Prevalence and Management of Septic Shock among Children Admitted at the Kenyatta National Hospital, Longitudinal Survey

Sex Differences in Pediatric Sepsis Mortality: A Systematic Review and Meta-Analysis

OBJECTIVES

Pediatric sepsis remains a leading cause of childhood mortality worldwide. Sex differences have been shown to modify risk factors, treatment, and outcome of various diseases, and adult studies revealed sex differences in pathophysiological responses to septic shock. We aimed to perform a systematic review and meta-analysis on the association of sex with outcomes in hospitalized children with sepsis.

DATA SOURCES

Medline and Embase databases were searched for studies of children < 18 years with sepsis published between January 01, 2005, and March 31, 2022.

STUDY SELECTION

We included cohort studies, and randomized controlled trials in children greater than or equal to 37-week-old postconception to 18 years which included sepsis, severe sepsis or septic shock, and mortality as an outcome.

DATA EXTRACTION

Study characteristics, patient demographics, and illness severity scores were extracted from eligible articles. Random-effects meta-analysis was performed.

DATA SYNTHESIS

We screened 14,791 studies, with 912 full-text reviews and inclusion of 124 studies. The total population involved 426,163 patients, of which 47% (201,438) were girls. Meta-regression showed moderate evidence for a higher mortality in boys compared with girls. The estimated risk difference of mortality between boys and girls with all types of sepsis was -0.005 (95% CI, -0.0099 to -0.00001; p = 0.049), indicating slightly higher mortality for boys. When including the World Bank income level as a moderator, the effect was -0.008 (95% CI, -0.013 to -0.002; p = 0.005).

CONCLUSIONS

This large systematic review and meta-analysis on sex differences in pediatric sepsis mortality showed moderate evidence for a higher sepsis mortality in boys compared with girls. The effect persisted when adjusting for country's income level.

Application of a sepsis flow chip (SFC) assay for the molecular diagnosis of paediatric sepsis

A delay in detecting sepsis pathogens is a problematic issue for determining definitive antibiotic therapy for the causative pathogens. The gold standard method for sepsis is blood culture but this requires 3 days to detect the definitive pathogen. Molecular methods offer rapid identification of pathogens. We evaluated the use of sepsis flow chip (SFC) assay for identifying pathogens from children with sepsis. Blood samples from children with sepsis were collected and incubated in a culture device. Positive samples were subjected to amplification-hybridization using SFC assay and culture. A total of 94 samples from 47 patients were recovered, from which 25 isolates were recovered, including Klebsiella pneumoniae (11) and Staphylococcus epidermidis (6). From 25 positive blood culture bottles subjected to SFC assay, 24 genus/species and 18 resistance genes were detected. The sensitivity, specificity and conformity was 80, 94.2 and 94.68 % respectively. SFC assay offers promise to identify pathogens from positive blood culture in paediatric patients with sepsis and may support the antimicrobial stewardship programme in hospitals.

Management of septic shock by pediatric residents: An area for quality improvement

BACKGROUND

Compliance with sepsis guidelines has been shown to be linked to better outcomes in patients with septic shock; however, adherence to these guidelines is not consistent among pediatric healthcare providers. In Tunisia, the management of children with septic shock is initiated by the pediatric resident on call.

METHODS

This study assessed the compliance of Tunisian pediatric residents with the 2020 "Surviving Sepsis Campaign" guidelines and identified factors that could improve compliance. We conducted a cross-sectional national study based on an online survey (SurveyMonkey) presenting a clinical pediatric case of septic shock. The survey was sent to the 200 residents registered in the Tunisian pediatric residency program.

RESULTS

The response rate was 72%, with 144 residents replying to the survey. Up to 72.9% of the residents had good compliance with the 1-h bundle: obtaining blood cultures prior to antibiotics, early administration of intravenous (IV) antibiotics, IV fluid expansion, and vasopressor for fluid-refractory septic shock. Factors independently associated with good compliance were a pediatric intensive care unit rotation (odds ratio [OR]: 5.17, 95% confidence interval [CI]: 1.44-18.58; p = 0.012), availability of a written protocol (OR: 9.09, 95% CI: 2.67-30.97; p<0.001), an on-call senior supervisor on site (OR: 6.76, 95% CI: 2.24-20.40; p = 0.001), and European Pediatric Advanced Life Support (EPALS) certification (OR: 13.47, 95% CI: 3.05-59.31; p = 0.001).

