Association Between Culture-Negative Versus Culture-Positive Sepsis and Outcomes of Patients Admitted to the Pediatric Intensive Care Unit

Antibiotic exposure for culture-negative early-onset sepsis in late-preterm and term newborns: an international study

BACKGROUND

Early-life antibiotic exposure is disproportionately high compared to the burden of culture-proven early-onset sepsis (CP-EOS). We assessed the contribution of culture-negative cases to the overall antibiotic exposure in the first postnatal week.

METHODS

We conducted a retrospective analysis across eleven countries in Europe, North America, and Australia. All late-preterm and term infants born between 2014 and 2018 who received intravenous antibiotics during the first postnatal week were classified as culture-negative cases treated for ≥5 days (CN ≥ 5d), culture-negative cases treated for <5 days (CN < 5d), or CP-EOS cases.

RESULTS

Out of 757,979 infants, 21,703 (2.9%) received intravenous antibiotics. The number of infants classified as CN ≥ 5d, CN < 5d, and CP-EOS was 7996 (37%), 13,330 (61%), and 375 (1.7%). The incidence of CN ≥ 5d, CN < 5d, and CP-EOS was 10.6 (95% CI 10.3-10.8), 17.6 (95% CI 17.3-17.9), and 0.49 (95% CI 0.44-0.54) cases per 1000 livebirths. The median (IQR) number of antibiotic days administered for CN ≥ 5d, CN < 5d, and CP-EOS was 77 (77-78), 53 (52-53), and 5 (5-5) per 1000 livebirths.

CONCLUSIONS

CN ≥ 5d substantially contributed to the overall antibiotic exposure, and was 21-fold more frequent than CP-EOS. Antimicrobial stewardship programs should focus on shortening antibiotic treatment for culture-negative cases.

IMPACT

In a study of 757,979 infants born in high-income countries, we report a presumed culture-negative early-onset sepsis incidence of 10.6/1000 livebirths with an associated antibiotic exposure of 77 antibiotic days per 1000 livebirths. This study sheds light on the major contribution of presumed culture-negative early-onset sepsis to early-life antibiotic exposure. Given the diagnostic uncertainty surrounding culture-negative early-onset sepsis, the low mortality rate, and the disproportionate antibiotic exposure associated with this condition, our study emphasizes the importance of targeting culture-negative early-onset sepsis in antimicrobial stewardship programs.

Prognostic Value of the Lactate/Albumin Ratio for 28-Day Mortality in Pediatric Septic Shock: A Prospective Cohort Study

Background Septic shock remains a leading cause of mortality in children. The lactate/albumin ratio (LAR) has emerged as a potential prognostic marker for mortality in septic shock, yet most existing research focuses on adults, with limited data available for pediatric populations, particularly in Vietnam. Objectives This study aims to evaluate the prognostic utility of the LAR in predicting 28-day mortality among children aged two months to 15 years with septic shock in Vietnam. Methods We conducted a prospective cohort study involving children diagnosed with septic shock at the largest pediatric intensive care unit (PICU) in the Mekong Delta, Vietnam, from July 2022 to June 2024. Clinical and laboratory parameters, including lactate and albumin levels, were measured at the time of septic shock diagnosis. Patients were followed for 28 days, with outcomes categorized as either survival or mortality. The prognostic performance of LAR was assessed through its discrimination and calibration capabilities. Results The 28-day mortality rate was 63.4%. LAR was significantly higher in non-survivors compared to survivors (p < 0.001). The area under the receiver operating characteristic curve (AUROC) for LAR was 0.91, indicating superior discriminatory power compared to lactate alone and comparable to albumin. Using a Youden index-derived cut-off of 1.84, LAR demonstrated a sensitivity of 84.6% and a specificity of 80%. Kaplan-Meier analysis and log-rank testing revealed significantly lower survival probabilities in children with LAR ≥1.84 (p < 0.05). The Hosmer-Lemeshow test confirmed good calibration of LAR in mortality prediction (p > 0.05). Conclusion The lactate/albumin ratio exhibits excellent discriminatory and calibration properties, making it a valuable tool for predicting 28-day mortality in pediatric septic shock. This ratio should be considered for routine use in clinical practice to improve prognostic assessments in this vulnerable population.

