Pediatric sepsis in the developing world: challenges in defining sepsis and issues in post-discharge mortality
Identifieur interne : 002E10 ( Pmc/Corpus ); précédent : 002E09; suivant : 002E11Pediatric sepsis in the developing world: challenges in defining sepsis and issues in post-discharge mortality
Auteurs : Matthew O. Wiens ; Elias Kumbakumba ; Niranjan Kissoon ; J Mark Ansermino ; Andrew Ndamira ; Charles P. LarsonSource :
- Clinical Epidemiology [ 1179-1349 ] ; 2012.
Abstract
Sepsis represents the progressive underlying inflammatory pathway secondary to any infectious illness, and ultimately is responsible for most infectious disease-related deaths. Addressing issues related to sepsis has been recognized as an important step towards reducing morbidity and mortality in developing countries, where the majority of the 7.5 million annual deaths in children under 5 years of age are considered to be secondary to sepsis. However, despite its prevalence, sepsis is largely neglected. Application of sepsis definitions created for use in resource-rich countries are neither practical nor feasible in most developing country settings, and alternative definitions designed for use in these settings need to be established. It has also been recognized that the inflammatory state created by sepsis increases the risk of post-discharge morbidity and mortality in developed countries, but exploration of this issue in developing countries is lacking. Research is urgently required to characterize better this potentially important issue.
Url:
DOI: 10.2147/CLEP.S35693
PubMed: 23226074
PubMed Central: 3514048
Links to Exploration step
PMC:3514048Le document en format XML
<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Pediatric sepsis in the developing world: challenges in defining sepsis and issues in post-discharge mortality</title><author><name sortKey="Wiens, Matthew O" sort="Wiens, Matthew O" uniqKey="Wiens M" first="Matthew O" last="Wiens">Matthew O. Wiens</name><affiliation><nlm:aff id="af1-clep-4-319">School of Population and Public Health, University of British Columbia, Vancouver, Canada;</nlm:aff></affiliation></author><author><name sortKey="Kumbakumba, Elias" sort="Kumbakumba, Elias" uniqKey="Kumbakumba E" first="Elias" last="Kumbakumba">Elias Kumbakumba</name><affiliation><nlm:aff id="af2-clep-4-319">Department of Pediatrics, Mbarara University of Science and Technology, Mbarara, Uganda;</nlm:aff></affiliation></author><author><name sortKey="Kissoon, Niranjan" sort="Kissoon, Niranjan" uniqKey="Kissoon N" first="Niranjan" last="Kissoon">Niranjan Kissoon</name><affiliation><nlm:aff id="af3-clep-4-319">Department of Pediatrics, BC Children’s Hospital and University of British Columbia, Vancouver, Canada;</nlm:aff></affiliation></author><author><name sortKey="Ansermino, J Mark" sort="Ansermino, J Mark" uniqKey="Ansermino J" first="J Mark" last="Ansermino">J Mark Ansermino</name><affiliation><nlm:aff id="af4-clep-4-319">Department of Anesthesia, BC Children’s Hospital and University of British Columbia, Vancouver, Canada;</nlm:aff></affiliation></author><author><name sortKey="Ndamira, Andrew" sort="Ndamira, Andrew" uniqKey="Ndamira A" first="Andrew" last="Ndamira">Andrew Ndamira</name><affiliation><nlm:aff id="af2-clep-4-319">Department of Pediatrics, Mbarara University of Science and Technology, Mbarara, Uganda;</nlm:aff></affiliation></author><author><name sortKey="Larson, Charles P" sort="Larson, Charles P" uniqKey="Larson C" first="Charles P" last="Larson">Charles P. Larson</name><affiliation><nlm:aff id="af5-clep-4-319">Department of Pediatrics and School of Population and Public Health, University of British Columbia, Vancouver, Canada</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">23226074</idno><idno type="pmc">3514048</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3514048</idno><idno type="RBID">PMC:3514048</idno><idno type="doi">10.2147/CLEP.S35693</idno><date when="2012">2012</date><idno type="wicri:Area/Pmc/Corpus">002E10</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">002E10</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Pediatric sepsis in the developing world: challenges in defining sepsis and issues in post-discharge mortality</title><author><name sortKey="Wiens, Matthew O" sort="Wiens, Matthew O" uniqKey="Wiens M" first="Matthew O" last="Wiens">Matthew O. Wiens</name><affiliation><nlm:aff id="af1-clep-4-319">School of Population and Public Health, University of British Columbia, Vancouver, Canada;</nlm:aff></affiliation></author><author><name sortKey="Kumbakumba, Elias" sort="Kumbakumba, Elias" uniqKey="Kumbakumba E" first="Elias" last="Kumbakumba">Elias Kumbakumba</name><affiliation><nlm:aff id="af2-clep-4-319">Department of Pediatrics, Mbarara University of Science and Technology, Mbarara, Uganda;</nlm:aff></affiliation></author><author><name sortKey="Kissoon, Niranjan" sort="Kissoon, Niranjan" uniqKey="Kissoon N" first="Niranjan" last="Kissoon">Niranjan Kissoon</name><affiliation><nlm:aff id="af3-clep-4-319">Department of Pediatrics, BC Children’s Hospital and University of British Columbia, Vancouver, Canada;</nlm:aff></affiliation></author><author><name sortKey="Ansermino, J Mark" sort="Ansermino, J Mark" uniqKey="Ansermino J" first="J Mark" last="Ansermino">J Mark Ansermino</name><affiliation><nlm:aff id="af4-clep-4-319">Department of Anesthesia, BC Children’s Hospital and University of British Columbia, Vancouver, Canada;</nlm:aff></affiliation></author><author><name sortKey="Ndamira, Andrew" sort="Ndamira, Andrew" uniqKey="Ndamira A" first="Andrew" last="Ndamira">Andrew Ndamira</name><affiliation><nlm:aff id="af2-clep-4-319">Department of Pediatrics, Mbarara University of Science and Technology, Mbarara, Uganda;</nlm:aff></affiliation></author><author><name sortKey="Larson, Charles P" sort="Larson, Charles P" uniqKey="Larson C" first="Charles P" last="Larson">Charles P. Larson</name><affiliation><nlm:aff id="af5-clep-4-319">Department of Pediatrics and School of Population and Public Health, University of British Columbia, Vancouver, Canada</nlm:aff></affiliation></author></analytic><series><title level="j">Clinical Epidemiology</title><idno type="eISSN">1179-1349</idno><imprint><date when="2012">2012</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><p>Sepsis represents the progressive underlying inflammatory pathway secondary to any infectious illness, and ultimately is responsible for most infectious disease-related deaths. Addressing issues related to sepsis has been recognized as an important step towards reducing morbidity and mortality in developing countries, where the majority of the 7.5 million annual deaths in children under 5 years of age are considered to be secondary to sepsis. However, despite its prevalence, sepsis is largely neglected. Application of sepsis definitions created for use in resource-rich countries are neither practical nor feasible in most developing country settings, and alternative definitions designed for use in these settings need to be established. It has also been recognized that the inflammatory state created by sepsis increases the risk of post-discharge morbidity and mortality in developed countries, but exploration of this issue in developing countries is lacking. 