Clinical Presentation and Outcomes among Children with Sepsis Presenting to a Public Tertiary Hospital in Tanzania

Abstract

BackgroundPediatric sepsis causes significant global morbidity and mortality and low- and middle-income countries (LMICs) bear the bulk of the burden. International sepsis guidelines may not be relevant in LMICs, especially in sub-Saharan Africa (SSA), due to resource constraints and population differences. There is a critical lack of pediatric sepsis data from SSA, without which accurate risk stratification tools and context-appropriate, evidence-based protocols cannot be developed. The study’s objectives were to characterize pediatric sepsis presentations, interventions, and outcomes in a public Emergency Medicine Department (EMD) in Tanzania.MethodsProspective descriptive study of children (28 days to 14 years) with sepsis [suspected infection with ≥2 clinical systemic inflammatory response syndrome (SIRS) criteria] presenting to a tertiary EMD in Dar es Salaam, Tanzania (July 1 to September 30, 2016). Outcomes included: in-hospital mortality (primary), EMD mortality, and hospital length of stay. We report descriptive statistics using means and SDs, medians and interquartile ranges, and counts and percentages as appropriate. Predictive abilities of SIRS criteria, the Alert-Verbal-Painful-Unresponsive (AVPU) score and the Lambaréné Organ Dysfunction Score (LODS) for in-hospital, early and late mortality were tested.ResultsOf the 2,232 children screened, 433 (19.4%) met inclusion criteria, and 405 were enrolled. There were 247 (61%) subjects referred from an outside facility. Approximately half (54.1%) received antibiotics in the EMD, and some form of microbiologic culture was collected in 35.8% (n = 145) of subjects. In-hospital and EMD mortality were 14.2 and 1.5%, respectively, median time to death was 3 days (IQR 1–6), and median length of stay was 6 days (IQR 1–12). SIRS criteria, the AVPU score, and the LODS had low positive (17–27.1, 33.3–43.9, 18.3–55.6%, respectively) and high negative predictive values (88.6–89.8, 86.5–91.2, 86.8–90.5%, respectively) for in-hospital mortality.ConclusionThis pediatric sepsis cohort had high and early in-hospital mortality. Current criteria and tested clinical scores were inadequate for risk-stratification and mortality prediction in this population and setting. Pediatric sepsis management must take into account the local patient population, etiologies of sepsis, healthcare system, and resource availability. Only through studies such as this that generate regional data in LMICs can accurate risk stratification tools and context-appropriate, evidence-based guidelines be developed.

Assessing the causes of under-five mortality and proportion associated with pneumococcal diseases in Cameroon. A case-finding retrospective observational study: 2006–2012

“…This finding aligns with previous reports that, in a malaria endemic region like Cameroon, affected children have an increased risk to die from septic shock resulting secondarily from severe anaemia and/or bacteraemia [32,33]. More so, sepsis is described as a cascade of diseases involving a systemic inflammatory response syndrome (SIRS) in the midst of infection, intensifying in septic shock to cardiovascular and organ system dysfunction [34]. Some authors have attributed this systemic organ dysfunction as the last inflammatory stage for a majority of infectious disease-related paediatric deaths globally [34–36].…”

“…More so, sepsis is described as a cascade of diseases involving a systemic inflammatory response syndrome (SIRS) in the midst of infection, intensifying in septic shock to cardiovascular and organ system dysfunction [34]. Some authors have attributed this systemic organ dysfunction as the last inflammatory stage for a majority of infectious disease-related paediatric deaths globally [34–36]. This phenomenon is consistent with our findings in which a myriad of infections resulting from HIV/AIDS (3.5%), Streptococcus pneumoniae (8.3%), malignancies (8.2%), ischemic heart diseases (2.3%), conditions from perinatal period (4.4%) and aplastic anaemia due to other external agents (6.1%) could be important underlying contributors to under-five deaths, although they were recorded as individual CoD (Table 2).…”

“…The contributions of non-communicable diseases including malignancies/tumours and/or generalized lymph nodes to under-five deaths in the Yaoundé study area should not be undermined. Previous studies on causes of under-five mortality in SSA have scarcely highlighted the role of malignancies and related CoD, as there is too much focus on communicable infections [1,18,34,35,38].…”

Distinct Biomarker Profiles Distinguish Malawian Children with Malarial and Non-malarial Sepsis

“…The logistic regression model used to calculate the AUROC for the combined model in Figure 3 is, therefore, restricted to subjects with available IL-1β measurements, limiting generalizability. Fifth, the SIRS criteria are the current accepted pediatric definition of sepsis, but these criteria have been criticized for being too sensitive and nonspecific for pediatric sepsis and outcomes 49,63 ; new criteria similar to the adult Sepsis-3 and Sequential Organ Failure Assessment (SOFA) score may be released shortly. [64][65][66] Finally, generalizability of the study is uncertain; there may be important differences between our study population, which excluded children with severe malaria, HIV infection, and chronic illnesses, and the general SSA pediatric population.…”

“…The logistic regression models included combinations of the highest performing biomarkers as well as risk factors for sepsis (age, malaria infection, and malnutrition determined by WAZ) selected a priori based on the literature. [47][48][49] To test whether parasite density was correlated with biomarkers, we tested for correlations between logtransformed biomarker concentrations and log-transformed malaria parasite density using Spearman's rank test. We used Stata MP 14.2 for data analysis.…”