Prevalence and outcomes of sepsis in children admitted to public and private hospitals in Latin America: a multicenter observational study

Souza, Daniela Carla; Barreira, Eliane Roseli; Shieh, Huei Hsin; Ventura, Andrea Maria Cordeiro; Bousso, Albert; Troster, Eduardo Juan

doi:10.5935/0103-507X.20210030

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Revista Brasileira de Terapia Intensiva

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ORIGINAL ARTICLE • Rev. bras. ter. intensiva 33 (2) • Apr-Jun 2021 • https://doi.org/10.5935/0103-507X.20210030 copy

Prevalence and outcomes of sepsis in children admitted to public and private hospitals in Latin America: a multicenter observational study

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objective:

To report the prevalence and outcomes of sepsis in children admitted to public and private hospitals.

Methods:

Post hoc analysis of the Latin American Pediatric Sepsis Study (LAPSES) data, a cohort study that analyzed the prevalence and outcomes of sepsis in critically ill children with sepsis on admission at 21 pediatric intensive care units in five Latin American countries.

Results:

Of the 464 sepsis patients, 369 (79.5%) were admitted to public hospitals and 95 (20.5%) to private hospitals. Compared to those admitted to private hospitals, sepsis patients admitted to public hospitals did not differ in age, sex, immunization status, hospital length of stay or type of admission but had higher rates of septic shock, higher Pediatric Risk of Mortality (PRISM), Pediatric Index of Mortality 2 (PIM 2), and Pediatric Logistic Organ Dysfunction (PELOD) scores, and higher rates of underlying diseases and maternal illiteracy. The proportion of patients admitted from pediatric wards and sepsis-related mortality were higher in public hospitals. Multivariate analysis did not show any correlation between mortality and the type of hospital, but mortality was associated with greater severity on pediatric intensive care unit admission in patients from public hospitals.

Conclusion:

In this sample of critically ill children from five countries in Latin America, the prevalence of septic shock within the first 24 hours at admission and sepsis-related mortality were higher in public hospitals than in private hospitals. Higher sepsis-related mortality in children admitted to public pediatric intensive care units was associated with greater severity on pediatric intensive care unit admission but not with the type of hospital. New studies will be necessary to elucidate the causes of the higher prevalence and mortality of pediatric sepsis in public hospitals.

Keywords:
Sepsis; Septic, shock; Critical illness; Child; Hospital, public; Hospital, private; Latin America; Intensive care units; Intensive care units, pediatric; Prevalence; Mortality