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<front><journal-meta><journal-id journal-id-type="nlm-ta">Clin Epidemiol</journal-id><journal-id journal-id-type="iso-abbrev">Clin Epidemiol</journal-id><journal-id journal-id-type="publisher-id">Clinical Epidemiology</journal-id><journal-title-group><journal-title>Clinical Epidemiology</journal-title></journal-title-group><issn pub-type="epub">1179-1349</issn><publisher><publisher-name>Dove Medical Press</publisher-name></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">23226074</article-id><article-id pub-id-type="pmc">3514048</article-id><article-id pub-id-type="doi">10.2147/CLEP.S35693</article-id><article-id pub-id-type="publisher-id">clep-4-319</article-id><article-categories><subj-group subj-group-type="heading"><subject>Review</subject></subj-group></article-categories><title-group><article-title>Pediatric sepsis in the developing world: challenges in defining sepsis and issues in post-discharge mortality</article-title></title-group><contrib-group><contrib contrib-type="author"><name><surname>Wiens</surname><given-names>Matthew O</given-names></name><xref ref-type="corresp" rid="c1-clep-4-319"></xref><xref ref-type="aff" rid="af1-clep-4-319"><sup>1</sup></xref></contrib><contrib contrib-type="author"><name><surname>Kumbakumba</surname><given-names>Elias</given-names></name><xref ref-type="aff" rid="af2-clep-4-319"><sup>2</sup></xref></contrib><contrib contrib-type="author"><name><surname>Kissoon</surname><given-names>Niranjan</given-names></name><xref ref-type="aff" rid="af3-clep-4-319"><sup>3</sup></xref></contrib><contrib contrib-type="author"><name><surname>Ansermino</surname><given-names>J Mark</given-names></name><xref ref-type="aff" rid="af4-clep-4-319"><sup>4</sup></xref></contrib><contrib contrib-type="author"><name><surname>Ndamira</surname><given-names>Andrew</given-names></name><xref ref-type="aff" rid="af2-clep-4-319"><sup>2</sup></xref></contrib><contrib contrib-type="author"><name><surname>Larson</surname><given-names>Charles P</given-names></name><xref ref-type="aff" rid="af5-clep-4-319"><sup>5</sup></xref></contrib></contrib-group><aff id="af1-clep-4-319"><label>1</label>School of Population and Public Health, University of British Columbia, Vancouver, Canada;</aff><aff id="af2-clep-4-319"><label>2</label>Department of Pediatrics, Mbarara University of Science and Technology, Mbarara, Uganda;</aff><aff id="af3-clep-4-319"><label>3</label>Department of Pediatrics, BC Children’s Hospital and University of British Columbia, Vancouver, Canada;</aff><aff id="af4-clep-4-319"><label>4</label>Department of Anesthesia, BC Children’s Hospital and University of British Columbia, Vancouver, Canada;</aff><aff id="af5-clep-4-319"><label>5</label>Department of Pediatrics and School of Population and Public Health, University of British Columbia, Vancouver, Canada</aff><author-notes><corresp id="c1-clep-4-319">Correspondence: Matthew O Wiens, School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC V6T 1Z3, Canada, Email <email>mowiens@outlook.com</email></corresp></author-notes><pub-date pub-type="collection"><year>2012</year></pub-date><pub-date pub-type="epub"><day>22</day><month>11</month><year>2012</year></pub-date><volume>4</volume><fpage>319</fpage><lpage>325</lpage><history><date date-type="received"><day>21</day><month>11</month><year>2012</year></date></history><permissions><copyright-statement>© 2012 Wiens et al, publisher and licensee Dove Medical Press Ltd.</copyright-statement><copyright-year>2012</copyright-year><license><license-p>This is an Open Access article which permits unrestricted noncommercial use, provided the original work is properly cited.</license-p></license></permissions><abstract><p>Sepsis represents the progressive underlying inflammatory pathway secondary to any infectious illness, and ultimately is responsible for most infectious disease-related deaths. Addressing issues related to sepsis has been recognized as an important step towards reducing morbidity and mortality in developing countries, where the majority of the 7.5 million annual deaths in children under 5 years of age are considered to be secondary to sepsis. However, despite its prevalence, sepsis is largely neglected. Application of sepsis definitions created for use in resource-rich countries are neither practical nor feasible in most developing country settings, and alternative definitions designed for use in these settings need to be established. It has also been recognized that the inflammatory state created by sepsis increases the risk of post-discharge morbidity and mortality in developed countries, but exploration of this issue in developing countries is lacking. Research is urgently required to characterize better this potentially important issue.</p></abstract><kwd-group><kwd>children</kwd><kwd>pediatric sepsis</kwd><kwd>developing countries</kwd></kwd-group></article-meta></front><body><sec><title>Introduction</title><p>Sepsis results from a wide spectrum of infectious agents and is a very common cause of death and disability worldwide. In Canadian hospitals, sepsis is more common than cardiovascular disease, and has a higher fatality rate.<xref ref-type="bibr" rid="b1-clep-4-319">1</xref> In the United Kingdom, evidence from the National Health Service has recently shown that sepsis is responsible for more deaths annually than lung cancer, bowel cancer, and breast cancer.<xref ref-type="bibr" rid="b2-clep-4-319">2</xref> In children, it is the most common cause of mortality in the developing world.<xref ref-type="bibr" rid="b3-clep-4-319">3</xref>,<xref ref-type="bibr" rid="b4-clep-4-319">4</xref> Despite its primacy, it is largely neglected globally, and especially in resource-poor environments.