1
|
Liu R, Yu Z, Xiao C, Xu F, Xiao S, He J, Shi Y, Hua Y, Zhou J, Zhang G, Wang T, Jiang J, Xiong D, Chen Y, Xu H, Yun H, Sun H, Pan T, Wang R, Zhu S, Huang D, Liu Y, Hu Y, Ren X, Shi M, Song S, Luo J, He G, Zhang J. Epidemiology and Clinical Characteristics of Pediatric Sepsis in PICUs in Southwest China: A Prospective Multicenter Study. Pediatr Crit Care Med 2024; 25:425-433. [PMID: 38353591 DOI: 10.1097/pcc.0000000000003450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/16/2024]
Abstract
OBJECTIVES To describe the epidemiological characteristics of pediatric sepsis in Southwest China PICUs. DESIGN A prospective, multicenter, and observational study. SETTING Twelve PICUs in Southwest China. PATIENTS The patients admitted to the PICU from April 1, 2022, to March 31, 2023. The age ranged from 28 days to 18 years. All patients met the criteria of severe sepsis or septic shock. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of the 31 PICUs invited to participate, 12 PICUs (capacity of 292 beds) enrolled patients in the study. During the study period, 11,238 children were admitted to the participating PICUs, 367 (3.3%) of whom met the diagnosis of severe sepsis or septic shock. The most prevalent sites of infection were the respiratory system (55%) and the digestive system (15%). The primary treatments administered to these patients included antibiotics (100%), albumin (61.3%), invasive mechanical ventilation (58.7%), glucocorticoids (55.6%), blood products (51%), gammaglobulin (51%), and vasoactive medications (46.6%). Sepsis-related mortality in the PICU was 11.2% (41/367). Nearly half of the sepsis deaths occurred within the first 3 days of PICU admission (22/41, 53.7%). The mortality rate of septic shock (32/167, 19.2%) was significantly higher than that of severe sepsis (9/200, 4.5%; p < 0.001). The outcomes of a multivariate logistic regression analysis suggested that a higher pediatric Sequential Organ Failure Assessment score, and the use of invasive mechanical ventilation and vasoactive medications were independently associated with PICU mortality in children with sepsis. CONCLUSIONS This report updates the epidemiological data of pediatric sepsis in PICUs in Southwest China. Sepsis is still a life-threatening disease in children.
Collapse
Affiliation(s)
- Rong Liu
- Department of Pediatric Critical Care, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Zhicai Yu
- Department of Pediatric Critical Care, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Changxue Xiao
- Department of Pediatric Critical Care, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Feng Xu
- Department of Pediatric Critical Care, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Shufang Xiao
- Department of Pediatric Critical Care, Kunming Children's Hospital, Kunming, China
| | - Juan He
- Department of Pediatric Critical Care, Kunming Children's Hospital, Kunming, China
| | - Yan Shi
- Department of Pediatric Critical Care, The First People's Hospital of Liangshan Yi Autonomous Prefecture, Liangshan Yi autonomous Prefecture, Sichuan, China
| | - Yuanyuan Hua
- Department of Pediatric Critical Care, The First People's Hospital of Liangshan Yi Autonomous Prefecture, Liangshan Yi autonomous Prefecture, Sichuan, China
| | - Jimin Zhou
- Department of Pediatric Critical Care, The First People's Hospital of Liangshan Yi Autonomous Prefecture, Liangshan Yi autonomous Prefecture, Sichuan, China
| | - Guoying Zhang
- Department of Pediatric Critical Care, Chengdu Women's and Children's Central Hospital, Chengdu, Sichuan, China
| | - Tao Wang
- Department of Pediatric Critical Care, Chengdu Women's and Children's Central Hospital, Chengdu, Sichuan, China
| | - Jianyu Jiang
- Department of Pediatric Critical Care, Chongqing University Three Gorges Hospital, Wanzhou, Chongqing, China
| | - Daoxue Xiong
- Department of Pediatric Critical Care, Chongqing University Three Gorges Hospital, Wanzhou, Chongqing, China
| | - Yan Chen
- Department of Pediatric Critical Care, Guizhou Provincial Children's Hospital, Zunyi, Guizhou, China
| | - Hongbo Xu