Variable	Public	Private	p value
General characteristics and physical structure
Type of hospital			0.48
General hospital	9 (69.2)	7 (87.5)
Children's hospital	3 (23.1)	1 (12.5)
Maternity hospital	1 (7.7)	0
Type of ICU			0.92
Neonatal and pediatric	3 (23.1)	2 (25)
Pediatric	9 (69.2)	5 (62.5)
Adult and pediatric	1 (7.1)	1 (12.5)
Specialized pediatric ICUs			> 0.99
No	12 (92.3)	8 (100)
Oncology	1 (7.7)	0
Number of hospital beds			0.05
< 100	0	2 (25)
100 - 500	11 (84.6)	6 (75)
> 500	2 (15.4)	0
Number of pediatric ICU beds.	11.5 ± 6.0	13.8 ± 4.9	0.21
Care for trauma patients	6 (46.2)	8 (100)	0.01
Care for heart surgery patients	3 (23.1)	6 (75)	0.03
Care for neurosurgery patients	10 (76.9)	8 (100)	0.25
Care for organ transplant patients	4 (30.8)	0	0.13
Human resources
Full-time chief medical officer	5 (38.5)	4 (50)	0.67
Full-time attending physician	13 (100)	8 (100)	-
Daily physician specialized in pediatric intensive care	12 (92.3)	5 (62.5)	0.25
Daily pediatric resident	13 (100)	4 (50)	0.01
Daily pediatric intensive care fellow	9 (69.2)	3 (37.5)	0.20
Full-time ICU nurse	13 (100)	8 (100)	-
Head nurse exclusive to the pediatric ICU	12 (92.3)	7 (87.5)	> 0.99
Attending nurse exclusive to the pediatric ICUs	12 (92.3)	7 (87.5)	> 0.99
Ratio of nurses/pediatric ICU beds up to 1:10	12 (100)	6 (75)	0.14
Ratio of nursing technicians/pediatric ICUs beds up to 1:2	9 (69.2)	4 (57.1)	0.65
Respiratory therapist exclusive to the pediatric ICU	6 (46.2)	8 (100)	0.01
Nutritionist working in the pediatric ICU	10 (76.9)	7 (100)	0.52
Pharmacist working in the pediatric ICU	6 (46.2)	4 (50)	> 0.99
Psychologist working in the pediatric ICU	10 (76.9)	6 (75)	> 0.99
Occupational therapist working in the pediatric ICU	5 (38.5)	1 (12.5)	0.33
Physical structure. equipment and services
Heart monitor/bed = 1:1	12 (92.3)	8 (100)	> 0.99
Pulse oximeter/bed = 1:1	12 (92.3)	8 (100)	> 0.99
Mechanical ventilator/bed = 1:1	12 (92.3)	8 (100)	> 0.99
Capnography monitoring	10 (90.9)	7 (87.5)	> 0.99
Medical prescription system	6 (66.7)	6 (75)	> 0.99
HFOV	5 (38.5)	4 (50)	0.67
Noninvasive ventilator	13 (100)	8 (100)	-
Continuous blood pressure monitoring	12 (92.3)	8 (100)	> 0.99
CO₂ monitoring	6 (46.2)	6 (75)	0.36
Continuous SvO₂ monitoring	3 (23.1)	1 (12.5)	> 0.99
Intracranial pressure monitoring	9 (69.2)	8 (100)	0.13
Respiratory mechanics monitoring	11 (84.6)	8 (100)	0.50
Invasive hemodynamics monitoring	9 (69.2)	6 (75)	> 0.99
iNO	6 (46.2)	2 (25)	0.40
Full time clinical analysis laboratory	13 (100)	8 (100)	-
Full time blood bank	13 (100)	7 (87.5)	0.38
Full time operating room	13 (100)	8 (100)	-
Full time radiology service	13 (100)	8 (100)	-
Daily echocardiography in the pediatric ICU	9 (75)	6 (75)	> 0.99
Full-time computed tomography	13 (100)	8 (100)	-
Access to MRI	8 (61.5)	5 (62.5)	> 0.99
Peritoneal dialysis in the pediatric ICU	13 (100)	8 (100)	-
Hemodialysis in the pediatric ICU	10 (76.9)	4 (50)	0.346

Variable	Public n = 369	Private n = 95	p value
Characteristics
Age in months	11.3 [3.2 - 52.2]	13 [3.4 - 43]	0.77
Male	188 (51.1)	54 (57.4)	0.27
PRISM	11 [6 - 17.3]	8 [5 - 14.8]	< 0.01
PIM 2	6.3 [1.9 - 15.1]	2.5 [1 - 8]	< 0.01
PELOD	11.2 ± 9.8	5.7 ± 7.2	< 0.01
Number of organ dysfunctions (PELOD)	2.1 ± 1.4	1.1 ± 1	< 0.01
Pediatric ICU length of stay in days	7 [3 - 14]	8 [3 - 16]	0.41
Complete immunization schedule	173 (74.2)	74 (81.3)	0.17
Maternal illiteracy	104 (36.1)	15 (17.9)	< 0.01
Source of admission			0.03
ED	154 (41.8)	55 (58.5)
Wards	127 (34.5)	22 (23.4)
Operating room	19 (5.2)	4 (4.3)
Other hospital	68 (18.5)	13 (13.8)
Admission for medical reasons	335 (91)	88 (93.6)	0.83
Chronic conditions	168 (46.5)	28 (29.8)	< 0.01
Immunodeficiency	59 (16.2)	3 (3.2)	< 0.01
Organ dysfunction
Respiratory	249 (67.8)	61 (64.2)	0.50
Cardiovascular	201 (54.8)	21 (22.1)	< 0.01
Hepatic	119 (32.6)	4 (4.3)	< 0.01
Neurologic	46 (12.5)	16 (16.8)	0.27
Hematologic	92 (25.1)	4 (4.2)	< 0.01
Renal	46 (12.5)	1 (1.1)	< 0.01
Therapies
Mechanical ventilation	261 (70.7)	52 (55.3)	< 0.01
Vasoactive drugs	168 (45.7)	34 (35.8)	0.08
Blood products	158 (43.1)	25 (26.6)	< 0.01
Renal replacement therapy	8 (2.2)	0	0.36
Prevalence
Sepsis	369 (43.8)	95 (38.3)	0.12
Severe sepsis	226 (26.8)	56 (22.6)	0.17
Septic shock	181 (21.5)	35 (14.1)	0.01
Mortality^* * 458 patients (public = 363; private	60 (16.5)	5 (5.3)	< 0.01
Sepsis	6 (1.7)	2 (2.1)	0.63
Severe sepsis	8 (2.2)	0	0.09
Septic shock	46 (12.7)	3 (3.2)	0.07
Death within 24 hours of admission	16 (4.5)	0	< 0.01
Death after 24 hours of admission	44 (12.1)	5 (5.2)