Burden of Respiratory Disease in Pediatric Intensive Care Unit: Experience from a PICU of a Tertiary Care Center in Pakistan

Introduction

We aimed to determine the burden of respiratory disease by examining clinical profiles and associated predictors of morbidity and mortality of patients admitted to a Pediatric Intensive Care Unit (PICU) in Pakistan, a resource limited country. We also stratified the respiratory diseases as defined by the Pediatric Advanced Life Support (PALS) Classification.

Methods

A retrospective study was conducted on children aged 1 month to 18 years who were diagnosed with respiratory illness at the PICU in a tertiary hospital in Karachi, Pakistan. Demographics, essential clinical details including immunization status, and the outcome in terms of mortality or survival were recorded. Predictors of mortality and morbidity including prolonged intubation and mechanical ventilation in the PICU were analyzed using the chi-square test or Fischer's exact test as appropriate.

Results

279 (63.8% male; median age 9 months, IQR 4-36 months) patients were evaluated of which 44.2% were malnourished and 23.3% were incompletely immunized. The median length of stay in the PICU was 3 days (IQR 2-5 days). Pneumonia was the principal diagnosis in 170 patients (62%) and accounted for most deaths. 76/279 (27.2%) were ventilated, and 67/279(24.0%) needed inotropic support. A high Pediatric Risk of Mortality (PRISM) III score, pneumothorax, and lower airway disease were significantly associated with ventilation support. The mortality rate of patients was 14.3%. Predictors of mortality were a high PRISM III score (OR 1.179; 95% CI 1.024-1.358, P=0.022) and a positive blood culture (OR 4.305; 95% CI 1.062-17.448, P=0.041).

Conclusion

Pneumonia is a significant contributor of respiratory diseases in the PICU in Pakistan and is the leading cause of morbidity and mortality. A high PRISM III score, pneumothorax, and lower airway disease were predictors for ventilation support. A high PRISM III score and a positive blood culture were predictors of patient mortality in our study.

Comparison of clinical outcomes between culture-positive and culture-negative sepsis or septic shock pediatrics patients: A systematic review and meta-analysis

Introduction

Comparatively, culture-negative septic shock or septic shock (CNSS) is frequently observed among pediatric patients, contrasting with the more distinct clinical profile and prognosis of post-surgical septic shock (CPSS). However, limited data are available on the outcomes of CNSS in comparison to CPSS in pediatric patients. This study seeks to conduct a systematic review and meta-analysis of existing literature to comprehensively compare outcomes between CNSS and CPSS in pediatric patients.

Methods

Electronic databases, such as PubMed, CINAHIL, and EMBASE, were systematically searched up to January 15, 2024, using predefined terms. We included all studies that compared outcomes between CPSS and CNSS in pediatric patients. The primary outcome evaluated in this study was all-cause mortality. Secondary outcomes included length of hospitalization, length of intensive care unit (ICU) stay, and duration of mechanical ventilation (all measured in days).

Results

Among the initially identified 1328 articles, six studies involving 2511 pediatric patients met the inclusion criteria and were part of this meta-analysis study. The pooled analysis revealed no significant differences in all-cause mortality (odds ratio: 1.26, 95% confidence interval (CI): 0.93 to 1.70, p = 0.14), length of ICU stay (mean difference (MD): 0.18, 95% CI: -0.33 to 0.68, p = 0.50), and duration of mechanical ventilation (MD: -0.74, 95% CI: -2.46 to 0.98, p-value = 0.40) between CPSS and CNSS. However, the length of hospital stay was longer in CPSS compared to CNSS (MD: 7.38, 95% CI: 5.50 to 9.27, p < 0.0001).