- Department of Pediatric Critical Care, Guizhou Provincial Children's Hospital, Zunyi, Guizhou, China
| | - Hong Yun
- Department of Pediatric Critical Care, Guizhou Provincial Children's Hospital, Zunyi, Guizhou, China
| | - Hui Sun
- Department of Pediatric Critical Care, Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou, China
| | - Tingting Pan
- Department of Pediatric Critical Care, Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou, China
| | - Rui Wang
- Department of Pediatric Critical Care, Yuxi Children's Hospital, Yuxi, Yunnan, China
| | - Shuangmei Zhu
- Department of Pediatric Critical Care, Yuxi Children's Hospital, Yuxi, Yunnan, China
| | - Dong Huang
- Department of Pediatric Critical Care, Guizhou Provincial People's Hospital, Guiyang, Guizhou, China
| | - Yujiang Liu
- Department of Pediatric Critical Care, Guizhou Provincial People's Hospital, Guiyang, Guizhou, China
| | - Yuhang Hu
- Department of Pediatric Critical Care, Sichuan Provincial Maternity and Child Health Hospital, Chengdu, Sichuan, China
| | - Xinrui Ren
- Department of Pediatric Critical Care, Sichuan Provincial Maternity and Child Health Hospital, Chengdu, Sichuan, China
| | - Mingfang Shi
- Department of Pediatric Critical Care, The First People's Hospital of Yibin, Yibin, Sichuan, China
| | - Sizun Song
- Department of Pediatric Critical Care, The First People's Hospital of Yibin, Yibin, Sichuan, China
| | - Jumei Luo
- Department of Pediatric Critical Care, The First People's Hospital of Yibin, Yibin, Sichuan, China
| | - Gang He
- Department of Pediatric Critical Care, Nanchong Central Hospital, Nanchong, China
| | - Juan Zhang
- Department of Pediatric Critical Care, Nanchong Central Hospital, Nanchong, China
| |
Collapse
|
2
|
Patterson SG, Lamb CK, Gong W, Resser J, Lindsell CJ, Van Driest SL, Stark RJ. Pediatric Persistent Inflammation, Immunosuppression, and Catabolism Syndrome Prevalence in Sepsis-Related Mortalities: A 23-Year Institutional History. Chest 2023; 164:1204-1215. [PMID: 37164130 PMCID: PMC10635837 DOI: 10.1016/j.chest.2023.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 05/01/2023] [Accepted: 05/01/2023] [Indexed: 05/12/2023] Open
Abstract
BACKGROUND Delayed mortality in sepsis often is linked to a lack of resolution in the inflammatory cascade termed persistent inflammation, immunosuppression, and catabolism syndrome (PICS). Limited research exists on PICS in pediatric patients with sepsis. RESEARCH QUESTION What is the prevalence of pediatric PICS (pPICS) in patients who died of sepsis-related causes and what associated pathogen profiles and comorbidities did they have compared with those patients without pPICS who died from sepsis? STUDY DESIGN AND METHODS A retrospective study of a single institution using a de-identified database from 1997 through 2020 for all patients aged 21 years or younger who died of culture-positive sepsis from a known source and who had laboratory data available were evaluated for the presence of pPICS. RESULTS Among records extracted from the institutional database, 557 patients had culture-positive sepsis, with 262 patients having pPICS (47%). Patients with pPICS were more likely to have underlying hematologic or oncologic disease or cardiac disease. In addition, patients who had pPICS showed increased odds of associated fungal infection compared with those patients who did not (OR, 2.69; 95% CI, 1.59-4.61; P < .001). When assessing laboratory criteria, having a sustained absolute lymphocyte count of < 1.0 × 103/μL was most closely associated with having pPICS compared with other laboratory parameters. Finally, the results of multivariate logistic regression analysis indicated that patients with pPICS were more common in the cardiac ICU, as opposed to the PICU (OR, 3.43; CI, 1.57-7.64; P = .002). INTERPRETATION Pediatric patients who died of a sepsis-related cause have a pPICS phenotype nearly one-half of the time. These patients are more likely to be in the cardiac ICU than the pediatric ICU and have associated fungal infections. Special attention should be directed toward this population in future research.
