Decline in sepsis-associated neonatal and infant deaths in the United States, 1979 through 1994

A biological approach to adult sex differences in skeletal indicators of childhood stress

OBJECTIVES

In previous work examining the etiology of cribra orbitalia (CO) and porotic hyperostosis (PH) in a contemporary juvenile mortality sample, we noted that males had higher odds of having CO lesions than females. Here, we examine potential reasons for this pattern in greater detail. Four non-mutually exclusive mechanisms could explain the observed sex differences: (1) sex-biased mortality; (2) sexual dimorphism in immune responses; (3) sexual dimorphism in bone turnover; or (4) sexual dimorphism in marrow conversion.

SUBJECTS AND METHODS

The sample consists of postmortem computed tomography scans and autopsy reports, field reports, and limited medical records of 488 individuals from New Mexico (203 females; 285 males) aged between 0.5 and 15 years. We used Kaplan-Meier survival analysis, predicted probabilities, and odds ratios to test each mechanism.

RESULTS

Males do not have lower survival probabilities than females, and we find no indications of sex differences in immune response. Overall, males have a higher probability of having CO or PH lesions than females.

CONCLUSIONS

All results indicate that lesion formation in juveniles is influenced by some combination of sex differences in the pace of red-yellow conversion of the bone marrow and bone turnover. The preponderance of males with CO and PH likely speaks to the potential for heightened osteoblastic activity in males. We find no support for the hypotheses that sex biases in mortality or immune responses impacted lesion frequency in this sample. Sex differences in biological processes experienced by children may affect lesion formation and lesion expression in later life.

Long-Term Outcomes and the Post-Intensive Care Syndrome in Critically Ill Children: A North American Perspective

Advances in medical and surgical care for children in the pediatric intensive care unit (PICU) have led to vast reductions in mortality, but survivors often leave with newly acquired or worsened morbidity. Emerging evidence reveals that survivors of pediatric critical illness may experience a constellation of physical, emotional, cognitive, and social impairments, collectively known as the “post-intensive care syndrome in pediatrics” (PICs-P). The spectrum of PICs-P manifestations within each domain are heterogeneous. This is attributed to the wide age and developmental diversity of children admitted to PICUs and the high prevalence of chronic complex conditions. PICs-P recovery follows variable trajectories based on numerous patient, family, and environmental factors. Those who improve tend to do so within less than a year of discharge. A small proportion, however, may actually worsen over time. There are many gaps in our current understanding of PICs-P. A unified approach to screening, preventing, and treating PICs-P-related morbidity has been hindered by disparate research methodology. Initiatives are underway to harmonize clinical and research priorities, validate new and existing epidemiologic and patient-specific tools for the prediction or monitoring of outcomes, and define research priorities for investigators interested in long-term outcomes.

Early-onset neonatal sepsis: Organism patterns between 2009 and 2014

OBJECTIVE

To evaluate trends in organisms causing early-onset neonatal sepsis (EONS). Congruent with recent reports, we hypothesized there would be an increase in EONS caused by Escherichia coli.

STUDY DESIGN

National data on infants admitted to neonatal intensive care units from 2009 to 2014 were compared to previously reported data from 2003 to 2008. We report 430 cases of EONS from 2009 to 2014. Bivariate analyses were used to analyze the distribution of causative organisms over time and differences by gestational age. Linear regression was used to estimate trends in causative organisms.

RESULTS

Since 2003, there has been a trend of increasing numbers of cases caused by E coli (P<0.01). The predominant organism was E coli in preterm infants and Group B Streptococcus in term infants.

CONCLUSIONS

With the majority of EONS cases now caused by E coli, our findings emphasize the importance of continued surveillance of causative organism patterns and developing approaches to reduce cases caused by E coli.

Challenges in developing a consensus definition of neonatal sepsis

Sepsis remains a leading cause of morbidity and mortality in the neonatal population, and at present, there is no unified definition of neonatal sepsis. Existing consensus sepsis definitions within paediatrics are not suited for use in the NICU and do not address sepsis in the premature population. Many neonatal research and surveillance networks have criteria for the definition of sepsis within their publications though these vary greatly and there is typically a heavy emphasis on microbiological culture. The concept of organ dysfunction as a diagnostic criterion for sepsis is rarely considered in neonatal literature, and it remains unclear how to most accurately screen neonates for organ dysfunction. Accurately defining and screening for sepsis is important for clinical management, health service design and future research. The progress made by the Sepsis-3 group provides a roadmap of how definitions and screening criteria may be developed. Similar initiatives in neonatology are likely to be more challenging and would need to account for the unique presentation of sepsis in term and premature neonates. The outputs of similar consensus work within neonatology should be twofold: a validated definition of neonatal sepsis and screening criteria to identify at-risk patients earlier in their clinical course. IMPACT: There is currently no consensus definition of neonatal sepsis and the definitions that are currently in use are varied.A consensus definition of neonatal sepsis would benefit clinicians, patients and researchers.Recent progress in adults with publication of Sepsis-3 provides guidance on how a consensus definition and screening criteria for sepsis could be produced in neonatology.We discuss common themes and potential shortcomings in sepsis definitions within neonatology.We highlight the need for a consensus definition of neonatal sepsis and the challenges that this task poses.

American College of Critical Care Medicine Clinical Practice Parameters for Hemodynamic Support of Pediatric and Neonatal Septic Shock

OBJECTIVES

The American College of Critical Care Medicine provided 2002 and 2007 guidelines for hemodynamic support of newborn and pediatric septic shock. Provide the 2014 update of the 2007 American College of Critical Care Medicine "Clinical Guidelines for Hemodynamic Support of Neonates and Children with Septic Shock."

DESIGN

Society of Critical Care Medicine members were identified from general solicitation at Society of Critical Care Medicine Educational and Scientific Symposia (2006-2014). The PubMed/Medline/Embase literature (2006-14) was searched by the Society of Critical Care Medicine librarian using the keywords: sepsis, septicemia, septic shock, endotoxemia, persistent pulmonary hypertension, nitric oxide, extracorporeal membrane oxygenation, and American College of Critical Care Medicine guidelines in the newborn and pediatric age groups.

MEASUREMENTS AND MAIN RESULTS

The 2002 and 2007 guidelines were widely disseminated, translated into Spanish and Portuguese, and incorporated into Society of Critical Care Medicine and American Heart Association/Pediatric Advanced Life Support sanctioned recommendations. The review of new literature highlights two tertiary pediatric centers that implemented quality improvement initiatives to improve early septic shock recognition and first-hour compliance to these guidelines. Improved compliance reduced hospital mortality from 4% to 2%. Analysis of Global Sepsis Initiative data in resource rich developed and developing nations further showed improved hospital mortality with compliance to first-hour and stabilization guideline recommendations.

CONCLUSIONS

The major new recommendation in the 2014 update is consideration of institution-specific use of 1) a "recognition bundle" containing a trigger tool for rapid identification of patients with septic shock, 2) a "resuscitation and stabilization bundle" to help adherence to best practice principles, and 3) a "performance bundle" to identify and overcome perceived barriers to the pursuit of best practice principles.

Drotrecogin Alfa (Activated) in an Infant with Gram-Negative Septic Shock

The authors observed the effect of drotrecogin alfa (activated) in a case of pediatric severe sepsis. A 4-month-old male infant with Serratia marcescens septic shock, multiple organ dysfunction syndrome (MODS), and consumptive coagulopathy was admitted. The safety and efficacy of drotrecogin alfa (activated) has not yet been established for patients younger than 18 years of age. This is the first published report of the use of drotrecogin alfa (activated) in an infant with severe sepsis. Within 6 hours of starting therapy, there was a significant improvement in hemodynamics, which was not maintained after the drotrecogin alfa (activated) infusion was temporarily discontinued. No significant bleeding complications occurred during the infusion. A brain MRI on day 22 after drotrecogin alfa (activated) infusion showed bilateral small occipital hemorrhages. Drotrecogin alfa (activated) in this infant was temporally related to significant improvement. It is unknown whether the MRI brain lesions are related to severe sepsis with disseminated intravascular coagulation or drotrecogin alfa (activated) infusion. The authors believe that drotrecogin alfa (activated) should be considered in select children with life-threatening severe sepsis.