Conclusion

Approximately 26.56% of pediatric septic cases were culture-positive. There were no statistically significant differences in mortality, ICU stay, and duration of mechanical ventilation between CPSS and CNSS. However, hospital stay was prolonged by more than 7 days in culture-positive cases. Further multicenter studies are warranted to validate these findings and explore additional presentation characteristics.

Haemodynamic support for paediatric septic shock: a global perspective

Septic shock is a leading cause of hospitalisation, morbidity, and mortality for children worldwide. In 2020, the paediatric Surviving Sepsis Campaign (SSC) issued evidence-based recommendations for clinicians caring for children with septic shock and sepsis-associated organ dysfunction based on the evidence available at the time. There are now more trials from multiple settings, including low-income and middle-income countries (LMICs), addressing optimal fluid choice and amount, selection and timing of vasoactive infusions, and optimal monitoring and therapeutic endpoints. In response to developments in adult critical care to trial personalised haemodynamic management algorithms, it is timely to critically reassess the current state of applying SSC guidelines in LMIC settings. In this Viewpoint, we briefly outline the challenges to improve sepsis care in LMICs and then discuss three key concepts that are relevant to management of children with septic shock around the world, especially in LMICs. These concepts include uncertainties surrounding the early recognition of paediatric septic shock, choices for initial haemodynamic support, and titration of ongoing resuscitation to therapeutic endpoints. Specifically, given the evolving understanding of clinical phenotypes, we focus on the controversies surrounding the concepts of early fluid resuscitation and vasoactive agent use, including insights gained from experience in LMICs and high-income countries. We outline the key components of sepsis management that are both globally relevant and translatable to low-resource settings, with a view to open the conversation to the large variety of treatment pathways, especially in LMICs. We emphasise the role of simple and easily available monitoring tools to apply the SSC guidelines and to tailor individualised support to the patient's cardiovascular physiology.

Comparison of the clinical characteristics and clinical outcomes of culture-positive septic shock and culture-negative septic shock among pediatric patients

OBJECTIVES

Among pediatric patients with septic shock, culture-negative septic shock (CNSS) is common but there have been limited data on its clinical characteristics and prognosis. We compared the clinical characteristics and clinical outcomes between culture-positive septic shock (CPSS) and CNSS in pediatric patients.

DESIGN

Retrospective single-center study.

SETTING

Pediatric intensive care unit (PICU) of a tertiary referral hospital.

PATIENTS

All pediatric patients who were admitted to the PICU due to septic shock between January 2010 and November 2021, except for those with fungal or viral infections and those who expired on the day of admittance to the PICU. The primary outcome was 30-day mortality and in-hospital mortality.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A total of 294 patients (CPSS group, n = 185 [62.9%]; CNSS group, n = 109 [37.1%]) were included. The rates of 30-day mortality and in-hospital mortality (30-day mortality 22.7% vs 22%, in-hospital mortality 29.7% vs 25.7%) were not significantly different between the CPSS group and the CNSS group. The two groups showed comparable results in clinical outcomes such as the requirement for mechanical ventilator and renal replacement therapy, PICU stay duration, and the duration of MV and vasopressor/inotrope support. Among the CPSS group, 98 (53%) patients who were infected with multi-drug resistance (MDR) bacteria had significantly higher rates of 30-day mortality and in-hospital mortality than those infected with non-MDR bacteria.

CONCLUSIONS

Among pediatric patients, the CPSS group and CNSS group did not show significant differences in clinical features and mortality. Among the CPSS group, those with MDR bacteria had poorer prognosis.