Collapse
Affiliation(s)
| | - Celia K Lamb
- Division of Critical Care, Vanderbilt University Medical Center, Nashville, TN
| | - Wu Gong
- Department of Biostatistics and Bioinformatics, Vanderbilt University Medical Center, Nashville, TN
| | - Jackson Resser
- Department of Biostatistics and Bioinformatics, Vanderbilt University Medical Center, Nashville, TN
| | - Christopher J Lindsell
- Division of Biostatistics, Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC
| | - Sara L Van Driest
- Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, TN
| | - Ryan J Stark
- Division of Critical Care, Vanderbilt University Medical Center, Nashville, TN
| |
Collapse
|
3
|
Brunetti MA, Griffis HM, O'Byrne ML, Glatz AC, Huang J, Schumacher KR, Bailly DK, Domnina Y, Lasa JJ, Moga MA, Zaccagni H, Simsic JM, Gaynor JW. Racial and Ethnic Variation in ECMO Utilization and Outcomes in Pediatric Cardiac ICU Patients. JACC. ADVANCES 2023; 2:100634. [PMID: 38938717 PMCID: PMC11198441 DOI: 10.1016/j.jacadv.2023.100634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 06/15/2023] [Accepted: 07/26/2023] [Indexed: 06/29/2024]
Abstract
Background Previous studies have reported racial disparities in extracorporeal membrane oxygenation (ECMO) utilization in pediatric cardiac patients. Objectives The objective of this study was to determine if there was racial/ethnic variation in ECMO utilization and, if so, whether mortality was mediated by differences in ECMO utilization. Methods This is a multicenter, retrospective cohort study of the Pediatric Cardiac Critical Care Consortium clinical registry. Analyses were stratified by hospitalization type (medical vs surgical). Logistic regression models were adjusted for confounders and evaluated the association between race/ethnicity with ECMO utilization and mortality. Secondary analyses explored interactions between race/ethnicity, insurance, and socioeconomic status with ECMO utilization and mortality. Results A total of 50,552 hospitalizations from 34 hospitals were studied. Across all hospitalizations, 2.9% (N = 1,467) included ECMO. In medical and surgical hospitalizations, Black race and Hispanic ethnicity were associated with severity of illness proxies. In medical hospitalizations, race/ethnicity was not associated with the odds of ECMO utilization. Hospitalizations of other race had higher odds of mortality (adjusted odds ratio [aOR]: 1.61; 95% CI: 1.22-2.12; P = 0.001). For surgical hospitalizations, Black (aOR: 1.24; 95% CI: 1.02-1.50; P = 0.03) and other race (aOR: 1.50; 95% CI: 1.17-1.93; P = 0.001) were associated with higher odds of ECMO utilization. Hospitalizations of Hispanic patients had higher odds of mortality (aOR: 1.31; 95% CI: 1.03-1.68; P = 0.03). No significant interactions were demonstrated between race/ethnicity and socioeconomic status indicators with ECMO utilization or mortality. Conclusions Black and other races were associated with increased ECMO utilization during surgical hospitalizations. There were racial/ethnic disparities in outcomes not explained by differences in ECMO utilization. Efforts to mitigate these important disparities should include other aspects of care.
Collapse
Affiliation(s)
- Marissa A. Brunetti
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania Perelman School of Medicine and Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Heather M. Griffis
- Data Science and Biostatistics Unit, Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Michael L. O'Byrne
- Division of Cardiology, Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Children’s Hospital of Philadelphia, and Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute and Cardiovascular Outcomes, Quality, and Evaluative Research Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Andrew C. Glatz
- Division of Cardiology, Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Children’s Hospital of Philadelphia, and Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jing Huang
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Kurt R. Schumacher
- Department of Pediatrics, University of Michigan Medical School and C.S. Mott Children’s Hospital, Ann Arbor, Michigan, USA
| | - David K. Bailly
- Department of Pediatrics, University of Utah and Primary Children’s Hospital, Salt Lake City, Utah, USA
| | - Yuliya Domnina
- Division of Cardiac Critical Care Medicine, George Washington University School of Medicine and Children’s National Hospital, Washington, DC, USA
| | - Javier J. Lasa
- Divisions of Critical Care Medicine and Cardiology, Department of Pediatrics, Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Michael Alice Moga
- Department of Critical Care Medicine, The Hospital for Sick Children, Toronto, Canada
| | - Hayden Zaccagni
- Section of Cardiac Critical Care Medicine, Department of Pediatrics, Children’s of Alabama and University of Alabama Medicine, Birmingham, Alabama, USA