Identification of Risk Factors for Elevated Neonatal Gentamicin Trough Concentrations

OBJECTIVES: The objective of this study was to identify neonatal and maternal characteristics that may be associated with elevated neonatal gentamicin trough concentrations despite application of a previously published gentamicin dosage strategy.

METHODS: Retrospective cohort study of all neonates admitted to University of Vermont Medical Center (562-bed academic teaching hospital, Burlington, VT) receiving gentamicin between June 1, 2009, and August 31, 2013. A total of 205 neonates were included, with 41 cases and 164 controls.

RESULTS: Postmenstrual age (PMA, gestational age plus chronological age) and small-for–gestational age (SGA) status were independently associated with elevated neonatal gentamicin trough concentrations. No maternal risk factor evaluated remained significantly associated in the multivariate analysis.

CONCLUSIONS: The probability of an elevated gentamicin trough concentration increases with lower PMA and is further accentuated in neonates with SGA status. In contrast, the presence of maternal risk factors did not increase the likelihood of elevated gentamicin trough concentrations. Neonates with lower PMA and SGA status may require an individualized dosage and monitoring strategy.

Vitamin-D status is not a confounder of the relationship between zinc and diarrhoea: a study in 6-24-month-old underweight and normal-weight children of urban Bangladesh

BACKGROUND/OBJECTIVE

The role of micronutrients particularly zinc in childhood diarrhoea is well established. Immunomodulatory functions of vitamin-D in diarrhoea and its role in the effect of other micronutrients are not well understood. This study aimed to investigate whether vitamin-D directly associated or confounded the association between other micronutrient status and diarrhoeal incidence and severity in 6-24-month underweight and normal-weight children in urban Bangladesh.

SUBJECTS/METHODS

Multivariable generalised estimating equations were used to estimate incidence rate ratios for incidence (Poisson) and severity (binomial) of diarrhoea on cohorts of 446 normal-weight and 466 underweight children. Outcomes of interest included incidence and severity of diarrhoea, measured daily during a follow-up period of 5 months. The exposure of interest was vitamin-D status at enrolment.

RESULTS

Normal-weight and underweight children contributed 62 117 and 62 967 day observation, with 14.2 and 12.8 days/child/year of diarrhoea, respectively. None of the models showed significant associations of vitamin-D status with diarrhoeal morbidity. In the final model, zinc-insufficient normal-weight children had 1.3 times more days of diarrhoea than sufficient children (P<0.05). Again zinc insufficiency and mother's education (1-5 and >5 years) had 1.8 and 2.3 times more risk of severe diarrhoea. In underweight children, older age and female had 24-63 and 17% fewer days of diarrhoea and 52-54 and 31% fewer chances of severe diarrhoea.

CONCLUSION

Vitamin-D status was not associated with incidence and severity of diarrhoea in study children. Role of zinc in diarrhoea was only evident in normal-weight children. Our findings demonstrate that vitamin-D is not a confounder of the relationship between zinc and diarrhoea.

Prolonged suppression of monocytic human leukocyte antigen-DR expression correlates with mortality in pediatric septic patients in a pediatric tertiary Intensive Care Unit

INTRODUCTION

Immunoparalysis is a syndrome with no clinical symptoms that occurs in some septic patients. Monocytic human leukocyte antigen-DR (mHLA-DR) expression has been used to identify patients in immunoparalysis and prolonged periods of reduced mHLA-DR expression have been correlated with a poor prognosis in sepsis. However, there is a lack of studies investigating mHLA-DR expression in pediatric septic patients.

AIM

To determine if mHLA-DR expression correlates with mortality in pediatric septic patients using the QuantiBRITE Anti HLA-DR/Anti-Monocyte,a Bechton Dickinson novel reagent that standardizes flow cytometry values.

METHODS

We determined mHLA-DR expression in 30 patients with severe sepsis or septic shock admitted to the pediatric intensive care unit at Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil, between January 2013 and February 2015. mHLA-DR expression was quantified between days 3 to 5 and 5 to 7 after the onset of sepsis and the ΔmHLA-DR (mHLA-DR2 - mHLA-DR1) was calculated. We also measured mHLA-DR levels in 21 healthy control patients.

RESULTS

Mean mHLA-DR expression was significantly lower in septic patients than in controls (P = .0001). Mortality was 46% in patients with negative ΔHLA-DR or <1000 mAb/cell and 7% in patients with positive ΔHLA-DR or >1000 mAb/cell. Mean ΔmHLA-DR levels were significantly different between survivors and non-survivors (P = .023).

CONCLUSION

ΔHLA-DR correlates with mortality in pediatric patients with septic shock or severe sepsis. This is the first study to have used the QuantiBRITE Anti HLA-DR/Anti-Monocyte reagent to quantify monocyte HLA-DR expression in pediatric septic patients.

Socioeconomic position, health behaviors, and racial disparities in cause-specific infant mortality in Michigan, USA

OBJECTIVES

Studies about racial disparities in infant mortality suggest that racial differences in socioeconomic position (SEP) and maternal risk behaviors explain some, but not all, excess infant mortality among Blacks relative to non-Hispanic Whites. We examined the contribution of these to disparities in specific causes of infant mortality.

METHODS

We analyzed data about 2,087,191 mother-child dyads in Michigan between 1989 and 2005. First, we calculated crude Black-White infant mortality ratios independently and by specific cause of death. Second, we fit multivariable Poisson regression models of infant mortality, overall and by cause, adjusting for SEP and maternal risk behaviors. Third, Crude Black-White mortality ratios were compared to adjusted predicted probability ratios, overall and by specific cause.

RESULTS

SEP and maternal risk behaviors explained nearly a third of the disparity in infant mortality overall, and over 25% of disparities in several specific causes including homicide, accident, sudden infant death syndrome, and respiratory distress syndrome. However, SEP and maternal risk behaviors had little influence on disparities in other specific causes, such as septicemia and congenital anomalies.

CONCLUSIONS

These findings help focus policy attention toward disparities in those specific causes of infant mortality most amenable to social and behavioral intervention, as well as research attention to disparities in specific causes unexplained by SEP and behavioral differences.

Timing of death in children referred for intensive care with severe sepsis: implications for interventional studies

OBJECTIVE

Early deaths in pediatric sepsis may limit the impact of therapies that can only be provided on PICUs. By introducing selection and survivorship biases, these very early deaths may also undermine the results of trials that employ standard consent procedures. We hypothesized that: 1) the majority of deaths in children with severe sepsis occur very early, within 24 hours of referral to PICU; and 2) a significant proportion of deaths occur before PICU admission.

DESIGN, SETTING, AND PATIENTS

We studied consecutive referrals of newborns through to 16 years of age, between 2005 and 2011 to the Children's Acute Transport Service, the North Thames regional pediatric intensive care transport service, with a working diagnosis of "sepsis," "severe sepsis," "meningococcal sepsis," or "septic shock."

INTERVENTIONS

The primary outcome measure was the proportion of deaths within 24 hours of referral. Survival distributions of previously healthy children were compared with those with significant comorbidities.

MEASUREMENTS AND MAIN RESULTS

Thirteen thousand four hundred and nine referrals were made to Children's Acute Transport Service, of whom 703 (5%) met inclusion criteria. Data on survival to 1 year were available in 627 of 703 patients (89%). One hundred thirty children (130/627; 21%; 95% CI, 18-24%) died in the first year. A higher proportion of children with comorbidity cases (46/85, 54%, 44-64) died compared with previously healthy cases (84/542; 16%; 13-19; p < 0.0005, Fisher exact test). Seventy-one deaths occurred within 24 hours of PICU referral (71/130, 55%, 46-63). The timing of death differed with comorbidity. Similar proportions of children survived to 24 hours (previously healthy children 90% vs children with comorbidity 83%, p = 0.06). However, deaths after 24 hours were infrequent among previously healthy cases (28/84 deaths, 33%, 24-44%) compared with children with comorbidity cases (31/46 deaths, 66%, 53-79%) (p < 0.001, Fisher exact test).