</p><p>Despite these figures, sepsis is largely unknown to the public and ignored by policy makers. For instance, in the United States, a national sample of adults over 18 years of age revealed that respondents were “not at all” or “not very” familiar with the term sepsis in 59% of cases, and “very” familiar in only 16% of cases.<xref ref-type="bibr" rid="b5-clep-4-319">5</xref> The Surviving Sepsis Campaign public awareness survey asked 1000 inhabitants in each of six countries whether they had previously heard the term sepsis. In total, 86%–92% of responders in France, Italy, Spain, and the United Kingdom said “no” as compared with 53% in Germany.<xref ref-type="bibr" rid="b6-clep-4-319">6</xref> While there are no figures regarding awareness of sepsis in the developing world, it is likely that awareness is even lower.</p><p>Of the 7.5 million deaths in children under 5 years of age, most are secondary to sepsis, the inflammatory pathway common to most deaths associated with infectious diseases.<xref ref-type="bibr" rid="b3-clep-4-319">3</xref>,<xref ref-type="bibr" rid="b4-clep-4-319">4</xref> A definition of sepsis that is practical for resource-poor environments is lacking, and may contribute to failure to recognize septic patients. Furthermore, the problem of mortality following discharge has been largely ignored, although there is some evidence to suggest that the post-discharge mortality rate is similar to that seen during hospitalization.<xref ref-type="bibr" rid="b7-clep-4-319">7</xref> The purpose of this review is to outline important issues relating to the definition of sepsis and follow-up care in populations with high mortality rates in children under 5 years of age. We propose possible pragmatic alternatives that may be useful in defining sepsis and conducting follow-up among sepsis survivors, and highlight potential research to test our assumptions.</p></sec><sec><title>Search strategy</title><p>For the purpose of identifying all potentially relevant articles for this review, a systematic search was conducted in both Medline and Embase from the earliest possible date until March 1, 2012. Because this article focuses on pediatric sepsis in developing countries, studies from high-income countries and those involving adults were generally not reviewed. In Medline, the medical subject heading (MeSH) “sepsis” was combined with the following MeSH terms: “developing countries” OR “Africa”. MeSH terms were exploded where appropriate. Free text words, including “pediatric sepsis” and “sepsis definitions”, were also used to increase capture of relevant publications. The MeSH terms “follow-up studies” and “hospitalization” were combined with “developing countries” OR “Africa” to capture studies addressing post-discharge mortality. Free text terms, including “post-discharge mortality”, “long-term outcomes” and other similar terms were also used. References of relevant publications were reviewed to identify any articles not captured during the initial search. A similar strategy was used in Embase.</p></sec><sec><title>Definitions of sepsis</title><p>Sepsis, as defined by the international pediatric sepsis consensus conference, is the systemic inflammatory response syndrome (SIRS) in the presence of a suspected or proven infection (<xref ref-type="table" rid="t1A-clep-4-319">Table 1</xref>).<xref ref-type="bibr" rid="b8-clep-4-319">8</xref> Sepsis can be due to any infectious etiology, but in developed settings it is most often bacterial, whereas in the developing world, coinfection is common and viral and parasitic infections also play a significant role. Most of the childhood deaths under 5 years in developing countries can be attributed to deterioration along the sepsis pathway (infection to sepsis, to severe sepsis, and to septic shock with progressive organ dysfunction). However, pediatric sepsis is rarely discussed as a leading cause of death in developing countries, with the notable exception of neonatal sepsis. Instead, clinical and research programs are vertical in nature, attempting to address specific infectious diseases, such as malaria, pneumonia, or diarrhea, and thus often neglect the common syndromic similarities of severe infectious disease, ie, an inflammatory response that if left uninterrupted often leads to progressive organ dysfunction, shock, and death. The limitations of this vertical focus are further compounded by the fact that many available diagnostic tests are not able to differentiate between vertical diseases.<xref ref-type="bibr" rid="b9-clep-4-319">9</xref>,<xref ref-type="bibr" rid="b10-clep-4-319">10</xref> Furthermore, children with sepsis are often coinfected with multiple pathogens, such as malaria and bacteremia, limiting the effect of vertical treatments.</p><p>The current pediatric sepsis definitions (ie, sepsis, severe sepsis, and septic shock) have evolved primarily as an identification tool for inclusion of children in clinical trials of sepsis interventions, such as activated protein C, rather than for clinical use.<xref ref-type="bibr" rid="b8-clep-4-319">8</xref> They were originally defined based on the adult definition for sepsis developed in 1992.<xref ref-type="bibr" rid="b11-clep-4-319">11</xref>,<xref ref-type="bibr" rid="b12-clep-4-319">12</xref> Despite the fact that these definitions were designed for research purposes, they are often used clinically in developed nations for identification of children who require urgent intervention to stop the progressive inflammatory response. More importantly, they form the basis for development of guidelines aimed at treating the various stages of the sepsis continuum. In both the adult and pediatric definitions of sepsis, meeting two of four variables is required to diagnose SIRS, and therefore sepsis. These variables are temperature, heart rate, respiratory rate, and leukocyte count. One major difference between the adult and pediatric SIRS definition, apart from age-specific cutoffs, is that the pediatric definition requires either an abnormal leukocyte count or abnormal temperature for a diagnosis of SIRS (in adults meeting any two criteria of four is sufficient). This is important because it has been recognized that derangements in heart rate and respiratory rate are common, and do not necessarily denote a significant inflammatory process. It is recognized that defining sepsis, and its various stages, is an iterative process in continual need of refinement.