| | - Janet M. Simsic
- The Heart Center at Nationwide Children’s Hospital, Columbus, Ohio, USA
| | - J. William Gaynor
- Department of Surgery, University of Pennsylvania Perelman School of Medicine and Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| |
Collapse
|
4
|
Magill SS, Sapiano MRP, Gokhale R, Nadle J, Johnston H, Brousseau G, Maloney M, Ray SM, Wilson LE, Perlmutter R, Lynfield R, DeSilva M, Sievers M, Irizarry L, Dumyati G, Pierce R, Zhang A, Kainer M, Fiore AE, Dantes R, Epstein L. Epidemiology of Sepsis in US Children and Young Adults. Open Forum Infect Dis 2023; 10:ofad218. [PMID: 37187509 PMCID: PMC10167985 DOI: 10.1093/ofid/ofad218] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 04/19/2023] [Indexed: 05/17/2023] Open
Abstract
Background Most multicenter studies of US pediatric sepsis epidemiology use administrative data or focus on pediatric intensive care units. We conducted a detailed medical record review to describe sepsis epidemiology in children and young adults. Methods In a convenience sample of hospitals in 10 states, patients aged 30 days-21 years, discharged during 1 October 2014-30 September 2015, with explicit diagnosis codes for severe sepsis or septic shock, were included. Medical records were reviewed for patients with documentation of sepsis, septic shock, or similar terms. We analyzed overall and age group-specific patient characteristics. Results Of 736 patients in 26 hospitals, 442 (60.1%) had underlying conditions. Most patients (613 [83.3%]) had community-onset sepsis, although most community-onset sepsis was healthcare associated (344 [56.1%]). Two hundred forty-one patients (32.7%) had outpatient visits 1-7 days before sepsis hospitalization, of whom 125 (51.9%) received antimicrobials ≤30 days before sepsis hospitalization. Age group-related differences included common underlying conditions (<5 years: prematurity vs 5-12 years: chronic pulmonary disease vs 13-21 years: chronic immunocompromise); medical device presence ≤30 days before sepsis hospitalization (1-4 years: 46.9% vs 30 days-11 months: 23.3%); percentage with hospital-onset sepsis (<5 years: 19.6% vs ≥5 years: 12.0%); and percentage with sepsis-associated pathogens (30 days-11 months: 65.6% vs 13-21 years: 49.3%). Conclusions Our data suggest potential opportunities to raise sepsis awareness among outpatient providers to facilitate prevention, early recognition, and intervention in some patients. Consideration of age-specific differences may be important as approaches are developed to improve sepsis prevention, risk prediction, recognition, and management.
Collapse
Affiliation(s)
- Shelley S Magill
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Mathew R P Sapiano
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Runa Gokhale
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Joelle Nadle
- California Emerging Infections Program, Oakland, California, USA
| | - Helen Johnston
- Division of Disease Control and Public Health Response, Colorado Department of Public Health and Environment, Denver, Colorado, USA
| | - Geoff Brousseau
- Division of Disease Control and Public Health Response, Colorado Department of Public Health and Environment, Denver, Colorado, USA
| | - Meghan Maloney
- Connecticut Emerging Infections Program, Hartford and New Haven, Connecticut, USA
| | - Susan M Ray
- Department of Medicine, Emory University, Atlanta, Georgia, USA
- Georgia Emerging Infections Program, Decatur, Georgia, USA
| | - Lucy E Wilson
- Infectious Disease Epidemiology and Outbreak Response Bureau, Maryland Department of Health, Baltimore, Maryland, USA
- Department of Emergency Health Services, University of Maryland, Baltimore County, Baltimore, Maryland, USA
| | - Rebecca Perlmutter
- Infectious Disease Epidemiology and Outbreak Response Bureau, Maryland Department of Health, Baltimore, Maryland, USA
| | - Ruth Lynfield
- Minnesota Department of Health, St Paul, Minnesota, USA
| | | | - Marla Sievers
- Epidemiology and Response Division, New Mexico Department of Health, Santa Fe, New Mexico, USA
| | - Lourdes Irizarry
- Epidemiology and Response Division, New Mexico Department of Health, Santa Fe, New Mexico, USA
| | - Ghinwa Dumyati
- New York Emerging Infections Program, University of Rochester Medical Center, Rochester, New York, USA
| | - Rebecca Pierce
- Public Health Division, Oregon Health Authority, Portland, Oregon, USA
| | - Alexia Zhang
- Public Health Division, Oregon Health Authority, Portland, Oregon, USA
| | - Marion Kainer
- Tennessee Department of Health, Nashville, Tennessee, USA
| | - Anthony E Fiore
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Raymund Dantes
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
- Department of Medicine, Emory University, Atlanta, Georgia, USA