CONCLUSIONS

This majority of deaths among children referred for pediatric intensive care with for severe sepsis occur within 24 hours. This has important implications for future clinical trials and quality improvement initiatives aimed at improving sepsis outcomes.

Alarmins MRP8 and MRP14 induce stress tolerance in phagocytes under sterile inflammatory conditions

Hyporesponsiveness by phagocytes is a well-known phenomenon in sepsis that is frequently induced by low-dose endotoxin stimulation of Toll-like receptor 4 (TLR4) but can also be found under sterile inflammatory conditions. We now demonstrate that the endogenous alarmins MRP8 and MRP14 induce phagocyte hyporesponsiveness via chromatin modifications in a TLR4-dependent manner that results in enhanced survival to septic shock in mice. During sterile inflammation, polytrauma and burn trauma patients initially present with high serum concentrations of myeloid-related proteins (MRPs). Human neonatal phagocytes are primed for hyporesponsiveness by increased peripartal MRP concentrations, which was confirmed in murine neonatal endotoxinemia in wild-type and MRP14(-/-) mice. Our data therefore indicate that alarmin-triggered phagocyte tolerance represents a regulatory mechanism for the susceptibility of neonates during systemic infections and sterile inflammation.

Prognostic factors in pediatric sepsis study, from the Spanish Society of Pediatric Intensive Care

BACKGROUND

Sepsis and septic shock represent up to 30% of admitted patients in pediatric intensive care units, with a mortality that can exceed 10%. The objective of this study is to determine the prognostic factors for mortality in sepsis.

METHODS

Multicenter prospective descriptive study with patients (aged 7 days to 18 years) admitted to the pediatric intensive care units for sepsis, between January 2011 and April 2012.

RESULTS

Data from 136 patients were collected. Eighty-seven were male (63.9%). The median age was a year and a half (P25-75 0.3-5.5 years). In 41 cases (30.1%), there were underlying diseases. The most common etiology was Neisseria meningitidis (31 cases, 22.8%) followed by Streptococcus pneumoniae (16 patients, 11.8%). Seventeen cases were fatal (12.5%). In the statistical analysis, the factors associated with mortality were nosocomial infection (P = 0.004), hypotension (P <0.001) and heart and kidney failure (P < 0.001 and P = 0.004, respectively). The numbers of leukocytes, neutrophils and platelets on admission were statistically lower in the group that died (P was 0.006, 0.013 and <0.001, respectively). Multivariate analysis showed that multiple organ failure, neutropenia, purpura or coagulopathy and nosocomial infection were independent risk factors for increased mortality (odds ratio: 17, 4.9, 9 and 9.2, respectively).

CONCLUSIONS

Patients with sepsis and multiorgan failure, especially those with nosocomial infection or the presence of neutropenia or purpura, have a worse prognosis and should be monitored and treated early.

Pediatric sepsis: preparing for the future against a global scourge

Sepsis is a leading cause of morbidity and mortality among children worldwide. As consensus statements emerge regarding early recognition and goal-directed management of sepsis, scrutiny should be given to the unique characteristics of sepsis in children. Pediatric patients are not small adults! Sepsis epidemiology, pathophysiology, and management strategy can vary significantly from those for adults. Herein, we describe the epidemiology of pediatric sepsis, in both resource-rich and resource-poor worlds, and discuss how the pathophysiology of pediatric sepsis differs from that for adults. We discuss the timeline of management of pediatric sepsis, studying how discoveries over the past 50 years have changed the way sepsis is treated. Finally, we discuss the future of pediatric sepsis. We focus on approaches that carry the most substantive impact on the global burden of disease.

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

OBJECTIVES

In 2002, the Surviving Sepsis Campaign pointed out the need to recognize sepsis as an important cause of death and high economic and social costs. There are few epidemiologic studies of this disease in pediatrics and none in Colombia. The objective of this study was to describe the sociodemographic and clinical characteristics of patients with sepsis who were admitted at participating pediatric intensive care units.

DESIGN

Prospective study.

SETTING AND PATIENTS

A Web site, http://www.sepsisencolombia.com, was created, in which 19 pediatric intensive care units from the ten principal cities in the country reported epidemiologic data about patients with sepsis between March 1, 2009, and February 28, 2010.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

There were 1,051 patients. Of these, 55% were male. Fifty-six percent came from urban areas. Fifty-six percent were <2 yrs of age. Seventy-six percent belonged to a low socioeconomic strata and 44% received government-subsidized health insurance. Forty-eight percent of patients had septic shock, 25% severe sepsis, and 27% sepsis. Forty-three percent were diagnosed with multiple organ dysfunction syndrome. In 54%, the infection was of respiratory origin followed by the abdomen as the site of origin in 18% of the patients. In almost 50%, the etiological agent was detected with Gram-negative bacteria being the most frequent and of highest mortality. Fifty percent had some type of relevant pathologic antecedent. Eleven percent had an invasive device on admission. Sixty-eight percent of the patients required mechanical ventilation. Mortality rate was 18%. The most important risk factors for mortality were age under 2 yrs, presence of shock or multiple organ dysfunction syndrome, and presence of Gram-negative bacteria.

CONCLUSIONS

Sepsis is common in Colombian pediatric intensive care units. Clear risk factors for getting sick and dying from this disease were identified. Mortality resulting from this disease is considerable for a developing society like ours.

Recombinant human activated protein C for severe sepsis in neonates

BACKGROUND

Sepsis is a common problem in preterm and term infants. The incidence of neonatal sepsis has declined, but mortality remains high. Recombinant human activated protein C (rhAPC) possess a broad spectrum of activity modulating coagulation and inflammation. In septic adults it may reduce mortality, but no significant benefit has been reported in children with severe sepsis.

OBJECTIVES

To determine whether treatment with rhAPC reduces mortality and/or morbidity in neonatal sepsis.

SEARCH METHODS

For this update searches were carried out in May 2011 of the Cochrane Central Register of Controlled Trials (The Cochrane Library), MEDLINE, EMBASE, CINAHL, and abstracts of annual meetings of the Pediatric Academic Societies. Doctoral dissertations, theses and the Science Citation Index for articles on activated protein C were searched. No language restriction was applied.

SELECTION CRITERIA

Randomized or quasi-randomized trials, assessing the efficacy of rhAPC compared to placebo or no intervention as an adjunct to antibiotic therapy of suspected or confirmed severe sepsis in term and preterm infants less than 28 days old. Eligible trials should report at least one of the following outcomes: mortality during initial hospital stay, neurodevelopmental assessment at two years of age or later, length of hospital stay, duration of ventilation, chronic lung disease, periventricular leukomalacia, intraventricular haemorrhage, necrotizing enterocolitis, bleeding, and any other adverse events.

DATA COLLECTION AND ANALYSIS

Review authors were to independently evaluate the articles for inclusion criteria and quality, and abstract information for the outcomes of interest. Differences were to be resolved by consensus. The statistical methods were to include relative risk, risk difference, number needed to treat to benefit or number needed to treat to harm for dichotomous and weighed mean difference for continuous outcomes reported with 95% confidence intervals. A fixed effect model was to be used for meta-analysis. Heterogeneity tests, including the I(2) statistic, were to be performed to assess the appropriateness of pooling the data.

MAIN RESULTS

No eligible trials were identified. In October 2011 rhAPC (Xigris®) was withdrawn from the market by Eli Lilly due to a higher mortality in a trial among adults. Xigris® (DrotAA)( rhAPC) should no longer be used in any age category and the product should be returned to the distributor.

AUTHORS' CONCLUSIONS

Despite the scientific rationale for its use, there is insufficient data to use rhAPC for the management of severe sepsis in newborn infants. Due to the results among adults with lack of efficacy, an increase in bleeding and resulting withdrawal of rhAPC from the market, neonates should not be treated with rhAPC and further trials should not be conducted.

