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Risk of Mortality in Immunocompromised Children With Severe Sepsis and Septic Shock.
Crit Care Med. 2020 07; 48(7):1026-1033.CC

Abstract

OBJECTIVES

To assess the prevalence of immunocompromised diagnoses among children with severe sepsis and septic shock, and to determine the association between immunocompromised diagnoses and clinical outcomes after adjustment for demographics and illness severity.

DESIGN

Retrospective multicenter cohort study.

SETTING

Eighty-three centers in the Virtual Pediatric Systems database.

PATIENTS

Children with severe sepsis or septic shock admitted to a participating PICU between January 1, 2012, and December 31, 2016.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Across 83 centers, we identified 10,768 PICU admissions with an International Classification of Diseases, 9th Revision, Clinical Modification code for severe sepsis or septic shock; 3,021 of these patients (28%) had an immunocompromised diagnosis. To evaluate variation across centers and determine factors associated with PICU mortality, we used mixed-effect logistic regression models. Among patients without hematopoietic cell transplant, congenital immunodeficiency (adjusted odds ratio, 1.90; 95% CI, 1.24-2.92), multiple prior malignancies (adjusted odds ratio, 1.86; 95% CI, 1.15-2.99), and hemophagocytic lymphohistiocytosis (adjusted odds ratio, 3.09; 95% CI, 1.91-4.98) were associated with an increased odds of PICU mortality. Among patients with prior hematopoietic cell transplant, liquid malignancy (adjusted odds ratio, 3.15; 95% CI, 2.09-4.74), congenital immunodeficiency (adjusted odds ratio, 6.94; 95% CI, 3.84-12.53), multiple prior malignancies (adjusted odds ratio, 3.54; 95% CI, 1.80-6.95), and hemophagocytic lymphohistiocytosis (adjusted odds ratio, 2.79; 95% CI, 1.36-5.71) were associated with an increased odds of PICU mortality. PICU mortality varied significantly by center, and a higher mean number of sepsis patients per month in a center was associated with lower PICU mortality (adjusted odds ratio, 0.94; 95% CI, 0.90-0.98). PICU resource utilization varied by immunocompromised diagnosis and history of hematopoietic cell transplant, and among survivors immunocompromised patients have shorter median PICU length of stay compared with patients without immunocompromised diagnoses (p < 0.001).

CONCLUSIONS

Immunocompromised diagnoses are present in 28% of children with severe sepsis or septic shock. Multiple prior malignancies, hemophagocytic lymphohistiocytosis, congenital immunodeficiency, and hematopoietic cell transplant are independently associated with an increased odds of PICU mortality in children with severe sepsis or septic shock. Significant variation exists in PICU mortality among centers despite adjustment for immunocompromised diagnoses, known risk factors for sepsis-related mortality, and center-level sepsis volume.

Authors+Show Affiliations

Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA. Pediatric Sepsis Program, Children's Hospital of Philadelphia, Philadelphia, PA.Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA. Center for Critical Care Evidence and Outcomes, Children's Hospital of Philadelphia, Philadelphia, PA.Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA. Pediatric Sepsis Program, Children's Hospital of Philadelphia, Philadelphia, PA.Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA. Center for Critical Care Evidence and Outcomes, Children's Hospital of Philadelphia, Philadelphia, PA.Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA. Pediatric Sepsis Program, Children's Hospital of Philadelphia, Philadelphia, PA.

Pub Type(s)

Journal Article
Multicenter Study
Research Support, N.I.H., Extramural
Research Support, Non-U.S. Gov't
Research Support, U.S. Gov't, P.H.S.

