygen extraction, gO2ER) and 28-day mortality. Results: Sixty-two children mean age (SD) 7.19 (5.44) years were studied. Fifty-seven (93%) children were sedated and mechanically ventilated and all received adrenaline or noradrenaline or both and added milrinone in 6 (9.6%). At 28 days, 9 (14.5%) were dead. The global oxygen extraction ratio (gO2ER) was consistently lower amongst the survivors and independently predicted mortality (ROC AUC = 0.75). A lactate level of 4 mmol/l or above, when associated with a concurrent metabolic acidosis predicted mortality with a sensitivity of 100% (95% CI 90.5-100) and a specificity of 67.7% (95% CI 62.2-72.9). A gO2ER of 0.48 or above on admission to the PICU was associated with death with a 66.7% sensitivity (95%CI 29.9-92.5) and 90.5% specificity (95%CI 79.3-96.8). A global O2ER of >0.48 combined with a concurrent blood lactate >4.0 mmol/l at any time within the first 42 h of therapy predicted death with a sensitivity of 63.9% (95% CI, 46.2-79.1) and specificity of 97.8% (95% CI, 95.7-99.0). A radar plot identified MBP-CVP difference, and CI as additional goals of therapy that may offer a survival benefit. Conclusions: Global O2ER of >0.48 with a concurrent blood lactate >4.0 mmol/l in children with metabolic acidosis was an independent factor associated with death in fluid resistant septic shock. Trends of gO2ER seem useful to recognize survivors and non-survivors early in the illness.