Tumor necrosis factor (TNF) and lymphotoxin-alpha (LTA) single nucleotide polymorphisms: importance in ARDS in septic pediatric critically ill patients

Accumulating evidence indicates that genetic background influences the outcome of sepsis, which despite medical advances continues to be a major cause of morbidity and mortality. This study aimed to evaluate the influence of SNPs LTA +252A>G, TNF-863C>A and TNF-308G>A on susceptibility to sepsis, acute respiratory distress syndrome (ARDS), septic shock and sepsis mortality. A prospective case-control study was carried out in a Brazilian pediatric intensive care unit and included 490 septic pediatric patients submitted to mechanical ventilation and 610 healthy children. No SNP association was found with respect to sepsis susceptibility. Nevertheless, a haplotype was identified that was protective against sepsis (+252A/-863A/-308G; OR=0.65; p=0.03). We further observed protection against ARDS in TNF-308 GA genotype carriers (OR=0.29; p=0.0006) and -308A allele carriers (OR=0.40; p=0.003). In addition, increased risk for ARDS was detectable with the TNF-863 CA genotype (OR=1.83; p=0.01) and the -863A carrier status (OR=1.82; p=0.01). After stratification according to age, this outcome remained significantly associated with the -308GA genotype in infants. Finally, protection against sepsis-associated mortality was found for the TNF-308 GA genotype (OR=0.22; p=0.04). Overall, our findings document a protective effect of the TNF-308 GA genotype for the ARDS and sepsis mortality outcomes, further providing evidence for an increased risk of ARDS associated with the TNF-863 CA genotype. Trial registration (www.clinicaltrials.gov): NCT00792883.

Comparison of the accuracy of neutrophil CD64 and C-reactive protein as a single test for the early detection of neonatal sepsis

Purpose

Early identification of neonatal sepsis is a global issue because of limitations in diagnostic procedures. The objective of this study was to compare the diagnostic accuracy of neutrophil CD64 and C-reactive protein (CRP) as a single test for the early detection of neonatal sepsis.

Methods

A prospective study enrolled newborns with documented sepsis (n=11), clinical sepsis (n=12) and control newborns (n=14). CRP, neutrophil CD64, complete blood counts and blood culture were taken at the time of the suspected sepsis for the documented or clinical group and at the time of venipuncture for laboratory tests in control newborns. Neutrophil CD64 was analyzed by flow cytometry.

Results

CD64 was significantly elevated in the groups with documented or clinical sepsis, whereas CRP was not significantly increased compared with controls. For documented sepsis, CD64 and CRP had a sensitivity of 91% and 9%, a specificity of 83% and 83%, a positive predictive value of 83% and 33% and a negative predictive value of 91% and 50%, respectively, with a cutoff value of 3.0 mg/dL for CD64 and 1.0 mg/dL for CRP. The area under the receiver-operating characteristic curves for CD64 index and CRP were 0.955 and 0.527 (P<0.01), respectively.

Conclusion

These preliminary data show that diagnostic accuracy of CD64 is superior to CRP when measured at the time of suspected sepsis, which implies that CD64 is a more reliable marker for the early identification of neonatal sepsis as a single determination compared with CRP.

Pediatric Sepsis Guidelines: Summary for resource-limited countries

Justification:

Pediatric sepsis is a commonly encountered global issue. Existing guidelines for sepsis seem to be applicable to the developed countries, and only few articles are published regarding application of these guidelines in the developing countries, especially in resource-limited countries such as India and Africa.

Process:

An expert representative panel drawn from all over India, under aegis of Intensive Care Chapter of Indian Academy of Pediatrics (IAP) met to discuss and draw guidelines for clinical practice and feasibility of delivery of care in the early hours in pediatric patient with sepsis, keeping in view unique patient population and limited availability of equipment and resources. Discussion included issues such as sepsis definitions, rapid cardiopulmonary assessment, feasibility of early aggressive fluid therapy, inotropic support, corticosteriod therapy, early endotracheal intubation and use of positive end expiratory pressure/mechanical ventilation, initial empirical antibiotic therapy, glycemic control, and role of immunoglobulin, blood, and blood products.

Objective:

To achieve a reasonable evidence-based consensus on the basis of published literature and expert opinion to formulating clinical practice guidelines applicable to resource-limited countries such as India.

Recommendations:

Pediatric sepsis guidelines are presented in text and flow chart format keeping resource limitations in mind for countries such as India and Africa. Levels of evidence are indicated wherever applicable. It is anticipated that once the guidelines are used and outcomes data evaluated, further modifications will be necessary. It is planned to periodically review and revise these guidelines every 3–5 years as new body of evidence accumulates.

Bacterial isolates of early-onset neonatal sepsis and their antibiotic susceptibility pattern between 1998 and 2004: an audit from a center in India

BACKGROUND

Epidemiology and surveillance of neonatal sepsis helps in implementation of rational empirical antibiotic strategy.

OBJECTIVE

To study the frequency of bacterial isolates of early onset neonatal sepsis (EONS) and their sensitivity pattern.

METHODS

In this retrospective study, a case of EONS was defined as an infant who had clinical signs or born to mothers with potential risk factors for infection, in whom blood culture obtained within 72 hours of life, grew a bacterial pathogen. Blood culture sample included a single sample from peripheral vein or artery. Relevant data was obtained from the unit register or neonatal case records.

RESULTS

Of 2182 neonates screened, there were 389 (17.8%) positive blood cultures. After excluding coagulase-negative Staphylococci (160), we identified 229 EONS cases. Preterm neonates were 40.6% and small for gestational age, 18.3%. Mean birth weight and male to female ratio were 2344.5 (696.9) g and 1.16:1 respectively. Gram negative species represented 90.8% of culture isolates. Pseudomonas (33.2%) and Klebsiella (31.4%) were common among them. Other pathogens included Acinetobacter (14.4%), Staphylococcus aureus (9.2%), E.coli (4.4%), Enterobacter (2.2%), Citrobacter (3.1%) and Enterococci (2.2%). In Gram negative group, best susceptibility was to Amikacin (74.5%), followed by other aminoglycosides, ciprofloxacin and cefotaxime. The susceptibility was remarkably low to ampicillin (8.4%). Gram positive group had susceptibility of 42.9% to erythromycin, 47.6% to ciprofloxacin and above 50% to aminoglycosides. Of all isolates, 83.8% were susceptible to either cefotaxime or amikacin

CONCLUSION

Gram-negative species especially Pseudomonas and Klebsiella were the predominant causative organisms. Initial empirical choice of cefotaxime in combination with amikacin appeared to be rational choice for a given cohort.

Predictors of mortality in neonatal septicemia in an underresourced setting

OBJECTIVE

To determine the predictors of mortality in neonatal septicemia.

METHOD

The records of babies with culture-proven septicemia managed in a Nigerian newborn unit between 2006 and 2008 were studied using bivariate and multivariate analysis.

RESULTS

Out of 174 babies with septicemia, 56 (32.2%) died. Outborn babies, babies with estimated gestational age (EGA) less than 32 weeks, weight less than 1.5 kg, temperature less than 38 degrees C, respiratory distress, abdominal distension, poor skin color, hypoglycemia, and infection with gram-negative pathogens were significantly associated with death by bivariate analysis. Multivariate analysis of these risk factors confirmed that EGA less than 32 weeks (odds ratio [OR], 5.5), respiratory distress (OR, 3.4), abdominal distension (OR, 2.7), poor skin color (OR, 3.3), and hypoglycemia (OR, 5.2) had significant independent contributions to the occurrence of death among babies with culture-proven septicemia.

CONCLUSION

Most of the identified predictors of mortality are modifiable and can be used to draw up a screening tool to determine the clinical severity among septic babies.

Trends in cause-specific mortality at a Canadian outborn NICU

OBJECTIVE

To retrospectively review changes in the causes of death of infants dying in the NICU at Canada's largest outborn pediatric center.