<xref ref-type="bibr" rid="b12-clep-4-319">12</xref> More importantly, it must also be recognized that sepsis definitions should be specific to a region’s resource capacity, much the same way that sepsis treatment guidelines are specific to low-resource versus high-resource settings.<xref ref-type="bibr" rid="b13-clep-4-319">13</xref>,<xref ref-type="bibr" rid="b14-clep-4-319">14</xref></p></sec><sec><title>Issues in resource-limited environments</title><p>Of the three sepsis categories defined in the international pediatric sepsis consensus conference (sepsis, severe sepsis, and septic shock), all require laboratory tests (eg, leukocyte count). In addition, severe sepsis and septic shock require complex organ dysfunction criteria that could only be determined at highly resourced institutions. In many developing countries, even simple laboratory tests, such as leukocyte counts, are often not measured because neither public sector systems nor patients can afford them. A further limitation in using the traditional sepsis definition is the requirement for a core temperature measurement. While probably ideal, the additional time and care required to obtain this, coupled with potential complications of rectal measurements, make a strong case for validation of axillary or oral temperature measurements. With this in mind, sepsis research aiming to influence clinical practice must consider the definitions being used and their applicability to the population being studied. Because sepsis forms the final common pathway of infectious disease mortality, a more pragmatic alternative for identification of children at high risk of mortality related to infectious disease may be justified.</p></sec><sec><title>Possible pragmatic alternatives</title><p>One modified definition of sepsis that could be investigated is to allow for SIRS diagnosis without the inclusion of leukocyte count. This would be a test based solely on the clinical findings of heart rate, respiratory rate, and core temperature (where an abnormal temperature would be a requirement). This approach is much more feasible because even in developed countries, hyperthermia (or hypothermia) is generally considered the first step in a SIRS investigation. A recent study in Latvia among 943 children who were screened for SIRS identified 92 subjects with abnormal temperature according to the sepsis definition, of whom 70% met the SIRS criteria. Only one additional subject met SIRS criteria based on an abnormal leukocyte count without the presence of an abnormal temperature. Although not explicitly stated, an abnormal temperature along with abnormal respiratory rate or heart rate appeared to account for the majority of SIRS cases compared with those who were diagnosed with SIRS based only on temperature and leukocyte count.<xref ref-type="bibr" rid="b15-clep-4-319">15</xref> Therefore, creating a sepsis definition with a focus solely on hyperthermia, rather than a focus on leukocytosis and hyperthermia, will not significantly weaken predictive capability. Currently no studies have examined this proposed definition.</p><p>A second modified definition of sepsis that could be tested is derived from the integrated management of childhood illness guidelines developed by the World Health Organization.<xref ref-type="bibr" rid="b16-clep-4-319">16</xref> The rationale for this is based on a recent cohort study in Kilifi, Kenya.<xref ref-type="bibr" rid="b10-clep-4-319">10</xref> The study applied seven observable criteria (six for subjects more than 60 days old) that are intended to identify children in need of antibiotic therapy, to a cohort of 11,874 admissions between 1999 and 2001 (this could be considered a vertical prediction model of serious bacterial illness). A total of 813 (7%) children died in hospital (no post-discharge surveillance was conducted). Application of these criteria identified 53% of all admitted patients (6281) among whom 12% died (93% sensitivity to predict inpatient death). Of the remaining 5593, only 1% of children died (99% negative predictive value). Therefore, this study provides robust evidence that the use of these criteria does more than identify potential bacterial infections, which is its intended use. It also captures other nonbacterial etiologies, such as severe malaria, which it is not specifically intended to do, and therefore appears to capture children who are entering the inflammatory sepsis pathway to death. Furthermore, it is not reliant on any laboratory tests (with the exception of pulse oximetry, a noninvasive technology growing rapidly for potential use in developing countries) and could be conducted in a variety of health care settings. Thus, in resource-poor settings, this may be a reliable and pragmatic alternative to the traditional sepsis definition, although some sensitivity would likely be lost (with increasing specificity). It would be a very simple criterion because it captures children based on primarily two features, ie, impaired consciousness and respiratory distress. This definition is meant to exclude neonates, and thus the sick infant criteria specifically for neonatal sepsis are excluded. The criteria of skin and soft tissue infection had 0% sensitivity in capturing patients who go on to die in hospital and therefore is not likely of significant value (<xref ref-type="table" rid="t2-clep-4-319">Table 2</xref>).</p><p>While the above proposed alternative sepsis definitions may be pragmatic in terms of the resources required for diagnosis, no research has yet been conducted outlining the sensitivity and specificity of these definitions in capturing either inpatient death or even the degree of overlap between the alternative definitions and the currently used definition. A further area of targeted research would be to develop definitions of increasing therapeutic urgency that are easily applied and would be analogous to the official definitions of severe sepsis and septic shock. The epidemiological discipline of clinical prediction modeling would be of significant benefit in the development of these definitions.</p></sec><sec><title>Post-discharge mortality in children with sepsis</title><p>Recently, a US study of readmission and late mortality after pediatric sepsis found that 50% of children who were discharged were readmitted within a median time of 3 months, most being urgent or emergent.