AUTHOR=Nijman Ruud G. , Jorgensen Rikke , Levin Michael , Herberg Jethro , Maconochie Ian K. 

TITLE=Management of Children With Fever at Risk for Pediatric Sepsis: A Prospective Study in Pediatric Emergency Care

JOURNAL=Frontiers in Pediatrics

VOLUME=8

YEAR=2020

URL=https://www.frontiersin.org/journals/pediatrics/articles/10.3389/fped.2020.548154

DOI=10.3389/fped.2020.548154

ISSN=2296-2360

ABSTRACT=<p><bold>Objective:</bold> To study warning signs of serious infections in febrile children presenting to PED, ascertain their risk of having sepsis, and evaluate their management.</p><p><bold>Design:</bold> Prospective observational study.</p><p><bold>Setting:</bold> A single pediatric emergency department (PED).</p><p><bold>Participants:</bold> Febrile children, aged 1 month−16 years, with &gt;= 1 warning signs of sepsis.</p><p><bold>Interventions and Main outcome measures:</bold> Clinical characteristics, including different thresholds for tachycardia and tachypnoea, and their association with (1) delivery of pediatric sepsis 6 (PS6) interventions, (2) final diagnosis of invasive bacterial infection (IBI), (3) the risk for pediatric intensive care unit (PICU) admission, and (4) death.</p><p><bold>Results:</bold> Forty-one percent of 5,156 febrile children had warning signs of sepsis. 1,606 (34%) children had tachypnoea and 1,907 (39%) children had tachycardia when using APLS threshold values. Using the NICE sepsis guidelines thresholds resulted in 1,512 (32%) children having tachypnoea (kappa 0.56) and 2,769 (57%) children having tachycardia (kappa 0.66). Of 1,628 PED visits spanning 1,551 disease episodes, six children (0.4%) had IBI, with one death (0.06%), corresponding with 256 children requiring escalation of care according to sepsis guideline recommendations for each child with IBI. There were five additional PICU admissions (0.4%). 121 (7%) had intravenous antibiotics in PED; 39 children (2%) had an intravenous fluid bolus, inotrope drugs were started in one child. 440 children (27%) were reviewed by a senior clinician. In 4/11 children with IBI or PICU admission or death, PS6 interventions were delivered within 60 min after arriving. 1,062 (65%) visits had no PS6 interventions. Diagnostic performance of vital signs or sepsis criteria for predicting serious illness yielded a large proportion of false positives. Lactataemia was not associated with giving iv fluid boluses (<italic>p</italic> = 0.19) or presence of serious bacterial infections (<italic>p</italic> = 0.128).</p><p><bold>Conclusion:</bold> Many febrile children (41%) present with warning signs for sepsis, with only few of them undergoing investigations or treatment for true sepsis. Children with positive isolates in blood or CSF culture presented in a heterogeneous manner, with varying levels of urgency and severity of illness. Delivery of sepsis care can be improved in only a minority of children with IBI or admitted to PICU.</p>