| | - Lauren Epstein
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| |
Collapse
|
5
|
Mitchell HK, Reddy A, Perry MA, Gathers CA, Fowler JC, Yehya N. Racial, ethnic, and socioeconomic disparities in paediatric critical care in the USA. THE LANCET CHILD & ADOLESCENT HEALTH 2021; 5:739-750. [PMID: 34370979 DOI: 10.1016/s2352-4642(21)00161-9] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 05/11/2021] [Accepted: 05/12/2021] [Indexed: 11/17/2022]
Abstract
In an era of tremendous medical advancements, it is important to characterise and address inequities in the provision of health care and in outcomes. There is a large body of evidence describing such disparities by race or ethnicity and socioeconomic position in critically ill adults; however, this important issue has received less attention in children and adolescents (aged ≤21 years). This Review presents a summary of the available evidence on disparities in outcomes in paediatric critical illness in the USA as a result of racism and socioeconomic privilege. The majority of evidence of racial and socioeconomic disparities in paediatric critical care originates from the USA and is retrospective, with only one prospective intervention-based study. Although there is mixed evidence of disparities by race or ethnicity and socioeconomic position in general paediatric intensive care unit admissions and outcomes in the USA, there are striking trends within some disease processes. Notably, there is evidence of disparities in management and outcomes for out-of-hospital cardiac arrest, asthma, severe trauma, sepsis, and oncology, and in families' perceptions of care. Furthermore, there is clear evidence that critical care research is limited by under-enrolment of participants from minority race or ethnicity groups. We advocate for rigorous research standards and increases in the recruitment and enrolment of a diverse range of participants in paediatric critical care research to better understand the disparities observed, including the effects of racism and poverty. A clearer understanding of when, where, and how such disparities affect patients will better enable the development of effective strategies to inform practice, interventions, and policy.
Collapse
Affiliation(s)
- Hannah K Mitchell
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| | - Anireddy Reddy
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, PA, USA
| | - Mallory A Perry
- Research Institute, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Cody-Aaron Gathers
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jessica C Fowler
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Nadir Yehya
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, PA, USA
| |
Collapse
|
6
|
Pediatric Severe Sepsis and Shock in Three Asian Countries: A Retrospective Study of Outcomes in Nine PICUs. Pediatr Crit Care Med 2021; 22:713-721. [PMID: 33729727 DOI: 10.1097/pcc.0000000000002680] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Pediatric sepsis remains a major health problem and is a leading cause of death and long-term disability worldwide. This study aims to characterize epidemiologic, therapeutic, and outcome features of pediatric severe sepsis and septic shock in three Asian countries. DESIGN A multicenter retrospective study with longitudinal clinical data over 1, 6, 24, 48, and 72 hours of PICU admission. The primary outcome was PICU mortality. Multivariable logistic regression analysis was used to identify factors at PICU admission that were associated with mortality. SETTING Nine multidisciplinary PICUs in three Asian countries. PATIENTS Children with severe sepsis or septic shock admitted to the PICU from January to December 2017. INTERVENTION None. MEASUREMENT AND MAIN RESULTS A total of 271 children were included in this study. Median (interquartile range) age was 4.2 years (1.3-10.8 yr). Pneumonia (77/271 [28.4%]) was the most common source of infection. Majority of patients (243/271 [90%]) were resuscitated within the first hour, with fluid bolus (199/271 [73.4%]) or vasopressors (162/271 [59.8%]). Fluid resuscitation commonly took the form of normal saline (147/199 [74.2%]) (20 mL/kg [10-20 mL/kg] over 20 min [15-30 min]). The most common inotrope used was norepinephrine 81 of 162 (50.0%). Overall PICU mortality was 52 of 271 (19.2%). Improved hemodynamic variables (e.g., heart rate, blood pressure, and arterial lactate) were seen in survivors within 6 hours of admission as compared to nonsurvivors. In the multivariable model, admission severity score was associated with PICU mortality. CONCLUSIONS Mortality from pediatric severe sepsis and septic shock remains high in Asia. Consistent with current guidelines, most of the children admitted to these PICUs received fluid therapy and inotropic support as recommended.