PATIENTS AND METHODS

All inpatient deaths at the Hospital for Sick Children's NICU that occurred in the years 1997, 2002, and 2007 were retrospectively reviewed to identify the primary cause of death. Classification of the cause of death was based on a modified version of the Perinatal Society of Australia and New Zealand's Neonatal Death Classification.

RESULTS

The annual mortality rate remained relatively constant (average of 7.6 deaths per 100 admissions between 1988 and 2007). A total of 156 deaths were analyzed: 53 in 1997; 50 in 2002; and 53 in 2007. The chronological age at which premature infants died increased significantly over the 3 time periods (P = .01). The proportion of deaths attributable to extreme prematurity and intraventricular hemorrhage decreased over the study period, whereas the proportion of deaths attributed to gastrointestinal causes (specifically necrotizing enterocolitis and focal intestinal perforation) increased. The proportion of infants for whom there was a decision to limit care before death was stable at between 83% and 92%.

CONCLUSIONS

A larger proportion of outborn premature infants admitted to the Hospital for Sick Children's NICU seem to be surviving the early problems of prematurity only to succumb to late complications.

Delayed neonatal lung macrophage differentiation in a mouse model of in utero ethanol exposure

We have previously demonstrated that fetal ethanol exposure deranges the function and viability of the neonatal alveolar macrophage. Although altered differentiation of the alveolar macrophage contributes to pulmonary disease states within the adult lung, the effects of fetal ethanol exposure on the normal differentiation of interstitial to alveolar macrophage in the newborn lung are unknown. In the current study, using a mouse model of fetal ethanol exposure, we hypothesized that altered terminal differentiation of the neonatal interstitial to alveolar macrophage contributes to the observed cellular dysfunction in the ethanol-exposed newborn mouse. Control alveolar macrophage differentiation was characterized by increased expression of CD32/CD11b (P < or = 0.05) and increased in vitro phagocytosis of Staphylococcus aureus (P < or = 0.05) compared with interstitial macrophage. After in utero ethanol exposure, both alveolar and interstitial macrophage lacked the acquisition of CD32/CD11b (P < or = 0.05) and displayed impaired in vitro phagocytosis (P < or = 0.05). Ethanol significantly increased transforming growth factor-beta(1) (TGF-beta(1)) in the bronchoalveolar lavage fluid (P < or = 0.05), as well as in both interstitial and alveolar macrophages (P < or = 0.05). Oxidant stress contributed to the ethanol-induced changes on the interstitial and alveolar cells, since maternal supplementation with the glutathione precursor S-adenosylmethionine during ethanol ingestion normalized CD32/CD11b (P < or = 0.05), phagocytosis (P < or = 0.05), and TGF-beta(1) in the bronchoalveolar lavage fluid and macrophages (P < or = 0.05). Contrary to our hypothesis, fetal ethanol exposure did not solely impair interstitial to alveolar macrophage differentiation. Rather, fetal ethanol exposure impaired both neonatal interstitial and alveolar macrophage phagocytic function and differentiation. Increased oxidant stress and elevated TGF-beta(1) contributed to the impaired differentiation of both interstitial and alveolar macrophage.

Neonatal blood cultures: effect of delayed entry into the blood culture machine and bacterial concentration on the time to positive growth in a simulated model

AIMS

To determine if: time from blood culture inoculation to positive growth (total time to positive) and time from blood culture machine entry to positive growth (machine time to positive) is altered by delayed entry into the automated blood culture machine, and if the total time to positive differs by the concentration of organisms inoculated into blood culture bottles.

METHODS

Staphylococcus epidermidis, Escherichia coli and group B beta-haemolytic streptococci were chosen as clinically significant representative organisms. Two concentrations (> or =10 colony-forming units per millilitre and <1 colony-forming units per millilitre) were inoculated into PEDS BacT/Alert blood culture bottles and randomly allocated to one of three delayed automated blood culture machine entry times (30 min/8.5 h/15.5 h).

RESULTS

For all organisms at all concentrations, except the Staphylococcus epidermidis, the machine time to positive was significantly decreased by delayed entry. For all organisms at all concentrations, the mean total time to positive significantly increased with increasing delayed entry into the blood culture machine. Higher concentrations of group B beta-haemolytic streptococci and Escherichia coli grew significantly faster than lower concentrations.

CONCLUSION

Bacterial growth in inoculated bottles, stored at room temperature, continues although at a slower rate than in those blood culture bottles immediately entered into the machine. If a blood culture specimen has been stored at room temperature for greater than 15.5 h, the currently allowed safety margin of 36 h (before declaring a result negative) may be insufficient.

Clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock: 2007 update from the American College of Critical Care Medicine

BACKGROUND

The Institute of Medicine calls for the use of clinical guidelines and practice parameters to promote "best practices" and to improve patient outcomes.

OBJECTIVE

2007 update of the 2002 American College of Critical Care Medicine Clinical Guidelines for Hemodynamic Support of Neonates and Children with Septic Shock.

PARTICIPANTS

Society of Critical Care Medicine members with special interest in neonatal and pediatric septic shock were identified from general solicitation at the Society of Critical Care Medicine Educational and Scientific Symposia (2001-2006).

METHODS

The Pubmed/MEDLINE literature database (1966-2006) was searched using the keywords and phrases: sepsis, septicemia, septic shock, endotoxemia, persistent pulmonary hypertension, nitric oxide, extracorporeal membrane oxygenation (ECMO), and American College of Critical Care Medicine guidelines. Best practice centers that reported best outcomes were identified and their practices examined as models of care. Using a modified Delphi method, 30 experts graded new literature. Over 30 additional experts then reviewed the updated recommendations. The document was subsequently modified until there was greater than 90% expert consensus.

RESULTS

The 2002 guidelines were widely disseminated, translated into Spanish and Portuguese, and incorporated into Society of Critical Care Medicine and AHA sanctioned recommendations. Centers that implemented the 2002 guidelines reported best practice outcomes (hospital mortality 1%-3% in previously healthy, and 7%-10% in chronically ill children). Early use of 2002 guidelines was associated with improved outcome in the community hospital emergency department (number needed to treat = 3.3) and tertiary pediatric intensive care setting (number needed to treat = 3.6); every hour that went by without guideline adherence was associated with a 1.4-fold increased mortality risk. The updated 2007 guidelines continue to recognize an increased likelihood that children with septic shock, compared with adults, require 1) proportionally larger quantities of fluid, 2) inotrope and vasodilator therapies, 3) hydrocortisone for absolute adrenal insufficiency, and 4) ECMO for refractory shock. The major new recommendation in the 2007 update is earlier use of inotrope support through peripheral access until central access is attained.

CONCLUSION

The 2007 update continues to emphasize early use of age-specific therapies to attain time-sensitive goals, specifically recommending 1) first hour fluid resuscitation and inotrope therapy directed to goals of threshold heart rates, normal blood pressure, and capillary refill 70% and cardiac index 3.3-6.0 L/min/m.

A prospective randomized controlled study of two fluid regimens in the initial management of septic shock in the emergency department

OBJECTIVES

To compare the impact of 40 mL/kg of fluid over 15 minutes followed by dopamine and further titration of therapy to achieve therapeutic goals (study protocol) versus 20 mL/kg over 20 minutes up to a maximum of 60 mL/kg over 1 hour followed by dopamine (control protocol) in septic shock.

DESIGN AND SETTING

Prospective randomized controlled study in the emergency department of a public hospital in India.

PATIENTS

One hundred forty-seven children older than 1 month presenting with septic shock were enrolled into the study.

OUTCOME MEASURES

Hospital mortality (primary outcome), 72-hour survival, achievement of therapeutic goals of shock resolution, incidence of hypoxia, hepatomegaly, intubation at 20, 40, and 60 minutes (secondary outcomes) were compared between the arms.