Comparison of Clinical Outcomes Between Culture-Positive and Culture-Negative Sepsis and Septic Shock Patients: A Meta-Analysis

This meta-analysis has been conducted to compare the clinical outcomes between culture-positive and culture-negative sepsis or septic patients. The present meta-analysis is reported as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Electronic databases, including PubMed and EMBASE, were searched by two authors independently from the inception to January 25, 2023, using the following key terms: "culture positive," "culture negative," "sepsis," and "septic shock." The primary outcome assessed in the present meta-analysis was all-cause mortality. Secondary outcomes included the need for mechanical ventilation, renal replacement therapy, length of ICU stay in days, and length of hospital stay in days. Total 10 studies met the inclusion criteria and were included in the meta-analysis involving 23,973 patients. No statistically significant difference was found between culture-positive and culture-negative patients in terms of all-cause mortality (risk ratio [RR]: 1.09, 95% CI: 0.95-1.24, p-value: 0.23), the need for mechanical ventilation (RR: 0.99, 95% CI: 0.93-1.05, p-value: 0.79), renal replacement therapy requirements (RR: 1.11, 95% CI: 0.95-1.31, p-value: 0.19), and ICU length of stay (mean difference [MD]: 1.70 days, 95% CI: -1.10, 4.49, p-value: 0.23). However, The mean hospital length of stay in days was significantly longer in patients in a culture-positive group compared to the culture-negative group (MD: 3.04, 95% CI: 2.25-3.82, p-value<0.001). In conclusion, the present meta-analysis of 10 studies, including 23,973 patients, found no significant differences in all-cause mortality, need for mechanical ventilation, need for renal replacement therapy, and length of ICU stay between culture-positive and culture-negative sepsis or septic patients. However, a significant difference was found in hospital length of stay, with culture-positive patients having a longer stay.

Metabolomics in pediatric lower respiratory tract infections and sepsis: a literature review

Lower respiratory tract infections (LRTIs) are a leading cause of morbidity and mortality in children. The ability of healthcare providers to diagnose and prognose LRTIs in the pediatric population remains a challenge, as children can present with similar clinical features regardless of the underlying pathogen or ultimate severity. Metabolomics, the large-scale analysis of metabolites and metabolic pathways offers new tools and insights that may aid in diagnosing and predicting the outcomes of LRTIs in children. This review highlights the latest literature on the clinical utility of metabolomics in providing care for children with bronchiolitis, pneumonia, COVID-19, and sepsis. IMPACT: This article summarizes current metabolomics approaches to diagnosing and predicting the course of pediatric lower respiratory infections. This article highlights the limitations to current metabolomics research and highlights future directions for the field.

β-lactam precision dosing in critically ill children: Current state and knowledge gaps

There has been emerging interest in implementing therapeutic drug monitoring and model-informed precision dosing of β-lactam antibiotics in critically ill patients, including children. Despite a position paper endorsed by multiple international societies that support these efforts in critically ill adults, implementation of β-lactam precision dosing has not been widely adopted. In this review, we highlight what is known about β-lactam antibiotic pharmacokinetics and pharmacodynamics in critically ill children. We also define the knowledge gaps that present barriers to acceptance and implementation of precision dosing of β-lactam antibiotics in critically ill children: a lack of consensus on which subpopulations would benefit most from precision dosing and the uncertainty of how precision dosing changes outcomes. We conclude with opportunities for further research to close these knowledge gaps.

Outcomes for paediatric acute leukaemia patients admitted to the paediatric intensive care unit

