New Scoring System Predicts In-Hospital Mortality in Critically Ill Children With Sepsis

A pediatric version of the Sequential Organ Failure Assessment (SOFA) score, which assesses organ dysfunction in adults with infection, accurately predicted in-hospital mortality in critically ill children with suspected or confirmed infection. These study results were published in JAMA Pediatrics.¹

For more than 20 years, sepsis has been defined as systemic inflammatory response syndrome (SIRS) in response to infection. However, new definitions are needed as the understanding of the pathobiology of sepsis expands.² In 2016, the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) proposed a new definition of sepsis: “life-threatening organ dysfunction caused by a dysregulated host response to infection.”²

Sepsis-3 recommends applying this definition to clinical practice using the SOFA score, which measures parameters of organ function such as blood pressure and platelet level, to assess disease severity and mortality risk in adults with suspected infection.² However, the SOFA score has only previously been validated in adults and cannot be used in children, since some measures of organ function — such as creatinine levels — vary with age.¹

Travis J. Matics, DO, from the University of Chicago, Illinois, and L. Nelson Sanchez-Pinto, MD, from Northwestern University in Evanston, Illinois, adapted the SOFA score for use in pediatric patients (pSOFA) and sought to validate the pSOFA score in critically ill children in a retrospective cohort study.¹

A total of 6303 pediatric patients had 8711 hospital admissions to the pediatric intensive care unit (PICU) during the study period. Of these admissions, 229 were nonsurvivors. Compared with survivors, nonsurvivors had significantly higher pSOFA scores (median, 13 vs 2; P <.001).¹

Infection was suspected or confirmed in 48.4% of the study population. Of the entire study cohort, 14.1% of patients were determined to have sepsis when the Sepsis-3 definition, using the pSOFA score, was applied. Patients with sepsis had a mortality rate of 12.1% and were 18 times more likely to die in the hospital than patients with infection without sepsis (odds ratio, 18; 95% CI, 11-28).¹

Septic shock, using the adapted Sepsis-3 definition, was identified in 4% of the study cohort, with a mortality rate of 32.3%.¹ The majority (65%) of all 229 nonsurvivors in the study met criteria for sepsis or septic shock.¹

The maximum pSOFA score had excellent accuracy for distinguishing between survivors and nonsurvivors in the entire cohort (area under the curve [AUC], 0.95) and in patients with infection (AUC, 0.92).

“The application of the Sepsis-3 definitions in pediatric patients shows promising results,” Dr Sanchez-Pinto said in an interview with Infectious Disease Advisor.

For predicting in-hospital mortality, the pSOFA score performed similarly to or better than other scoring systems, including the updated Pediatric Logistic Organ Dysfunction (PELOD-2) score, the Pediatric Multiple Organ Dysfunction Score, and the Pediatric Risk of Mortality III (PRISM III) score.¹

Unlike the pSOFA score, which adjusts the original SOFA score thresholds for age in the pediatric population, other pediatric organ dysfunction scores differ significantly from SOFA. Using these scoring systems, rather than pSOFA, to define sepsis in children would lead to different definitions of sepsis and septic shock in children and adults.¹

“We should not have different definitions of sepsis in adults and in kids. There is no known difference in the way sepsis works that magically changes at 18 or 21 years of age,” Dr Sanchez-Pinto told Infectious Disease Advisor. “Age has a huge impact on outcomes, but it is not a dichotomous issue that changes when you are legally allowed to drink alcohol. So while age is a big factor for outcomes, it should not affect the underlying definition.”

Dr Sanchez-Pinto noted that this study was conducted at a single center and that the pSOFA based on Sepsis-3 definitions requires further validation in the pediatric population.

“We are already talking with colleagues from all over the United States and some international collaborators who are interested in validating the Sepsis-3 definitions in kids using data from multiple sites,” he indicated.

References

1. Matics TJ, Sanchez-Pinto LN. Adaptation and validation of a pediatric Sequential Organ Failure Assessment Score and evaluation of the Sepsis-3 definitions in critically ill children [published online August 7, 2017]. JAMA Pediatr. doi:10.1001/jamapediatrics.2017.2352 
2. Singer M, Deutschman CS, Seymour CW, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):801-810. doi:10.1001/jama.2016.0287.