<xref ref-type="bibr" rid="b17-clep-4-319">17</xref> These effects were not primarily due to comorbidities because more than 30% of these patients had no identified comorbidity. While short-term post-discharge mortality was relatively uncommon in this North American population (long-term mortality was 7%), one would expect that in areas where post-discharge follow-up is rare and access to health facilities is difficult, the rates of short-term (eg, 6-month) post-discharge mortality will be substantial. Currently, very little is known as to the reasons why persons who seem to recover from sepsis suffer from re-emergence of illness. Studies of septic patients who died have found that these patients suffered from a significant loss of adaptive immunity, demonstrated by reductions in B cells, CD4 T cells, and follicular dendritic cells.<xref ref-type="bibr" rid="b18-clep-4-319">18</xref> It is possible that these effects may persist, thus predisposing septic patients to recurrent infections following an initial recovery.</p></sec><sec><title>Issues in resource-limited environments</title><p>While our literature search did not identify any post-discharge studies among children admitted with sepsis in developing countries, several studies that were identified did examine post-discharge mortality amongst differing groups of patients in very general terms (<xref ref-type="table" rid="t3-clep-4-319">Table 3</xref>). A 1996 cohort study examined childhood mortality during and after hospitalization in western Kenya, with the intention of determining the therapeutic effect of regimens for the treatment of malaria.<xref ref-type="bibr" rid="b7-clep-4-319">7</xref> Although this study was not designed to elucidate the general burden of disease following discharge from hospital, both baseline demographic and diagnostic information, as well as post-discharge vital status, allow important conclusions to be drawn in this regard. Among the 1223 children admitted to hospital during the observation period, 23% died between admission and 8 weeks post-discharge, with 10% of deaths occurring in hospital and 13% of deaths within 8 weeks following discharge. The largest risk factor for mortality in this study was baseline bacteremia. Patients with bacteremia had a case fatality rate of 35% and accounted for 23% of inpatient deaths and 17% of outpatient deaths. The results of this study reflect results of a more recent study from 2005 examining the effect of community acquired bacteremia among nearly 20,000 children admitted to a district hospital in Kilifi, Kenya.<xref ref-type="bibr" rid="b19-clep-4-319">19</xref> Although this study did not conduct post-discharge follow-up, the overall inhospital mortality rate of 7.1% and the mortality rate of 28.2% among bacteremic patients suggest that the burden of post-discharge morbidity and mortality will likely remain substantial. Recently, the Kilifi Health and Demographic Surveillance Study, which collects information on births, deaths, and migrations in a population of 240,000 people, was linked to the Kilifi district hospital database and a retrospective cohort analysis of post-discharge deaths was conducted.<xref ref-type="bibr" rid="b20-clep-4-319">20</xref> This study reported a post-discharge mortality rate of 4.5% among all children younger than 15 years of age. The most important risk factors for mortality after discharge included weight, hypoxia, and bacteremia.</p><p>Proper post-discharge follow-up is scarce and is further influenced by poor access to quality health services. A study conducted in Guinea Bissau between 1991 and 1996 using a population registry found that of 3647 children discharged, 221 (6.1%) died during the post-discharge period of 12 months, with one third of deaths occurring within 2 weeks of discharge.<xref ref-type="bibr" rid="b21-clep-4-319">21</xref> Most of these deaths (77%) occurred in the home/community rather than during a readmission (14.5%). This study also identified some risk factors for post-discharge mortality, and found that lower age, ethnicity, lower maternal education, discharge without authorization, and a diagnosis of anemia or diarrhea were associated with increased post-discharge mortality.</p><p>Some disease-specific studies have been conducted, with mixed results relating to post-discharge mortality. A reanalysis of a randomized controlled trial of vitamin A intervention in children under 5 years of age living in Tanzania presenting with pneumonia showed that among all patients, intervention and control, the hospital mortality was approximately 3%, with a 24-month post-discharge mortality rate of over 10% (the majority occurring within the first few months).<xref ref-type="bibr" rid="b22-clep-4-319">22</xref> Despite the significant effect of human immunodeficiency virus on overall mortality in this study, several other factors were independently associated with death, including severity of pneumonia, as defined by respiratory rate, hyperthermia, and hypoxemia (very similar to the definition of SIRS). Another study from Guinea-Bissau examined the effect of a financial incentive on childhood mortality from malaria.<xref ref-type="bibr" rid="b23-clep-4-319">23</xref> This study showed that among all patients (control and intervention), the inpatient mortality was approximately 7.5% during the inpatient phase and approximately 2% at day 28. With a mean length of stay of 8 days, this indicates an approximation of 3-week post-discharge mortality. These two studies show that while post-discharge mortality is a problem in all children, etiological-based effects are nevertheless important.</p><p>A recent study in Malawi conducted between 2002 and 2006 examined the association between inpatient and post-discharge mortality among children with severe anemia.<xref ref-type="bibr" rid="b29-clep-4-319">29</xref> Three hundred and fifty-three children aged 6 months to 5 years of age were followed for 18 months post-discharge. In this study, the inpatient mortality rate was 6% and the post-discharge mortality rate was 12%, and with nearly an 18% loss to follow-up, this is likely to be an underestimate. While it is difficult to make a justified correlation between outcomes among those with anemia and those with sepsis, the high proportion of bacteremia, malaria, and human immunodeficiency virus in this cohort (15%, 59%, and 13%, respectively) is quite convincing that sepsis may have contributed to some deaths.