Children with acute leukaemia (AL) are a high-risk population for infections and life-threatening conditions requiring paediatric intensive care unit (PICU) admission, presenting an increased mortality rate. A few literature exists about PICU outcomes in this kind of patients, especially with haematopoietic stem cell transplant (HSCT) background. We investigated the clinical and epidemiological characteristics of these patients as well as their outcomes. A retrospective, single-centre analytical/observational study was conducted from January 2011 to December 2018 in the PICU of a tertiary care hospital. AL patients from 28 days to 18 years old admitted to the PICU were included, excluding those with histories of HSCT or CAR T-cell therapy. We collected epidemiological and clinical characteristics, laboratory and microbiology results and outcomes. Forty-three patients with AL required urgent admission (35 lymphoblastic and 8 myeloblastic) for 63 different episodes. The main reasons were sepsis (21, 33.3%), hyperleukocytosis (12, 19%), respiratory failure (11, 17.5%) and seizures (8, 12.7%). Nineteen (30.2%) required inotropic support, and fifteen (23.8%) required mechanical ventilation. Three patients died at the hospital (3/43, 6.9%). Sixty-day mortality was 9.3%, and 1-year mortality was 13.9%. There was no differences regarding the type of AL and 60-day mortality (log-rank 2.652, p = 0.103).Conclusion: In our study, the main cause of admission for AL patients was infection, which was associated to more severity and longer hospital admission. What is Known: • Acute leukaemia is the most common childhood cancer. Admission to a paediatric intensive care unit is required in 30% of children with acute leukaemia. • Regarding the outcomes of children with acute leukaemia that require admission to the intensive care unit data are scarce. What is New: • Mortality in acute leukaemia patients admitted to the paediatric intensive care unit is lower than that of patients with a history of stem cell therapy but higher than that of patients with solid tumours. • The main reason for admission was sepsis, which is related in literature to more severity and long length of stay.

Comparing outcomes between culture-positive and culture-negative septic shock in a PICU: A retrospective cohort study

BACKGROUND

We assessed the outcomes and characteristics of culture-negative septic shock (CNSS) and culture-positive septic shock (CPSS) in pediatric intensive care unit (PICU).

METHODS

We performed a retrospective study on the data of children admitted to the PICU due to septic shock between January 2018 and December 2021. The primary outcome was in-hospital mortality. The secondary outcomes were the length of stay (LOS) of hospital, the need for mechanical ventilation (MV) and continue renal replacement therapy (CRRT).

RESULTS

Overall, 238 patients were enrolled. 114 patients (47.9%) had positive cultures (60 blood samples, 41 sputum samples, 17 pus samples, and 19 others), 18 of whom were cultured positive at two sites, 1 at three sites, and 3 had two different types of bacteria at same site. The in-hospital mortality was 47.1%. There were no significant differences in the in-hospital mortality (47.6% vs. 46.5%, P = 0.866), PRISM-III score (10 vs. 12, P = 0.409), PIM-3 score (0.08 vs. 0.07, P = 0.845), pSOFA score (10 vs. 10, P = 0.677) or the need for MV (64.5% vs. 68.4%, P = 0.524) and CRRT (29.8% vs. 34.2%, P = 0.470) between the CNSS group and the CPSS group. The Procalcitonin (8.89 ng/ml vs. 28.39 ng/ml, P = 0.001) and C-reactive protein (28 mg/L vs. 58 mg/L, P = 0.001) levels were significantly lower in the CNSS group than in the CPSS group, while WBC count (9.03 × 10⁹/L vs. 5.02 × 10⁹/L, P = 0.002) and serum sodium (137 mmol/L vs. 132 mmol/L, P = 0.001) was significantly higher in CNSS. The LOS of hospital was significantly longer (16 days vs. 11 days, P = 0.011) in the CPSS group than in the CNSS group, while the LOS of PICU (5 days vs. 4 days, P = 0.094) stay was not significantly different.

CONCLUSION

Compared with children with CNSS, children with CPSS had higher PCT and CRP levels, but lower WBC count. Children with CPSS had longer LOS of hospital. However, positive or negative culture results were not associated with in-hospital mortality, the LOS of PICU, the need for MV or CRRT in children with septic shock.

Mass Spectrometry Proteotyping-Based Detection and Identification of Staphylococcus aureus, Escherichia coli, and Candida albicans in Blood