Collapse
|
7
|
Mitchell HK, Reddy A, Montoya-Williams D, Harhay M, Fowler JC, Yehya N. Hospital outcomes for children with severe sepsis in the USA by race or ethnicity and insurance status: a population-based, retrospective cohort study. THE LANCET. CHILD & ADOLESCENT HEALTH 2021; 5:103-112. [PMID: 33333071 PMCID: PMC9020885 DOI: 10.1016/s2352-4642(20)30341-2] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 10/02/2020] [Accepted: 10/08/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Disparities in outcomes of adult sepsis are well described by insurance status and race and ethnicity. There is a paucity of data looking at disparities in sepsis outcomes in children. We aimed to determine whether hospital outcomes in childhood severe sepsis were influenced by race or ethnicity and insurance status, a proxy for socioeconomic position. METHODS This population-based, retrospective cohort study used data from the 2016 database release from the Healthcare Cost and Utilization Project Kids' Inpatient Database (KID). The 2016 KID included 3 117 413 discharges, accounting for 80% of national paediatric discharges from 4200 US hospitals across 47 states. Using multilevel logistic regression, clustered by hospital, we tested the association between race or ethnicity and insurance status and hospital mortality, adjusting for individual-level and hospital-level characteristics, in children with severe sepsis. The secondary outcome of length of hospital stay was examined through multilevel time to event (hospital discharge) regression, with death as a competing risk. FINDINGS 12 297 children (aged 0-21 years) with severe sepsis with or without shock were admitted to 1253 hospitals in the 2016 KID dataset. 1265 (10·3%) of 12 297 patients did not have race or ethnicity data recorded, 15 (0·1%) were missing data on insurance, and 1324 (10·8%) were transferred out of hospital, resulting in a final cohort of 9816 children. Black children had higher odds of death than did White children (adjusted odds ratio [OR] 1·19, 95 % CI 1·02-1·38; p=0·028), driven by higher Black mortality in the south (1·30, 1·04-1·62; p=0·019) and west (1·58, 1·05-2·38; p=0·027) of the USA. We found evidence of longer hospital stays for Hispanic children (adjusted hazard ratio 0·94, 95% CI 0·88-1·00; p=0·049) and Black children (0·88, 0·82-0·94; p=0·0002), particularly Black neonates (0·53, 95% CI 0·36-0·77; p=0·0011). We observed no difference in survival between publicly and privately insured children; however, other insurance status (self-pay, no charge, and other) was associated with increased mortality (adjusted OR 1·30, 95% CI 1·04-1·61; p=0·021). INTERPRETATION In this large, representative analysis of paediatric severe sepsis in the USA, we found evidence of outcome disparities by race or ethnicity and insurance status. Our findings suggest that there might be differential sepsis recognition, approaches to treatment, access to health-care services, and provider bias that contribute to poorer sepsis outcomes for racial and ethnic minority patients and those of lower socioeconomic position. Studies are warranted to investigate the mechanisms of poorer sepsis outcomes in Black and Hispanic children. FUNDING None.
Collapse
Affiliation(s)
- Hannah K Mitchell
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| | - Anireddy Reddy
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - Michael Harhay
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA; Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA; Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Jessica C Fowler
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Nadir Yehya
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| |
Collapse
|
8
|
Sader HS, Castanheira M, Streit JM, Carvalhaes CG, Mendes RE. Frequency and antimicrobial susceptibility of bacteria causing bloodstream infections in pediatric patients from United States (US) medical centers (2014-2018): therapeutic options for multidrug-resistant bacteria. Diagn Microbiol Infect Dis 2020; 98:115108. [PMID: 32640386 DOI: 10.1016/j.diagmicrobio.2020.115108] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 06/01/2020] [Accepted: 06/06/2020] [Indexed: 11/19/2022]
Abstract
Studies evaluating large series of pediatric patients with bloodstream infections (BSIs) are scarce. We evaluated the frequency and antimicrobial susceptibility of organisms isolated from pediatric patients with BSI and therapeutic options for BSI caused by multidrug-resistant (MDR) organisms. A total of 2423 organisms were consecutively collected from 33 US medical centers between 2014 and 2018, and susceptibility was tested by reference broth microdilution methods. Isolates with an extended-spectrum β-lactamase phenotype were screened for β-lactamase genes. Overall, 40.2% of organisms were Gram-negative bacteria, 57.0% Gram-positives, and 2.8% Candida spp. The 5 most common organisms were Staphylococcus aureus (26.0%), Escherichia coli (13.0%), coagulase-negative staphylococci (8.3%), Enterococcus faecalis (7.1%), and Klebsiella pneumoniae (6.9%). Among S. aureus, 26.0% were oxacillin-resistant and 99.8% were susceptible to ceftaroline (MIC50/90, 0.25/0.5 mg/L). Enterobacterales and Pseudomonas aeruginosa isolates combined represented >85% of Gram-negative bacteria, and all isolates (100.0%) were susceptible to ceftazidime-avibactam.
Collapse
|