New pediatric sepsis criteria shift focus to organ dysfunction

Young child in hospital

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The Society of Critical Care Medicine (SCCM) yesterday released new criteria for sepsis in children that experts say have the potential to improve diagnosis, care, and outcomes.

The criteria developed by SCCM's Pediatric Sepsis Definition Taskforce replace 2005 guidelines from the International Pediatric Sepsis Consensus Conference (IPSCC) that characterized sepsis as suspected or confirmed infection in the presence of systemic inflammatory response syndrome, a definition now seen as outdated and as having poor predictive value. To develop the new criteria, the SCCM task force used evidence from an international survey of clinicians, systematic review and meta-analysis, and an international cohort study that collected data on more than 3 million children in both low- and high-income countries.

Pediatric sepsis causes an estimated 3.3 million deaths annually, with the biggest impact seen in children in lower-resource settings, where the risk of developing sepsis is higher in children than in any other age group. Given the high morbidity and mortality associated with pediatric sepsis, the World Health Organization has called for dedicated efforts to improve its diagnosis, prevention, and management.

The updated criteria were presented at the 2024 Critical Care Congress and appeared yesterday in JAMA.

New criteria perform better in diagnosing sepsis, predicting mortality

Based on the survey, the task force determined that sepsis is defined by most clinicians as infection with life-threatening organ dysfunction. Subsequent review of 16 studies evaluating sepsis and 71 evaluating outcomes confirmed that organ dysfunction is strongly associated with both sepsis and mortality. The task force then used data from the cohort study to determine which organ dysfunction criteria best predict mortality among children with suspected or confirmed infection.

Of the 172,984 children in the study with suspected infection in the first 24 hours, a 4-organ-system model­­­ (including cardiovascular, coagulation, neurological, and respiratory systems) performed better in diagnosing sepsis and septic shock and predicting morality than the existing IPSCC criteria, and that model was translated into an integer score called the Phoenix Criteria Score. Under the new criteria, pediatric sepsis in children with suspected infection is identified by at least 2 points in the Phoenix Criteria Score, and septic shock as sepsis with at least 1 point in the score.

These new definitions and shared conceptual understanding of pediatric sepsis will support improvements in the management, research, and outcomes of children with sepsis worldwide.

In a validation study, the task force found that children meeting with the Phoenix criteria for sepsis in high- and low-income settings had 7% and 29% in-hospital mortality, respectively, while those who met the septic shock criteria had 11% and 34% mortality.

"These criteria are better than the old ones at identifying children with infections at higher risk of poor outcomes and are globally applicable, including in low-resource settings," L. Nelson Sanchez-Pinto, MD, a critical care physician at Lurie Children's Hospital in Chicago who co-led the data group of the SCCM task force, said in a hospital press release.

The task force cautions that the Phoenix Sepsis Score is intended to identify children with sepsis or septic shock and not as a screening tool to predict which children are at risk of developing sepsis.

"Thus, it is imperative to continue to develop sepsis screening and early warning tools to correctly identify patients at higher risk of developing sepsis, in both outpatient and inpatient settings, which may lead to early interventions that could decrease the morbidity and mortality associated with pediatric sepsis," they wrote.

Broadly applicable definition, criteria

In an accompanying editorial, experts with the University of Michigan and the University of Connecticut say the new definition and criteria are data driven, pragmatic, and broadly applicable.

"This sepsis definition is supported by a robust body of research, inclusive of diverse geographic and resource settings," they wrote. "These new definitions and shared conceptual understanding of pediatric sepsis will support improvements in the management, research, and outcomes of children with sepsis worldwide."

Task force member Tell Bennett, MD, a professor at the University of Colorado School of Medicine, said in a press release that new tools are being developed based on the criteria to help clinicians in all settings monitor and diagnose pediatric sepsis.

"We are actively working on clinical decision support tools for both higher and lower resource environments that will bring these new criteria to the bedside," he said.

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