Language

eng

PubMed ID

32301846

Citation

Lindell, Robert B., et al. "Risk of Mortality in Immunocompromised Children With Severe Sepsis and Septic Shock." Critical Care Medicine, vol. 48, no. 7, 2020, pp. 1026-1033.
Lindell RB, Nishisaki A, Weiss SL, et al. Risk of Mortality in Immunocompromised Children With Severe Sepsis and Septic Shock. Crit Care Med. 2020;48(7):1026-1033.
Lindell, R. B., Nishisaki, A., Weiss, S. L., Traynor, D. M., & Fitzgerald, J. C. (2020). Risk of Mortality in Immunocompromised Children With Severe Sepsis and Septic Shock. Critical Care Medicine, 48(7), 1026-1033. https://doi.org/10.1097/CCM.0000000000004329
Lindell RB, et al. Risk of Mortality in Immunocompromised Children With Severe Sepsis and Septic Shock. Crit Care Med. 2020;48(7):1026-1033. PubMed PMID: 32301846.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Risk of Mortality in Immunocompromised Children With Severe Sepsis and Septic Shock. AU - Lindell,Robert B, AU - Nishisaki,Akira, AU - Weiss,Scott L, AU - Traynor,Danielle M, AU - Fitzgerald,Julie C, PY - 2020/4/18/pubmed PY - 2021/5/19/medline PY - 2020/4/18/entrez SP - 1026 EP - 1033 JF - Critical care medicine JO - Crit Care Med VL - 48 IS - 7 N2 - OBJECTIVES: To assess the prevalence of immunocompromised diagnoses among children with severe sepsis and septic shock, and to determine the association between immunocompromised diagnoses and clinical outcomes after adjustment for demographics and illness severity. DESIGN: Retrospective multicenter cohort study. SETTING: Eighty-three centers in the Virtual Pediatric Systems database. PATIENTS: Children with severe sepsis or septic shock admitted to a participating PICU between January 1, 2012, and December 31, 2016. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Across 83 centers, we identified 10,768 PICU admissions with an International Classification of Diseases, 9th Revision, Clinical Modification code for severe sepsis or septic shock; 3,021 of these patients (28%) had an immunocompromised diagnosis. To evaluate variation across centers and determine factors associated with PICU mortality, we used mixed-effect logistic regression models. Among patients without hematopoietic cell transplant, congenital immunodeficiency (adjusted odds ratio, 1.90; 95% CI, 1.24-2.92), multiple prior malignancies (adjusted odds ratio, 1.86; 95% CI, 1.15-2.99), and hemophagocytic lymphohistiocytosis (adjusted odds ratio, 3.09; 95% CI, 1.91-4.98) were associated with an increased odds of PICU mortality. Among patients with prior hematopoietic cell transplant, liquid malignancy (adjusted odds ratio, 3.15; 95% CI, 2.09-4.74), congenital immunodeficiency (adjusted odds ratio, 6.94; 95% CI, 3.84-12.53), multiple prior malignancies (adjusted odds ratio, 3.54; 95% CI, 1.80-6.95), and hemophagocytic lymphohistiocytosis (adjusted odds ratio, 2.79; 95% CI, 1.36-5.71) were associated with an increased odds of PICU mortality. PICU mortality varied significantly by center, and a higher mean number of sepsis patients per month in a center was associated with lower PICU mortality (adjusted odds ratio, 0.94; 95% CI, 0.90-0.98). PICU resource utilization varied by immunocompromised diagnosis and history of hematopoietic cell transplant, and among survivors immunocompromised patients have shorter median PICU length of stay compared with patients without immunocompromised diagnoses (p < 0.001). CONCLUSIONS: Immunocompromised diagnoses are present in 28% of children with severe sepsis or septic shock. Multiple prior malignancies, hemophagocytic lymphohistiocytosis, congenital immunodeficiency, and hematopoietic cell transplant are independently associated with an increased odds of PICU mortality in children with severe sepsis or septic shock. Significant variation exists in PICU mortality among centers despite adjustment for immunocompromised diagnoses, known risk factors for sepsis-related mortality, and center-level sepsis volume. SN - 1530-0293 UR - https://www.unboundmedicine.com/medline/citation/32301846/Risk_of_Mortality_in_Immunocompromised_Children_With_Severe_Sepsis_and_Septic_Shock_ L2 - https://dx.doi.org/10.1097/CCM.0000000000004329 DB - PRIME DP - Unbound Medicine ER -