Variable	Nonsurvivors (n = 65)	Survivors (n = 393)	Univariate analysis (p value)	Multivariate analysis p value; OR (95%CI)
Characteristics
Age in months	16.6 [3.9 - 85.1]	11.5 [3.2 - 45.7]	0.398	-
Female	39 (60)	178 (45.5)	0.03	NS
PRISM	17 [12.8 - 28]	9 [5 - 16]	<0.001	0.005; 1.06 (1.02 - 1.11)
PIM 2	13.8 [6.4 - 41.5]	4.8 [1.4 - 11.3]	<0.001
PELOD	21 [11 - 30]	10 [1 - 12]	< 0.001	0.001; 1.06 (1.02 - 1.11)
Number of organ dysfunctions	3 ± 1.4	1.7 ± 1.3	< 0.001	NA^* * A significant variable in the univariate analysis that was not included in the multivariate analysis. Results expressed as median [interquartile range], n (%) mean ± standard deviation.
Pediatric ICU length of stay in days	8.3 ± 11.9	11.9 ± 15.4	< 0.001	NA^* * A significant variable in the univariate analysis that was not included in the multivariate analysis. Results expressed as median [interquartile range], n (%) mean ± standard deviation.
Complete immunization schedule	30 (83.3)	212 (75.2)	0.28	-
Maternal illiteracy	23 (49.9)	94 (29.7)	0.077	NA^* * A significant variable in the univariate analysis that was not included in the multivariate analysis. Results expressed as median [interquartile range], n (%) mean ± standard deviation.
Source of admission			0.009
ED	23 (35.4)	184 (47.1)		1.00
Wards	33 (50.8)	114 (29.2)		0.015; 2.44 (1.19 - 5.01)
Operating room	2 (3.1)	21 (5.4)		0.506; 1.80 (0.32 - 10.24)
Other hospital	7 (10.8)	72 (18.4)		0.486; 1.42 (0.53 - 3.820
Admission for medical conditions	63 (96.9)	355 (90.8)	0.311	-
No. of chronic conditions			< 0.001	0.003
< 2	40 (61.5)	321 (81.9)		1.00
≥ 2	25 (38.5)	71 (18.1)		2.74 (1.4 - 5.36)
Organ dysfunction
Respiratory	55 (85.9)	250 (63.8)	< 0.001	NA^* * A significant variable in the univariate analysis that was not included in the multivariate analysis. Results expressed as median [interquartile range], n (%) mean ± standard deviation.
Cardiovascular	43 (67.2)	177 (45.2)	< 0.001	NA^* * A significant variable in the univariate analysis that was not included in the multivariate analysis. Results expressed as median [interquartile range], n (%) mean ± standard deviation.
Hepatic	34 (53.1)	88 (22.6)	< 0.001	NA^* * A significant variable in the univariate analysis that was not included in the multivariate analysis. Results expressed as median [interquartile range], n (%) mean ± standard deviation.
Neurologic	14 (21.9)	48 (12.2)	0.037	NA^* * A significant variable in the univariate analysis that was not included in the multivariate analysis. Results expressed as median [interquartile range], n (%) mean ± standard deviation.
Hematologic	25 (39.1)	71 (18.1)	< 0.001	NA^* * A significant variable in the univariate analysis that was not included in the multivariate analysis. Results expressed as median [interquartile range], n (%) mean ± standard deviation.
Renal	18 (28.1)	29 (7.4)	< 0.001	NA^* * A significant variable in the univariate analysis that was not included in the multivariate analysis. Results expressed as median [interquartile range], n (%) mean ± standard deviation.
Type of hospital			0.005	NS
Public	60 (92.3)	303 (77.1)
Private	5 (7.7)	90 (22.9)

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[1] Corresponding author: Daniela Carla de Souza, Unidade de Terapia Intensiva Pediátrica, Hospital Universitário, Universidade de São Paulo, Avenida Professor Lineu Prestes, 2.565, Zip code: 05508-000 - São Paulo (SP), Brazil. E-mail: daniela@hu.usp.br