CONCLUSION

These factors could be considered in the process of a quality improvement strategy that ultimately better promotes performance in pediatric sepsis management and may improve patient outcomes.

Epidemiology and treatment of sepsis at a public pediatric emergency department

Objective

To describe the clinical characteristics and treatment of children with sepsis, severe sepsis, and septic shock at a pediatric emergency department of a public hospital.

Methods

A retrospective, observational study. The medical records of patients included in the hospital Pediatric Sepsis Protocol and patients with discharge ICD-10 A41.9 (sepsis, unspecified), R57 (shock) and A39 (meningococcal meningitis) were evaluated.

Results

A total of 399 patients were included. The prevalence of sepsis, severe sepsis, and septic shock at the emergency room were 0.41%, 0.14% and 0.014%, respectively. The median age was 21.5 months for sepsis, 12 months for severe sepsis, and 20.5 months for septic shock. Sepsis, severe sepsis, and septic shock were more often associated with respiratory diseases. The Respiratory Syncytial Virus was the most common agent. The median time to antibiotic and fluid administration was 3 hours in patients with sepsis and severe sepsis. In patients with septic shock, the median times to administer antibiotics, fluid and vasoactive drugs were 2 hours, 2.5 hours and 6 hours, respectively. The median length of hospital stay for patients with sepsis, severe sepsis and septic shock were 3 days, 4 days and 1 day, respectively. The overall mortality was 2%.

Conclusion

Sepsis had a low prevalence. Early diagnosis and recognition are a challenge for the emergency care pediatrician, the first place of admission.

Patterns, Outcomes and Predictors of Pediatric Medical Admissions at Gadarif Hospital in Eastern Sudan

BACKGROUND

The reduction of childhood mortality is a reliable indicator of a national health system's progress and improvement. Sudan's population is still suffering from communicable diseases, with a considerably higher mortality rate among children. Efforts are therefore needed to reduce mortality and achieve the Millennium Development Goals and Sustainable Development Goals. This study was conducted to determine the morbidity, mortality and outcomes of children admitted to Gadarif Hospital in eastern Sudan.

METHOD

A retrospective study was conducted by reviewing the medical files of pediatric patients who were admitted to Gadarif Hospital between March 1, 2019 and March 31, 2020.

RESULT

A total of 740 medical files were reviewed. Most, 453 (61.2%) of the admissions were males. The median (interquartile range) age was 3.0 (8.0) years and 433 (58.8%) of the admissions were under 5 years of age. The median (interquartile range) of the length of hospital stay was 9.0 (12.0) days. Visceral leishmaniasis, malnutrition, severe malaria, sickle cell disease, acute watery diarrhea, severe anemia (regardless of its cause), septicemia and acute respiratory infection were the most common causes of admission. The mortality rate was 5.7%, and it was significantly higher in females than males [24/287 (8.4%) vs. 18/453 (4.0%), P = 0.01] and in children under 5 years [36/433 (8.3%) vs. 6/307 (2.0%), P < 0.001]. Malnutrition, visceral leishmaniasis, septicemia and meningitis/encephalitis were the main diseases causing death in the study population. The case fatality rate was not significantly different in malnutrition than in visceral leishmaniasis [9/93 (9.7%) vs. 7/178 (3.9%), P = 0.05].

CONCLUSION

The main causes of morbidity and mortality for children admitted to Gadarif Pediatric Hospital were communicable diseases. The mortality rate was 5.7%. Females and children under 5 years were the most vulnerable groups for fatality.