RESULTS

Seventy-four and 73 children were assigned to the study and control group, respectively. Overall mortality was 17.6%, 26 deaths with 13 in each arm. Mortality in the study cohort was lower than our historical mortality of 50% (P<0.0001), 95% confidence interval (CI), 11.9-24.8. Cumulative survival at 72 hours was 72.5% (95% CI, 58.9-86.1) and 77.6% (95% CI, 66.0%-89.2%) in the control and study groups, respectively. Resolution of shock in the emergency department was associated with survival odds ratio (OR) 9.2 (95% CI, 2.1-40.8). Rapidity of achieving therapeutic goals was not significantly different between groups. Intubation rates were also the same (46.5% in the control group versus 55% in the study group; P=0.28). At 20 minutes, 35.6% of the control group and 70% of the study group had hepatomegaly (P<0.01).

CONCLUSION

There was no difference in the overall mortality, rapidity of shock resolution, or incidence of complications between the groups. The occurrence of hepatomegaly at 20 minutes following 40 mL/kg is of concern in settings with limited access to post-resuscitation ventilator care.

Infectious disease hospitalizations among infants in the United States

OBJECTIVE

This study describes the burden and epidemiologic features of infectious disease hospitalizations among infants in the United States.

METHODS

Hospitalizations with an infectious disease listed as a primary diagnosis for infants (<1 year of age) in the United States during 2003 were examined by using the Kids' Inpatient Database. National estimates of infectious disease hospitalizations, hospitalization rates, and various hospital parameters were examined.

RESULTS

During 2003, an estimated 286,739 infectious disease hospitalizations occurred among infants in the United States and accounted for 42.8% of all infant hospitalizations. The national infectious disease hospitalization rate was 7010.8 hospitalizations per 100,000 live births, or approximately 1 infectious disease hospitalization for every 14 infants. The median length of stay was 3 days, and stays totaled >1 million hospital days for infants. Infectious disease hospitalization rates were highest among boys and nonwhite infants. The most commonly listed diagnoses among the infant infectious disease hospitalizations included lower respiratory tract infections (59.0%), kidney, urinary tract, and bladder infections (7.6%), upper respiratory tract infections (6.5%), and septicemia (6.5%). The median cost of an infectious disease hospitalization was $2235, with total annual hospital costs of approximately $690 million, among infants in the United States.

CONCLUSIONS

Infectious disease hospitalizations among infants account for substantial health care expenditures and hospital time in the United States, with respiratory disease hospitalizations constituting more than one half of all hospitalizations. Younger infants, boys, and nonwhite infants were at increased risk for infectious disease hospitalization. Measures to reduce racial disparities and the occurrence of respiratory tract infections should substantially decrease the infectious disease burden among infants.

Levels of pro-inflammatory cytokines produced from cord blood in-vitro are pathogen dependent and increased in comparison to adult controls

BACKGROUND

Overproduction of pro-inflammatory cytokines may play a role in increased morbidity and mortality from neonatal sepsis. Objective of this study was to compare secretion of pro-inflammatory cytokines by the cord blood cells of healthy term neonates to the venous blood cells of healthy adults in vitro after stimulation with common neonatal pathogens.

METHOD

Blood samples were cultured in the presence of heat-killed group B beta-hemolytic streptococci (GBS), Escherichia coli (E. coli) and Staphylococcus epidermidis (S. epi). Concentrations of secreted cytokines (interleukine-6, IL-6, tumor necrosis factor-alpha, TNF-alpha, interleukine-1 beta, IL-1beta and interleukine-8, IL-8) were measured after 0, 1, 2 and 4 h of incubation using chemiluminescent immunometric automated assay.

RESULTS

Blood samples from 22 neonates and 16 adults were compared. After stimulation by GBS and E. coli, cord blood cells secreted significantly higher levels of IL-6 and IL-8 than blood cells of healthy adults. In cord blood, E. coli induced secretion of higher concentration of IL-6, TNF-alpha, IL-1beta and IL-8 than S. epi, and more IL-6 than GBS; GBS induced more IL-1beta than S.epi.

CONCLUSIONS

Response of cord blood to microbial activators is different from that of adult controls. Each isolate of heat-killed bacteria induced different amount of pro-inflammatory cytokines in vitro. This may represent a useful in vitro virulence test.

Incidencia estimada y análisis de la sepsis en un área de Valencia

OBJECTIVES

To study the incidence of sepsis in an area of Valencia, as well as its characteristics, and to evaluate short-term outcomes.

PATIENTS AND METHODS

An active surveillance program was carried out to determine the incidence and characteristics of sepsis. All patients attending the Hospital de La Ribera from January 1999 to December 2004 were included. Incidence rates were calculated and logistic regression analysis was performed.

RESULTS

The incidence rate was 60.9 per 100,000 person-years. The incidence was highest among children younger than 1 year (1,138 per 100,000 person-years). A total of 14.4 % of cases were nosocomial infections. The most common microorganisms found were Escherichia coli, Streptococcus pneumoniae and Neisseria meningitidis. Microbiologically undocumented sepsis accounted for 32 % of the cases. The case-fatality rate was 1.3 %. Seventeen patients (11.1 %) were transferred to an intensive care unit (ICU). The risk of being transferred to an ICU was 14 times higher in patients with meningitis than in those with other sources of infection, independently of age and microbiological characteristics (OR 13.9, 95 % CI 2.6-75.3, P = 0.002).

CONCLUSIONS

The incidence rate of sepsis is high in the pediatric age group. Clinical sepsis represented an important percentage of pediatric sepsis in our center. The main factor associated with patient transfer to the ICU was the central nervous system as the source of sepsis.

Changing epidemiology of pediatric Staphylococcus aureus bacteremia in Denmark from 1971 through 2000

BACKGROUND

Staphylococcus aureus is known to be a leading cause of bacteremia in childhood, and is associated with severe morbidity and increased mortality. To determine developments in incidence and mortality rates, as well as risk factors associated with outcome, we analyzed data from 1971 through 2000.

METHODS

Nationwide registration of S. aureus bacteremia (SAB) among children and adolescents from birth to 20 years of age was performed. Data on age, sex, source of bacteremia, comorbidity and outcome were extracted from discharge records. Rates were population adjusted and risk factors for death were assessed by multivariate logistic regression analysis.

RESULTS

During the 30-year study period, 2648 cases of SAB were reported. Incidence increased from 4.6 to 8.4 cases per 100,000 population and case-mortality rates decreased from 19.6% to 2.5% (P = 0.0001). Incidence in the infant age group (<1 year) were 10- to 17-fold greater compared with that in the other age strata and mortality rate was twice as high. Hospital-acquired infections dominated the infant group, accounting for 73.9%-91.0% versus 39.2%-50.5% in the other age groups. By multivariate analysis, pulmonary infection and endocarditis for all age groups, comorbidity for the older than 1 year, and hospital-acquired infections for the oldest group were independently associated with an increased risk of death.

CONCLUSIONS

Mortality rates associated with SAB decreased significantly in the past 3 decades, possibly because of new and improved treatment modalities. However, incidence rates have increased significantly in the same period, underscoring that S. aureus remains an important invasive pathogen.

Impaired energy metabolism during neonatal sepsis: the effects of glutamine

Neonatal sepsis is an important cause of morbidity and mortality as a result of multiple organ system failure, particularly in neonates requiring total parenteral nutrition. Suitable therapies and support are needed both to prevent sepsis and to prevent multiple organ failure. After bacterial infection, pro-inflammatory cytokines trigger the antimicrobial activity of macrophages and neutrophils, resulting in production of reactive species such as H2O2, NO, superoxide and peroxynitrite. However, excess production can lead to host tissue damage. Incubation of either hepatocytes or heart mitochondria from neonatal rats with these reactive species, or with cytokines, leads to impairment of mitochondrial oxidative function, and in an animal model of neonatal sepsis similar results to thein vitrofindings have been demonstrated. Recentin vivostudies, using indirect calorimetry of suckling rat pups, show that during endotoxaemia there is a profound hypometabolism, associated with hypothermia. Having determined that cellular oxidative function may be impaired during sepsis, it is of great importance to try to identify therapeutic measures. Much interest has been shown in glutamine, which may become essential during sepsis. It has been shown that hepatic glutamine is rapidly depleted during endotoxaemia. When hepatocytes from endotoxaemic rats were incubated with glutamine, there was a restoration of mitochondrial structure and metabolism.In vivo, intraperitoneal injection of glutamine into endotoxic suckling rats partially reversed hypometabolism, markedly reduced the incidence of hypothermia and improved clinical status. These results suggest that glutamine has a beneficial effect during sepsis in neonates.

