Development and Validation of the Phoenix Criteria for Pediatric Sepsis and Septic Shock

Abstract

ImportanceThe Society of Critical Care Medicine Pediatric Sepsis Definition Task Force sought to develop and validate new clinical criteria for pediatric sepsis and septic shock using measures of organ dysfunction through a data-driven approach.ObjectiveTo derive and validate novel criteria for pediatric sepsis and septic shock across differently resourced settings.Design, Setting, and ParticipantsMulticenter, international, retrospective cohort study in 10 health systems in the US, Colombia, Bangladesh, China, and Kenya, 3 of which were used as external validation sites. Data were collected from emergency and inpatient encounters for children (aged <18 years) from 2010 to 2019: 3 049 699 in the development (including derivation and internal validation) set and 581 317 in the external validation set.ExposureStacked regression models to predict mortality in children with suspected infection were derived and validated using the best-performing organ dysfunction subscores from 8 existing scores. The final model was then translated into an integer-based score used to establish binary criteria for sepsis and septic shock.Main Outcomes and MeasuresThe primary outcome for all analyses was in-hospital mortality. Model- and integer-based score performance measures included the area under the precision recall curve (AUPRC; primary) and area under the receiver operating characteristic curve (AUROC; secondary). For binary criteria, primary performance measures were positive predictive value and sensitivity.ResultsAmong the 172 984 children with suspected infection in the first 24 hours (development set; 1.2% mortality), a 4-organ-system model performed best. The integer version of that model, the Phoenix Sepsis Score, had AUPRCs of 0.23 to 0.38 (95% CI range, 0.20-0.39) and AUROCs of 0.71 to 0.92 (95% CI range, 0.70-0.92) to predict mortality in the validation sets. Using a Phoenix Sepsis Score of 2 points or higher in children with suspected infection as criteria for sepsis and sepsis plus 1 or more cardiovascular point as criteria for septic shock resulted in a higher positive predictive value and higher or similar sensitivity compared with the 2005 International Pediatric Sepsis Consensus Conference (IPSCC) criteria across differently resourced settings.Conclusions and RelevanceThe novel Phoenix sepsis criteria, which were derived and validated using data from higher- and lower-resource settings, had improved performance for the diagnosis of pediatric sepsis and septic shock compared with the existing IPSCC criteria.

Pediatric Phoenix Sepsis Score Validation Challenges in Low-Resource Settings and in the Emergency Department—Reply

“…In comparison, at the other] lower resource site with complete data…[the] prevalence” was estimated at 15.1% of children with suspected infection. We agree that, overall, the mortality for each score is higher in lower- vs higher-resource settings . As noted in eFigure 2, children from lower-resource settings also had higher mortality among all hospitalizations (1.7% vs 0.1%) and hospitalizations with suspected infection (3.6% vs 0.7%).…”

Phoenix Sepsis Score and Risk of Attributable Mortality in Children With Cancer

“…We calculated the Phoenix Sepsis Score using worst values recorded within 24 hours after the ICU admission, and then recalculated excluding platelet count (PHO-Phoenix). 4 We estimated area under the receiver operating characteristic curve (AUROC) for classification of outcomes, including attributable mortality, definitely attributable mortality, all-cause mortality, and prolonged ICU stay (ie, more than 7 days). 1 , 5 AUROCs were numerically compared with PRISM3, pSOFA, qSOFA, and PELOD2 scores.…”

“… 3 However, children with cancer may have preexisting organ dysfunction affecting score performance, pediatric oncology subgroup analyses are unpublished, and the score has not been validated in pediatric oncology. 3 , 4 …”

phoenix: an R package and Python module for calculating the Phoenix pediatric sepsis score and criteria

“… 1 In January 2024, the Phoenix diagnostic criteria for pediatric sepsis were published to supersede the criteria 2 defined by the International Pediatrics Sepsis Criteria Conference in 2005. 3 , 4 Transitioning to the Phoenix criteria is a conceptual change, moving away from an inflammatory response-based criteria to a life-threatening organ dysfunction-based criteria. This change parallels the conceptual change for the diagnostic criteria of adult sepsis.…”