Socio-demographic characteristics and pre-hospital care of children with circulatory failure in a children's emergency room in southern Nigeria

Introduction

circulatory failure is a major childhood emergency. Several disease-related and patient-related factors can predispose children to shock. Early detection of such factors will improve its prevention, management and outcome. This study aimed to evaluate the incidence, socio-demographic characteristics and pre-hospital care of children presenting with circulatory failure (shock) in children´s emergency room (CHER).

Methods

this study adopted cross-sectional design in CHER of the University of Benin Teaching Hospital, Nigeria, from October 2018 to March 2019. Data were collected using a semi-structured questionnaire eliciting demography, socio-economic status, pre-hospital care and presence of shock. In a sub-analysis, multiple logistic regression identified variables that are independently associated with circulatory failure in the participants, using adjusted odds ratio (OR) and 95% confidence intervals (CI).

Results

a total of 554 acutely-ill children participated in the study. Their median age was 60 (IQR: 24-132) months. Shock was present in 79 (14.3%) of the children on arrival at CHER. Children referred from private clinics were more likely to arrive CHER in shock compared to those coming directly from home (OR = 2.67, 95%CI: 1.07-6.69; p = 0.036) while children from lower socio-economic class families presented more frequently with shock than those from higher class (OR = 14.39, 95% CI: 2.61-79.44; p = 0.002). Also, children that received oral rehydration solution as pre-hospital care seemed more likely to present with shock in CHER (OR = 6.63, 95% CI: 2.15-20.46; p =0.001).

Conclusion

quality of pre-hospital care and parental socio-economic status influence the presence of shock in children seen at the emergency unit. Focused health education and prevention of finance-related delays in emergency care are needed.

Sex and Gender Appraisal Tool-Systematic Reviews-2 and Participation-To-Prevalence Ratio assessed to whom the evidence applies in sepsis reviews

OBJECTIVES

To revise a sex and gender appraisal tool for systematic reviews (SGAT-SR) and apply it to Cochrane sepsis reviews.

STUDY DESIGN AND SETTING

The revision process was informed by existing literature on sex, gender, intersectionality, and feedback from an expert advisory board. We revised the items to consider additional factors associated with health inequities and appraised sex and gender considerations using the SGAT-SR-2 and female Participation-to-Prevalence Ratio (PPR) in Cochrane sepsis reviews.

RESULTS

SGAT-SR-2 consists of 19 questions appraising the review's sections and use of the terms sex and gender. amongst 71 SRs assessed, 50.7% included at least one tool item, the most frequent being the number of participants by sex or gender at included study-level (24/71 reviews). Only four reviews provided disaggregated data for the full set of included trials, while two considered other equity-related factors. Reviews rarely appraised possible similarities and differences across sex and gender. In half of a subset of reviews, female participants were under-represented relative to their share of the sepsis population (PPR<0.8).

CONCLUSION

The SGAT-SR-2 tool and the PPR can support the design and appraisal of systematic reviews to assess sex and gender considerations, address to whom evidence applies, and determine future research needs.

Barriers and Proposed Solutions to a Successful Implementation of Pediatric Sepsis Protocols

The implementation of managed protocols contributes to a systematized approach to the patient and continuous evaluation of results, focusing on improving clinical practice, early diagnosis, treatment, and outcomes. Advantages to the adoption of a pediatric sepsis recognition and treatment protocol include: a reduction in time to start fluid and antibiotic administration, decreased kidney dysfunction and organ dysfunction, reduction in length of stay, and even a decrease on mortality. Barriers are: absence of a written protocol, parental knowledge, early diagnosis by healthcare professionals, venous access, availability of antimicrobials and vasoactive drugs, conditions of work, engagement of healthcare professionals. There are challenges in low-middle-income countries (LMIC). The causes of sepsis and resources differ from high-income countries. Viral agent such as dengue, malaria are common in LMIC and initial approach differ from bacterial infections. Some authors found increased or no impact in mortality or increased length of stay associated with the implementation of the SCC sepsis bundle which reinforces the importance of adapting it to most frequent diseases, disposable resources, and characteristics of healthcare professionals. Conclusions: (1) be simple; (2) be precise; (3) education; (5) improve communication; (5) work as a team; (6) share and celebrate results.

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.