Incubation time required for neonatal blood cultures to become positive

AIM

We aimed to determine the laboratory detection time of bacteraemia in neonatal blood cultures, and whether this differed by: organism; samples deemed to represent true bacteraemia versus contaminants; and blood cultures collected from an infant <48 h of age (early) or >or=48 h of age (late).

METHODS

A retrospective audit of all positive blood cultures collected from neonates in the Grantley Stable Neonatal Unit, Royal Women's Hospital, Brisbane, between 1 January 2000 and 31 December 2004 was undertaken. The bacteraemia detection method used was the BacTAlert system with Peds bottles.

RESULTS

Two hundred and three positive blood cultures were included in the analysis. One hundred and sixteen (57%) were deemed septicaemia, 87 (43%) were deemed contaminants. The median (interquartile range) time to positivity for positive blood cultures deemed septicaemia and contaminants were 15.9 (11.6, 22.2) and 30.2 (20.4, 43.9) h, respectively. Fifty-six (28%) positive blood cultures were collected when infants were <48 h of age and 147 (72%) were collected in infants >or=48 h of age. Post hoc analysis revealed that the time to positivity for early septicaemia was 13.7 (11, 16.7) h; early contaminant was 25.2 (19.2, 33.8) h; late septicaemia was 17.2 (12.2, 23.4) h; and late contaminant was 37.9 (21.7, 51.2) h. The time to positivity for: Group B streptococcus was 9.3 (8.2, 11.0) h; Escherichia coli was 11.3 (10.0, 13.5) h; and coagulase-negative staphylococci was 28.9 (20.5, 41.2) h.

CONCLUSION

The incubation time for positive blood cultures significantly differs by organism type and whether they are considered early or late septicaemia versus contaminants. We recommend that: infants who are <48 h of age at the time of blood culture collection, who remain clinically well and have negative cultures 36 h after the initial collection can safely have their antibiotic treatment ceased; infants who are >or=48 h of age at the time of collection should continue antibiotic treatment for at least 48 h before cessation is considered.

The role of infection and comorbidity: Factors that influence disparities in sepsis

OBJECTIVE

Large healthcare disparities exist in the incidence of sepsis based on both race and gender. We sought to determine factors that may influence the occurrence of these healthcare disparities, with respect to the source of infection, causal organisms, and chronic comorbid medical conditions.

DESIGN

Historical cohort study.

SETTING

U.S. acute care hospitals from 1979 to 2003.

PATIENTS

Hospitalized patients with a diagnosis of sepsis were identified from the National Hospital Discharge Survey per codes of the International Statistical Classification of Diseases, Ninth Revision (ICD-9CM). Chronic comorbid medical conditions and the source and type of infection were characterized by corresponding ICD-9CM diagnoses.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Sepsis incidence rates are mean cases per 100,000 after age adjustment to the 2000 U.S. Census. Males and nonwhite races were confirmed at increased risk for sepsis. Both proportional source distribution and incidence rates favored respiratory sources of sepsis in males (36% vs. 29%, p < .01) and genitourinary sources in females (35% vs. 27%, p < .01). Incidence rates for all common sources of sepsis were greater in nonwhite races, but proportional source distribution was approximately equal. After stratification by the source of infection, males (proportionate ratio 1.16, 95% confidence interval 1.04-1.29) and black persons (proportionate ratio 1.25, 95% confidence interval 1.18-1.32) remained more likely to have Gram-positive infections. Chronic comorbid conditions that alter immune function (chronic renal failure, diabetes mellitus, HIV, alcohol abuse) were more common in nonwhite sepsis patients, and cumulative comorbidities were associated with greater acute organ dysfunction. Compared with white sepsis patients, nonwhite sepsis patients had longer hospital length of stay (2.0 days, 95% confidence interval 1.9-2.1) and were less likely to be discharged to another medical facility (30% whites, 25% blacks, 18% other races). Case-fatality rates were not significantly different across racial and gender groups.

CONCLUSIONS

Healthcare disparities exist in the incidence of sepsis within all major sources of infection, and males and blacks have greater frequency of Gram-positive infections independent of the infection source. The differential distribution of specific chronic comorbid medical conditions may contribute to these disparities. Large cohort and administrative studies are required to confirm discrete root causes of sepsis disparities.

Recombinant human activated protein C for severe sepsis in neonates

BACKGROUND

Sepsis is a common problem in both preterm and term infants. Although the overall incidence of neonatal sepsis has declined over the past decade, mortality remains high. Recombinant human activated protein C (rhAPC) has been shown to possess a broad spectrum of activity modulating coagulation and has been shown in septic adults to reduce mortality. In septic children, an open label study has shown similar pharmacokinetics, adverse reaction profile and frequency as in adults with severe sepsis.

OBJECTIVES

To determine whether treatment with rhAPC will reduce mortality and/or morbidity in neonates with severe sepsis.

SEARCH STRATEGY

Searches were carried out in July 2005 by the review authors independently of MEDLINE (1966 to July 2005), EMBASE (1980 to July 2005), CINAHL (1982 to July 2005), the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 3, 2005), abstracts of annual meetings of the Pediatric Academic Societies and Society for Pediatric Research which were published in Pediatric Research from 1980, and contacts were made with subject experts. Doctoral dissertations, theses and the Science Citation Index for articles on activated protein C were searched from 1980. No language restriction was applied.

SELECTION CRITERIA

Studies were included if they were randomized or quasi-randomized trials, assessing the efficacy of rhAPC compared to placebo or no intervention as an adjunct to antibiotic therapy of suspected or confirmed severe sepsis in term and preterm infants less than 28 days old. Eligible trials were required to report treatment effects on at least one of the following outcomes: all cause mortality during initial hospital stay, neurological development and neurodevelopmental assessment at two years of age or later, length of hospital stay, duration of ventilation, chronic lung disease in survivors, periventricular leukomalacia, intraventricular hemorrhage, necrotizing enterocolitis, bleeding, and any other adverse events.

DATA COLLECTION AND ANALYSIS

Both review authors independently evaluated the papers for inclusion criteria and quality, and abstracted information for the outcomes of interest. Differences were resolved by mutual discussion. The statistical methods were to include relative risk, risk difference, number needed to treat to benefit or number needed to treat to harm for dichotomous and weighed mean difference for continuous outcomes reported with 95% confidence intervals. A fixed effects model was to be used for meta-analysis. Heterogeneity tests, including the I(2) statistic, were to be performed to assess the appropriateness of pooling the data.

MAIN RESULTS

No eligible trials were identified.

AUTHORS' CONCLUSIONS

Despite the scientific rationale for its use, there are insufficient data to support the use of rhAPC for the management of severe sepsis in newborn infants. There is a need for large well-designed trials to elucidate the effectiveness of rhAPC to reduce mortality and adverse outcomes in neonates with severe sepsis. The results of such trials would guide clinical practice. Currently, a cautious approach to the use of rhAPC is warranted due to the high incidence of bleeding with its use; especially as severe sepsis in preterm infants is commonly associated with bleeding problems and intraventricular hemorrhage. Its use is not recommended outside of randomized controlled trials.