</p></sec><sec><title>Possible pragmatic alternatives</title><p>While the resources to follow up all children hospitalized with sepsis exist in developed countries, countries with resource limitations cannot follow suit due to the relatively high prevalence of sepsis and the lack of a robust health infrastructure. Therefore, the models of treatment and follow-up used in developed countries are not applicable in the resource-poor context. The first step in addressing the issue of post-discharge mortality in resource-limited settings is the ability to risk-stratify children with sepsis based on their post-discharge mortality risk. Once high-risk children can be identified, innovative solutions to reduce their mortality risk must be sought. Potential interventions to reduce this risk that could be explored in a research context may include home follow-up by community health workers and nutritional supplements or antimicrobials at discharge.</p><p>Innovative community-based solutions for reduction of neonatal sepsis have been examined and found to have significant potential in reducing mortality. Using a participatory intervention among community clusters in Nepal, a group facilitator met with women to identify local perinatal problems and formulate strategies to address them. While this approach improved institutional delivery, antenatal care, and trained birth attendance, it also significantly reduced neonatal and maternal mortality.<xref ref-type="bibr" rid="b24-clep-4-319">24</xref> In another study, the training of village health workers to treat newborns with serious infectious disease according to a simple algorithm demonstrated that use of village health workers resulted in a lower case fatality rate than referral to a qualified medical provider either locally or at a subdistrict hospital (4.4% versus 14.2%).<xref ref-type="bibr" rid="b25-clep-4-319">25</xref> Therefore, use of a community-based model for follow-up of sepsis survivors at high risk of post-discharge mortality may be a practical solution.</p><p>Post-discharge medications may also be a feasible solution to decrease the burden of morbidity and mortality in children following sepsis. Recently, a randomized, controlled trial in India examined the effect of zinc supplementation during hospitalization in infants with suspected serious bacterial infections. While the study was underpowered to detect a meaningful difference in mortality, a 40% relative reduction in treatment failure was observed.<xref ref-type="bibr" rid="b26-clep-4-319">26</xref> Because zinc has been closely linked with immune function, post-discharge supplementation may prove to reduce mortality significantly, if a high-risk group can be easily identified. Zinc may also play a role in post-discharge morbidity and mortality from sepsis secondary to malaria, pneumonia, and diarrhea because these conditions, especially pneumonia and diarrhea, are thought to benefit from treatment with zinc.<xref ref-type="bibr" rid="b27-clep-4-319">27</xref> Another study investigated the use of post-discharge intermittent prophylactic therapy for malaria in children with severe anemia, and found a 26% reduction in the composite endpoint of readmission or death within 6 months.<xref ref-type="bibr" rid="b28-clep-4-319">28</xref> More studies are needed to determine the effect, if any, on mortality after discharge in this population.</p></sec><sec><title>Conclusion</title><p>Sepsis, while associated with many childhood deaths in developing countries, remains largely neglected. Sepsis definitions that were developed for use in resource-rich nations are perhaps a key limitation to recognition of sepsis at a clinical level and at a research level in resource-poor nations. Furthermore, issues pertaining to mortality following discharge have been largely neglected by the global health community, despite the fact that post-discharge mortality is a key contributor to the millions of unnecessary deaths in children under 5 years of age. Addressing these issues is critical to achieving further reductions in child deaths in developing regions, such as sub-Saharan Africa.</p></sec></body><back><ack><p>Matthew Wiens is supported by fellowships from the Canadian Institutes of Health Research and the Michael Smith Foundation for Health Research and receives research support from the Canadian Child Health Clinician Scientist Program.</p></ack><fn-group><fn><p><bold>Disclosure</bold></p><p>The authors report no conflicts of interest in this work.</p></fn></fn-group><ref-list><title>References</title><ref id="b1-clep-4-319"><label>1</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Husak</surname><given-names>L</given-names></name><name><surname>Marcuzzi</surname><given-names>A</given-names></name><name><surname>Herring</surname><given-names>J</given-names></name><etal></etal></person-group><article-title>National analysis of sepsis hospitalizations and factors contributing to sepsis in-hospital mortality in Canada</article-title><source>Healthc Q</source><year>2010</year><volume>13</volume><issue>Spec No:35</issue><lpage>41</lpage></element-citation></ref><ref id="b2-clep-4-319"><label>2</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Daniels</surname><given-names>R</given-names></name></person-group><article-title>Surviving the first hours in sepsis: getting the basics right (an intensivist’s perspective)</article-title><source>The Journal of antimicrobial chemotherapy</source><year>2011</year><volume>66</volume><issue>Suppl 2</issue><fpage>ii11</fpage><lpage>23</lpage><pub-id pub-id-type="pmid">21398303</pub-id></element-citation></ref><ref id="b3-clep-4-319"><label>3</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Watson</surname><given-names>RS</given-names></name><name><surname>Carcillo</surname><given-names>J</given-names></name></person-group><article-title>Scope and epidemiology of pediatric sepsis</article-title><source>Pediatr Crit Care Med</source><year>2005</year><volume>6</volume><issue>Suppl 3</issue><fpage>S3</fpage><lpage>S5</lpage><pub-id pub-id-type="pmid">15857554</pub-id></element-citation></ref><ref id="b4-clep-4-319"><label>4</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Mangia</surname><given-names>CMF</given-names></name><name><surname>Kissoon</surname><given-names>N</given-names></name><name><surname>Carcillo</surname><given-names>JA</given-names></name></person-group><article-title>Sepsis and septic shock: a global overview</article-title><source>J Pediatr Infect Dis</source><year>2009</year><volume>4</volume><issue>2</issue><fpage>71</fpage><lpage>76</lpage><comment><ext-link ext-link-type="uri" xlink:href="http://iospress.meta-press.com/content/k0675874488027w0/">http://iospress.meta-press.com/content/k0675874488027w0/</ext-link></comment></element-citation></ref><ref id="b5-clep-4-319"><label>5</label><element-citation publication-type="webpage"><collab>Anon</collab><source>Most US adults unfamiliar with sepsis, one of nation’s leading causes of death</source><comment>Available from: <ext-link ext-link-type="uri" xlink:href="http://www.feinsteininstitute.org/Feinstein/Most+US+Adults+Unfamiliar+with+Sepsis">http://www.feinsteininstitute.org/Feinstein/Most+US+Adults+Unfamiliar+with+Sepsis</ext-link>. 