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Published on: January 27, 2019
Risk of Mortality in Immunocompromised Children With Severe Sepsis and Septic Shock
Robert B Lindell1,2, Akira Nishisaki1,3, Scott L Weiss1,2
1Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
Insights
Twenty-eight percent of children with severe sepsis or septic shock have immunocompromised diagnoses. Conditions like congenital immunodeficiency and prior malignancies increase mortality risk in these pediatric patients.
Area of Science:
- Pediatric critical care medicine
- Immunology
- Epidemiology
Background:
- Severe sepsis and septic shock pose significant risks to children.
- Understanding the impact of immunocompromised status on pediatric sepsis outcomes is crucial for targeted interventions.
Purpose of the Study:
- To determine the prevalence of immunocompromised diagnoses in children with severe sepsis or septic shock.
- To analyze the association between immunocompromised status and clinical outcomes, including pediatric intensive care unit (PICU) mortality.
Main Methods:
- A retrospective multicenter cohort study was conducted using data from 83 centers.
- International Classification of Diseases, 9th Revision, Clinical Modification codes identified 10,768 pediatric severe sepsis/septic shock admissions.
- Mixed-effect logistic regression models were used to assess mortality risk factors.
Main Results:
- 28% of pediatric severe sepsis/septic shock patients had an immunocompromised diagnosis.
- Congenital immunodeficiency, multiple prior malignancies, and hemophagocytic lymphohistiocytosis were associated with increased PICU mortality.
- Hematopoietic cell transplant recipients with liquid malignancy also showed higher mortality risk.
Conclusions:
- Immunocompromised diagnoses are common in pediatric severe sepsis and septic shock, significantly impacting mortality.
- Specific conditions like congenital immunodeficiency and prior malignancies are independent risk factors for mortality.
- Variations in PICU mortality exist across centers, independent of patient factors and center sepsis volume.
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.
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