TNF-alpha is a mediator of the anti-inflammatory response in a human neonatal model of the non-septic shock syndrome

The anti-inflammatory/immunoparalytic phase of the systemic inflammatory response syndrome (SIRS) following major insult (surgery, thermal/traumatic injury) is of major clinical importance in the neonate, during which the risk of infection is particularly great. Here, the mechanisms by which TNF-alpha production is suppressed in response to infection are largely unknown. We questioned whether TNF-alpha itself could be a critical mediator of this suppression. Monocytes, isolated from cord blood (n=3), were treated with LPS (100 ng/ml), TNF-alpha (10 ng/ml, +/- anti-TNF-alpha antibody) for 18 and 36 h. Cells were then restimulated with LPS (Gram -ve) or Pam-3-Cys (Gram +ve) for 24 h. This was also done in the presence of selective inhibitors of MAP kinases p38, MEK and JNK. TNF-alpha, IL-6, IL-10 and IL-8 were quantified by ELISA CD86 and HLA-DR expression were determined flow cytometrically. Cells stimulated with LPS for 24 h produced TNF-alpha (282 pg/ml), IL-10 (1,236 pg/ml), IL-6 (2,694 pg/ml) and IL-8 (2,144 pg/ml). In cells pre-exposed to TNF-alpha for 36 h, there was a significant suppression in TNF-alpha and IL-6 levels (9 and 221 pg/ml, respectively) (P<0.05) with minimal impact on IL-10 (1,206 pg/ml) and IL-8 levels (1,886 pg/ml). A similar effect was seen with Pam-3-Cys with a tenfold decrease in levels of TNF-alpha and IL-6 (86-->8.5 pg/ml and 458-->46 pg/ml, respectively) with no effect on IL-10 and IL-8 levels. Anti-TNF-alpha antibody negated this effect. Inhibition of p38 kinase reversed the TNF-alpha effect. Inhibition of the JNK and MEK kinases had no effect. A reduction in the expression of CD86 and HLA-DR was observed. This ex-vivo model of non-septic SIRS demonstrates that TNF-alpha, released during a major insult, can suppress subsequent monocyte responses to bacterial agents through p38 MAP kinase, making it a potential therapeutic target.

Pediatric Sepsis: The Infection unto Death

A significant percentage of pediatric patients admitted to an ICU have an infectious disease process. Many infants and children go on to develop sepsis, a major cause of death in the intensive care unit. Caring for these children presents a collaborative challenge because of the multifactorial etiology and the complicated pathophysiology. This article focuses on the specific implications of sepsis for infants and children.

A history of pediatric critical care medicine

Critical care medicine developed out of other subspecialties' need to provide care for their most critically ill patients. Advanced technologies, the understanding of the pathophysiology of critical illness, and the development of the multidisciplinary team have made this care possible. Pediatric critical care medicine emerged in the 1960s and has expanded dramatically since then. The field has made major advances in the areas of lung injury, sepsis, traumatic brain injury, and postoperative care. We review here the evolution of modern pediatric critical care medicine from its roots in general pediatric and cardiac surgery, adult respiratory care medicine, neonatology, and pediatric anesthesiology to its current state as a unique discipline.

Seventy-five years of neonatal sepsis at Yale: 1928-2003

OBJECTIVE

Yale-New Haven Hospital (Y-NHH) has maintained the longest running, single-center longitudinal database of neonatal sepsis, started in 1928. The objective of this study was to update this database with review of neonatal sepsis cases at Y-NHH to identify longitudinal trends in demographics, pathogens, and outcome.

METHODS

Records of infants with positive blood cultures obtained while they were inpatients in the NICU at Y-NHH from 1989 to 2003 were reviewed retrospectively. Records of infants who were < or =30 days of age, had positive blood cultures, and were hospitalized at Y-NHH outside the NICU from the same period were also reviewed, and all findings were compared with 60 years of preexisting data.

RESULTS

A total of 862 organisms were identified in 755 episodes of sepsis from 647 infants. The percentage of cases of early-onset sepsis decreased and late-onset sepsis increased compared with the previous 10-year study period. A marked increase in cases as a result of commensal species was observed, particularly in preterm infants who had indwelling central vascular catheters, were receiving parenteral nutrition, and required prolonged mechanical ventilation. The overall percentage of sepsis caused by group B streptococcus and Escherichia coli decreased. No episodes of sepsis from Streptococcus pneumoniae or S pyogenes, common in the early years of the survey, were observed. The sepsis-related mortality rate steadily decreased, from 87% in 1928 to 3% in 2003.

CONCLUSIONS

The demographics, pathogens, and outcome associated with neonatal sepsis continue to change. The increase in late-onset sepsis in preterm infants who required prolonged intensive care indicates that strategies to prevent infection are urgently needed for this population of infants.

Reducing the global burden of sepsis in infants and children: a clinical practice research agenda

OBJECTIVE

Sepsis remains a predominant cause of mortality and morbidity in children in the developing and industrialized world. This review discusses a clinical practice research agenda to reduce this global burden.

DESIGN

Summary of the literature with analysis by experts.

RESULTS

Many interventions have been proven effective in decreasing sepsis. Heterologous immunization with attenuated Bacillus Camille Guerin vaccine reduces all-cause mortality, and specific immunizations further reduce morbidity and mortality from many specific microbes. Antepartum antibiotics reduce the prevalence of cerebral palsy and mortality in infants. Administration of antibiotics to neonates with signs of sepsis reduces all-cause mortality five-fold and can also reduce mortality in the big four killers of children: severe pneumonia, diarrhea, malaria, or measles. Immunonutrition with zinc and vitamin A can further reduce morbidity in diarrhea and pneumonia and reduce mortality in measles. First-hour rapid intravenous fluid resuscitation achieves 100% survival in dengue shock, and time-sensitive fluid resuscitation and inotropic support reduces mortality ten-fold in meningococcal septic shock. Multiple organ failure occurs when late or inadequate resuscitation results in systemic thrombosis or when infection is not eradicated because of immunosuppression or inadequate source control.

CONCLUSIONS

The global burden of sepsis can be reduced by 1) prevention with improved heterologous or specific vaccines and vitamin or mineral supplement programs; 2) early recognition and treatment with appropriate antibiotics, intravenous fluid resuscitation, and inotropic support in organized healthcare-delivery systems; and 3) development of new diagnostics and therapeutics that reduce systemic thrombosis, improve immune function, and kill resistant organisms.

International pediatric sepsis consensus conference: definitions for sepsis and organ dysfunction in pediatrics

OBJECTIVE

Although general definitions of the sepsis continuum have been published for adults, no such work has been done for the pediatric population. Physiologic and laboratory variables used to define the systemic inflammatory response syndrome (SIRS) and organ dysfunction require modification for the developmental stages of children. An international panel of 20 experts in sepsis and clinical research from five countries (Canada, France, Netherlands, United Kingdom, and United States) was convened to modify the published adult consensus definitions of infection, sepsis, severe sepsis, septic shock, and organ dysfunction for children.

DESIGN

Consensus conference.

METHODS

This document describes the issues surrounding consensus on four major questions addressed at the meeting: a) How should the pediatric age groups affected by sepsis be delineated? b) What are the specific definitions of pediatric SIRS, infection, sepsis, severe sepsis, and septic shock? c) What are the specific definitions of pediatric organ failure and the validity of pediatric organ failure scores? d) What are the appropriate study populations and study end points required to successfully conduct clinical trials in pediatric sepsis? Five subgroups first met separately and then together to evaluate the following areas: signs and symptoms of sepsis, cell markers, cytokines, microbiological data, and coagulation variables. All conference participants approved the final draft of the proceedings of the meeting.

RESULTS

Conference attendees modified the current criteria used to define SIRS and sepsis in adults to incorporate pediatric physiologic variables appropriate for the following subcategories of children: newborn, neonate, infant, child, and adolescent. In addition, the SIRS definition was modified so that either criteria for fever or white blood count had to be met. We also defined various organ dysfunction categories, severe sepsis, and septic shock specifically for children. Although no firm conclusion was made regarding a single appropriate study end point, a novel nonmortality end point, organ failure-free days, was considered optimal for pediatric clinical trials given the relatively low incidence of mortality in pediatric sepsis compared with adult populations.

CONCLUSION

We modified the adult SIRS criteria for children. In addition, we revised definitions of severe sepsis and septic shock for the pediatric population. Our goal is for these first-generation pediatric definitions and criteria to facilitate the performance of successful clinical studies in children with sepsis.