Bloodstream infections (BSIs), the presence of microorganisms in blood, are potentially serious conditions that can quickly develop into sepsis and life-threatening situations. When assessing proper treatment, rapid diagnosis is the key; besides clinical judgement performed by attending physicians, supporting microbiological tests typically are performed, often requiring microbial isolation and culturing steps, which increases the time required for confirming positive cases of BSI. The additional waiting time forces physicians to prescribe broad-spectrum antibiotics and empirically based treatments, before determining the precise cause of the disease. Thus, alternative and more rapid cultivation-independent methods are needed to improve clinical diagnostics, supporting prompt and accurate treatment and reducing the development of antibiotic resistance. In this study, a culture-independent workflow for pathogen detection and identification in blood samples was developed, using peptide biomarkers and applying bottom-up proteomics analyses, i.e., so-called "proteotyping". To demonstrate the feasibility of detection of blood infectious pathogens, using proteotyping, Escherichia coli and Staphylococcus aureus were included in the study, as the most prominent bacterial causes of bacteremia and sepsis, as well as Candida albicans, one of the most prominent causes of fungemia. Model systems including spiked negative blood samples, as well as positive blood cultures, without further culturing steps, were investigated. Furthermore, an experiment designed to determine the incubation time needed for correct identification of the infectious pathogens in blood cultures was performed. The results for the spiked negative blood samples showed that proteotyping was 100- to 1,000-fold more sensitive, in comparison with the MALDI-TOF MS-based approach. Furthermore, in the analyses of ten positive blood cultures each of E. coli and S. aureus, both the MALDI-TOF MS-based and proteotyping approaches were successful in the identification of E. coli, although only proteotyping could identify S. aureus correctly in all samples. Compared with the MALDI-TOF MS-based approaches, shotgun proteotyping demonstrated higher sensitivity and accuracy, and required significantly shorter incubation time before detection and identification of the correct pathogen could be accomplished.

Comparison of culture-negative and culture-positive sepsis or septic shock: a systematic review and meta-analysis

Background

Mortality and other clinical outcomes between culture-negative and culture-positive septic patients have been documented inconsistently and are very controversial. A systematic review and meta-analysis was performed to compare the clinical outcomes of culture-negative and culture-positive sepsis or septic shock.

Methods

We searched the PubMed, Cochrane and Embase databases for studies from inception to the 1st of January 2021. We included studies involving patients with sepsis or septic shock. All authors reported our primary outcome of all-cause mortality and clearly compared culture-negative versus culture-positive patients with clinically relevant secondary outcomes (ICU length of stay, hospital length of stay, mechanical ventilation requirements, mechanical ventilation duration and renal replacement requirements). Results were expressed as odds ratio (OR) and mean difference (MD) with accompanying 95% confidence interval (CI).

Results

Seven studies including 22,655 patients were included. The primary outcome of this meta-analysis showed that there was no statistically significant difference in the all-cause mortality between two groups (OR = 0.95; 95% CI, 0.88 to 1.01; P = 0.12; Chi-² = 30.71; I² = 80%). Secondary outcomes demonstrated that there was no statistically significant difference in the ICU length of stay (MD = − 0.19;95% CI, − 0.42 to 0.04; P = 0.10;Chi-² = 5.73; I² = 48%), mechanical ventilation requirements (OR = 1.02; 95% CI, 0.94 to 1.11; P = 0.61; Chi² = 6.32; I² = 53%) and renal replacement requirements (OR = 0.82; 95% CI, 0.67 to 1.01; P = 0.06; Chi-² = 1.21; I² = 0%) between two groups. The hospital length of stay of culture-positive group was longer than that of the culture-negative group (MD = − 3.48;95% CI, − 4.34 to − 2.63; P < 0.00001;Chi-² = 1.03; I² = 0%). The mechanical ventilation duration of culture-positive group was longer than that of the culture-negative group (MD = − 0.64;95% CI, − 0.88 to − 0.4; P < 0.00001;Chi-² = 4.86; I² = 38%).

Conclusions

Culture positivity or negativity was not associated with mortality of sepsis or septic shock patients. Furthermore, culture-positive septic patients had similar ICU length of stay, mechanical ventilation requirements and renal replacement requirements as those culture-negative patients. The hospital length of stay and mechanical ventilation duration of culture-positive septic patients were both longer than that of the culture-negative patients. Further large-scale studies are still required to confirm these results.