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publication-type="journal"><person-group person-group-type="author"><name><surname>Phiri</surname><given-names>KS</given-names></name><name><surname>Calis</surname><given-names>JCJ</given-names></name><name><surname>Faragher</surname><given-names>B</given-names></name><etal></etal></person-group><article-title>Long term outcome of severe anaemia in Malawian children</article-title><source>PLoS One</source><year>2008</year><volume>3</volume><issue>8</issue><fpage>e2903</fpage><pub-id pub-id-type="pmid">18682797</pub-id></element-citation></ref></ref-list></back><floats-group><table-wrap id="t1A-clep-4-319" position="float"><label>Table 1A</label><caption><p>Definition of sepsis according to the international pediatric sepsis consensus conference<xref ref-type="bibr" rid="b8-clep-4-319">8</xref></p></caption><table frame="hsides" rules="groups"><tbody><tr><td align="left" valign="top" rowspan="1" colspan="1"><bold>Systemic inflammatory response syndrome</bold><list list-type="simple"><list-item><p>Presence of at least two of the following, one of which must be abnormal temperature or leukocyte count</p><list list-type="bullet"><list-item><p>Core temperature > 38.5°C or <36°C</p></list-item><list-item><p>Tachycardia or bradycardia (see <xref ref-type="table" rid="t1B-clep-4-319">Table 1B</xref>) in the absence of, eg, external stimulus and drugs</p></list-item><list-item><p>Tachypnea (see <xref ref-type="table" rid="t1B-clep-4-319">Table 1B</xref>) not related to underlying neuromuscular disease or anesthesia</p></list-item><list-item><p>Leukocyte count elevated or depressed (see below)</p></list-item></list></list-item><list-item><p><bold>Infection</bold></p><list list-type="bullet"><list-item><p>Suspected or proven infection caused by any pathogen OR a clinical syndrome associated with a high probability of infection</p></list-item></list></list-item></list></td></tr></tbody></table><table-wrap-foot><fn id="tfn1-clep-4-319"><p>© 2005, Wolters Kluwer Health. Adapted with permission from Goldstein B, Giroir B, Randolph A. International pediatric sepsis consensus conference: definitions for sepsis and organ dysfunction in pediatrics. <italic>Pediatr Crit Care Med</italic>. 2005;6(1):2–8.</p></fn></table-wrap-foot></table-wrap><table-wrap id="t1B-clep-4-319" position="float"><label>Table 1B</label><caption><p>Age specific cutoff values</p></caption><table frame="hsides" rules="groups"><thead><tr><th align="left" valign="top" rowspan="2" colspan="1"><bold>Age group</bold></th><th colspan="2" align="left" valign="top" rowspan="1"><bold>Heart rate, beats per minute</bold><hr></hr></th><th align="left" valign="top" rowspan="2" colspan="1"><bold>Respiratory rate, breaths per minute</bold></th><th align="left" valign="top" rowspan="2" colspan="1"><bold>Leukocyte count × 10<sup>3</sup>/mm<sup>3</sup></bold></th></tr><tr><th align="left" valign="top" rowspan="1" colspan="1"><bold>Tachycardia</bold></th><th align="left" valign="top" rowspan="1" colspan="1"><bold>Bradycardia</bold></th></tr></thead><tbody><tr><td align="left" valign="top" rowspan="1" colspan="1">1 month – 1 year</td><td align="left" valign="top" rowspan="1" colspan="1">>180</td><td align="left" valign="top" rowspan="1" colspan="1"><90</td><td align="left" valign="top" rowspan="1" colspan="1">>34</td><td align="left" valign="top" rowspan="1" colspan="1">>17.5 or <5</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">2–5 years</td><td align="left" valign="top" rowspan="1" colspan="1">>140</td><td align="left" valign="top" rowspan="1" colspan="1">N/A</td><td align="left" valign="top" rowspan="1" colspan="1">>22</td><td align="left" valign="top" rowspan="1" colspan="1">>15.5 or <6</td></tr></tbody></table><table-wrap-foot><fn id="tfn2-clep-4-319"><p><bold>Abbreviation:</bold> N/A, not applicable.</p></fn></table-wrap-foot></table-wrap><table-wrap id="t2-clep-4-319" position="float"><label>Table 2</label><caption><p>Clinical Syndromes for Antibiotic Treatment (age 60 days – 5 years).<xref ref-type="bibr" rid="b10-clep-4-319">10</xref> The new proposed heading reflects that these criteria are not specific to bacterial infections only</p></caption><table frame="hsides" rules="groups"><thead><tr><th align="left" valign="middle" rowspan="1" colspan="1"><bold>IMCI<xref ref-type="table-fn" rid="tfn4-clep-4-319"><sup>§</sup></xref> Heading</bold></th><th align="left" valign="middle" rowspan="1" colspan="1"><bold>Criteria</bold></th><th align="left" valign="middle" rowspan="1" colspan="1"><bold>Modified Sepsis Definition</bold></th><th align="left" valign="middle" rowspan="1" colspan="1"><bold>Criteria</bold></th></tr></thead><tbody><tr><td align="left" valign="top" rowspan="1" colspan="1">Meningitis/encephalopathy</td><td align="left" valign="top" rowspan="1" colspan="1">Neck stiffness, bulging fontanel or impaired consciousness (Blantyre coma score ≤2)</td><td align="left" valign="top" rowspan="1" colspan="1">Impaired Consciousness<break></break>Meningitis/encephalitis</td><td align="left" valign="top" rowspan="1" colspan="1">Blantyre coma score ≤2<break></break>Neck Stiffness or Bulging fontanel</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">Severe malnutrition</td><td align="left" valign="top" rowspan="1" colspan="1">Severe wasting<xref ref-type="table-fn" rid="tfn5-clep-4-319"><sup>¶</sup></xref> or kwashiorkor</td><td align="left" valign="top" rowspan="1" colspan="1">Excluded</td><td align="left" valign="top" rowspan="1" colspan="1">Excluded</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">Very severe pneumonia</td><td align="left" valign="top" rowspan="1" colspan="1">Respiratory distress plus one or more of prostration<xref ref-type="table-fn" rid="tfn7-clep-4-319"><sup>ϕ</sup></xref>, cyanosis or hypoxia<xref ref-type="table-fn" rid="tfn9-clep-4-319">*</xref></td><td align="left" valign="top" rowspan="1" colspan="1">Respiratory Distress</td><td align="left" valign="top" rowspan="2" colspan="1">One of the following: Tachypnea (with cough or difficulty