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February 19, 2018

Defining Pediatric Sepsis

Author Affiliations
  • 1Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
  • 2Paediatric Critical Care Research Group, Mater Research Institute, University of Queensland, Brisbane, Queensland, Australia
  • 3University of British Columbia, Vancouver, British Columbia, Canada
  • 4British Columbia Children’s Hospital, Vancouver, British Columbia, Canada
JAMA Pediatr. 2018;172(4):313-314. doi:10.1001/jamapediatrics.2017.5208

The resolution on sepsis by the United Nations World Health Assembly in May 2017 recognizes sepsis as a global threat in adults and children and a priority for the World Health Organization to address during the next decade.1 This resolution on sepsis acknowledges that sepsis represents a major contributor to childhood morbidity and mortality and the associated economic burden. The United Nations Sustainable Development Goal 3 (https://sustainabledevelopment.un.org/sdg3) defined specific targets for infections and pandemics.2 Despite the huge burden that sepsis imposes on the health of children,3,4 current definitions of pediatric sepsis are of limited value to bedside clinicians to identify cases of sepsis. Moreover, these definitions have poor predictive value and have not been validated, thus lessening their utility in benchmarking, performance monitoring, and patient stratification. These shortcomings have been increasingly recognized since the definitions were crafted by consensus in 20052 and aligned with the 2001 adult Sepsis Consensus (Sepsis-2) definitions. The goal of the 2005 expert consensus was to identify children with sepsis who were unresponsive to initial therapy, and thus at high risk for mortality, to be enrolled in a trial. Sepsis-2 highlighted the need for sensitive criteria allowing early recognition of and intervention for sepsis, with an emphasis on a clinician-defined spectrum of disease. Presumed or proven infection with systemic inflammation (SIRS) was defined as sepsis, with progressive organ dysfunction defined as severe sepsis and cardiovascular dysfunction as septic shock. However, SIRS is very commonly manifested in otherwise well febrile children, and even in children without infections, leading to low specificity and thus limited use to clinicians.5 During the winter months, more than half the population of children in emergency departments present with runny noses due to viral infections, which would satisfy the present criteria for sepsis. Apart from the stress on resources even in high-income countries, many health care facilities in low- and middle-income countries do not have the resources to perform white blood cell counts (a requirement for diagnosing SIRS); hence, the present definition is of limited benefit in many parts of Asia and sub-Saharan Africa, where the burden of sepsis is highest and the most mortality from sepsis occurs. The difficulties in applying the definitions of sepsis have led to considerable variability in sepsis reporting. Accordingly, studies have identified considerable discrepancies in applying definitions of pediatric sepsis, leading to a large variation in incidence estimates when comparing clinical, administrative, and research data. Too often, sepsis was used interchangeably with severe sepsis, despite clear criteria for organ dysfunction, which is the final common pathway to adverse patient outcomes.

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