Children Who Die From Sepsis Frequently Have Pediatric PICS Phenotype

Nearly half of pediatric patients who died with culture-positive sepsis had a phenotype for pediatric persistent inflammation, immunosuppression, and catabolism syndrome (pPICS), according to a study in Chest.

PICS, which describes a lack of resolution in the inflammatory cascade, has been linked to delayed mortality from sepsis. Researchers sought to determine the prevalence of this condition in pediatric patients with sepsis-related mortality and to compare clinical characteristics of these pediatric patients to those of pediatric patients that survived sepsis.

The study used de-identified electronic health record data from Nashville-based Vanderbilt University Medical Center from all deceased patients born after 1997 with an ICD-9 or -10 code associated with sepsis or a systemic infection. Participants were up to 21 years of age at admission, died in the hospital, and had a culture-positive sepsis event during the terminal hospitalization.

The criteria for pPICS were documentation of at least 2 of the following conditions within 7 days of each other: albumin less than 3.0 g/dL; C-reactive protein (CRP) greater than 10 mg/L; and/or absolute lymphocyte count (ALC) less than 1.0 × 10³/μL.

The analysis included 557 patients, of whom 262 (47%) were classified as having pPICS. The median age for all children included for analysis was less than 1 year old; however, participants with pPICS were older, with a median age of 0.75 years (interquartile range [IQR], 0.24-8.58) vs a median age of 0.22 years (IQR, 0.05-0.97); for those without pPICS (P <.001).

There was an increased frequency of pPICS among patients with vs without hematologic/oncologic disease (29% vs 17.3%; an adjusted odds ratio [aOR], 3.19; CI, 1.62-6.43; P =.001).

Multivariable logistic regression analysis demonstrated that the odds of a pPICS phenotype were greater among pediatric patients admitted to the cardiac intensive care unit (CICU) vs the pediatric intensive care unit (PICU) (aOR, 3.43; CI, 1.57-7.64; P =.002).

A subgroup analysis of 366 patients (65.7%) who were hospitalized for at least 14 days was consistent with the primary results; this subgroup also found that the odds of pPICS were higher in patients with hematologic/oncologic disease vs those without (aOR 2.81; CI, 1.07-7.66; P =.038) and in those admitted to the CICU vs those admitted to the PICU (aOR 2.95; CI, 1.13-7.83; P =.028).

Patients with a fungal infection vs those without had a greater than 2 times odds of pPICS (aOR 2.69; CI, 1.59-4.61, P <.001), according to multivariable logistic regression. Comparable odds of fungal infections in patients with pPICS occurred in those who survived to day 14 of hospitalization (aOR 2.03; CI, 1.11-3.75; P =.022).

In a comparison of data from patients with pPICS vs those without pPICS by day of hospitalization, an expected reduced lymphocyte count was observed in patients with pPICS, which decreased during the hospital stay. Of the 3 laboratory criteria for pPICS, the ALC was the best predictor (area under the curve, 0.84; P <.001), with CRP and albumin performing less well.

Study limitations include the retrospective analysis of de-identified medical records and possible underestimation of the overall number of confirmed patients with pPICS and number of culture-positive patients. Also, because only patients who died were evaluated, there was no cohort of culture-positive survivors for comparing the overall prevalence of pPICS in sepsis or of the pathogens present.

“The development of pPICS occurred in approximately 47% of all patients who died with culture-positive sepsis,” stated the study authors. “In addition, it was found that patients who died with a pPICS phenotype were older, had increased odds of mortality related to fungal infections, and an increased likelihood of having underlying hematologic/oncologic or cardiac disease with the highest overall proportion occurring in patients in the CICU.”

This article originally appeared on Pulmonology Advisor