breathing)</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">Severe pneumonia</td><td align="left" valign="top" rowspan="1" colspan="1">Respiratory Distress<xref ref-type="table-fn" rid="tfn6-clep-4-319"><sup>¥</sup></xref></td><td align="left" valign="top" rowspan="1" colspan="1"></td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">Mild pneumonia</td><td align="left" valign="top" rowspan="1" colspan="1">Tachypnea<xref ref-type="table-fn" rid="tfn8-clep-4-319"><sup>ϕ</sup></xref> plus a history of either cough or difficulty breathing</td><td align="left" valign="top" rowspan="1" colspan="1"></td><td align="left" valign="top" rowspan="1" colspan="1">≥ 50 breaths/min if 60d – 1 yr<break></break>≥ 40 breaths/min if ≥ 1 yr<break></break>SaO2 < 90% by pulse oximetry</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">Skin or soft tissue infection</td><td align="left" valign="top" rowspan="1" colspan="1">Cellulitis, abscess, pyomyositis</td><td colspan="2" align="left" valign="top" rowspan="1">Not applicable as 0% sensitive in Kilifi study</td></tr></tbody></table><table-wrap-foot><fn id="tfn3-clep-4-319"><p><bold>Notes:</bold></p></fn><fn id="tfn4-clep-4-319"><label>§</label><p>Integrated Management of Childhood Illness;</p></fn><fn id="tfn5-clep-4-319"><label>¶</label><p>Weight for age z score <−4;</p></fn><fn id="tfn6-clep-4-319"><label>¥</label><p>Lower chest wall indrawing or abnormally deep breathing;</p></fn><fn id="tfn7-clep-4-319"><label>ϕ</label><p>Inability to sit unassisted if aged ≥ 1 year or inability to drink or breastfeed if aged < 1 year;</p></fn><fn id="tfn8-clep-4-319"><label>φϕ</label><p>≥ 50 breaths per minute if aged 60 days to 1 year; ≥ 40 breaths per minute if ≥ 1 year old;</p></fn><fn id="tfn9-clep-4-319"><label>*</label><p>SaO2 < 90% by pulse oximetry. © 2005, BMJ Publishing Group Ltd. Adapted with permission from Berkley JA, Maitland K, Mwangi I et al. Use of clinical syndromes to target antibiotic prescribing in seriously ill children in malaria endemic area: observational study. <italic>BMJ</italic>. 2005;330(7498):995.</p></fn></table-wrap-foot></table-wrap><table-wrap id="t3-clep-4-319" position="float"><label>Table 3</label><caption><p>Summary of most pertinent studies evaluating post-discharge mortality in children in Africa</p></caption><table frame="hsides" rules="groups"><thead><tr><th align="left" valign="top" rowspan="1" colspan="1"><bold>Study</bold></th><th align="left" valign="top" rowspan="1" colspan="1"><bold>Study period</bold></th><th align="left" valign="top" rowspan="1" colspan="1"><bold>Country</bold></th><th align="left" valign="top" rowspan="1" colspan="1"><bold>Population</bold></th><th align="left" valign="top" rowspan="1" colspan="1"><bold>Inpatient mortality</bold></th><th align="left" valign="top" rowspan="1" colspan="1"><bold>Post-discharge mortality</bold></th><th align="left" valign="top" rowspan="1" colspan="1"><bold>Post-discharge observation period</bold></th></tr></thead><tbody><tr><td align="left" valign="top" rowspan="1" colspan="1">Zucker et al<xref ref-type="bibr" rid="b7-clep-4-319">7</xref></td><td align="left" valign="top" rowspan="1" colspan="1">1991</td><td align="left" valign="top" rowspan="1" colspan="1">Kenya</td><td align="left" valign="top" rowspan="1" colspan="1">All children under 5 years admitted to hospital</td><td align="left" valign="top" rowspan="1" colspan="1">10%</td><td align="left" valign="top" rowspan="1" colspan="1">13%</td><td align="left" valign="top" rowspan="1" colspan="1">8 weeks</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">Moïsi et al<xref ref-type="bibr" rid="b20-clep-4-319">20</xref></td><td align="left" valign="top" rowspan="1" colspan="1">2003–2008</td><td align="left" valign="top" rowspan="1" colspan="1">Kenya</td><td align="left" valign="top" rowspan="1" colspan="1">All children under 15 years in KHDSS population</td><td align="left" valign="top" rowspan="1" colspan="1">n/a</td><td align="left" valign="top" rowspan="1" colspan="1">4.5%</td><td align="left" valign="top" rowspan="1" colspan="1">12 months</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">Phiri et al<xref ref-type="bibr" rid="b29-clep-4-319">29</xref></td><td align="left" valign="top" rowspan="1" colspan="1">2002–2004</td><td align="left" valign="top" rowspan="1" colspan="1">Malawi</td><td align="left" valign="top" rowspan="1" colspan="1">6–60 months with severe anemia</td><td align="left" valign="top" rowspan="1" colspan="1">6.4%</td><td align="left" valign="top" rowspan="1" colspan="1">12.6%</td><td align="left" valign="top" rowspan="1" colspan="1">18 months</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">Veirum et al<xref ref-type="bibr" rid="b21-clep-4-319">21</xref></td><td align="left" valign="top" rowspan="1" colspan="1">1991–1996</td><td align="left" valign="top" rowspan="1" colspan="1">Guinea-Bissau</td><td align="left" valign="top" rowspan="1" colspan="1">All children</td><td align="left" valign="top" rowspan="1" colspan="1">12.1%</td><td align="left" valign="top" rowspan="1" colspan="1">6.1%</td><td align="left" valign="top" rowspan="1" colspan="1">12 months</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">Villamor et al<xref ref-type="bibr" rid="b22-clep-4-319">22</xref></td><td align="left" valign="top" rowspan="1" colspan="1">1993–1997</td><td align="left" valign="top" rowspan="1" colspan="1">Tanzania</td><td align="left" valign="top" rowspan="1" colspan="1">6–60 months with pneumonia</td><td align="left" valign="top" rowspan="1" colspan="1">3%</td><td align="left" valign="top" rowspan="1" colspan="1">10%</td><td align="left" valign="top" rowspan="1" colspan="1">24 months</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">Biai et al<xref ref-type="bibr" rid="b23-clep-4-319">23</xref></td><td align="left" valign="top" rowspan="1" colspan="1">2004–2006</td><td align="left" valign="top" rowspan="1" colspan="1">Guinea-Bissau</td><td align="left" valign="top" rowspan="1" colspan="1">3–60 months with malaria</td><td align="left" valign="top" rowspan="1" colspan="1">7.5%</td><td align="left" valign="top" rowspan="1" colspan="1">1.5%</td><td align="left" valign="top" rowspan="1" colspan="1">About 20 days</td></tr></tbody></table><table-wrap-foot><fn id="tfn10-clep-4-319"><p><bold>Abbreviations:</bold> KHDSS, Kilifi Health Demographic Surveillance Study; n/a, not available.</p></fn></table-wrap-foot></table-wrap></floats-group></pmc></record>Pour manipuler ce document sous Unix (Dilib)
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