Burden of sepsis in children: perspectives from pediatric intensive care.

The worldwide mortality in children <5 yrs of age has declined from 89 per 1000 live births to 60 per 1000 live births between 1990 and 2009 implying a one-third reduction. However, there are regions of the world where it remains high reaching 127 deaths per 1000 live births in Africa. In the American region, the decline in annual rate of mortality measured in percentage has not shown significant changes when comparing the two last decades: 4.2% (1990–1999) vs. 4.3% (2000–2009). The regional average in the American region is 18 deaths per 1000 live births with a range that varies from six deaths in Canada to 87 deaths per 1000 live births in Haiti. The rate in Colombia is very similar to the regional average (1). The principal causes of death are linked to acute infections alone or associated with other morbidity, including malnutrition, congenital malformations, sequelae linked to the neonatal period, or other chronic diseases. The importance of infections has lead to two important initiatives of the World Health Organization and UNICEF for a global action to tackle pneumonia, which causes one of five deaths worldwide (2). One of them is the creation of an international forum to coordinate actions targeting this problem. A priority in health research related to pneumonia and sepsis should be the development of epidemiologic studies aiming to identify the gaps of knowledge in the prediction of infection severity, risk factors, and accessibility to appropriate healthcare. This research has great potential for finding new strategies to improve results. The importance of collaborative studies that include representative samples of a country or region needs to be highlighted. After the 2009 pH1N1 pandemic, several collaborative studies from South America have been published allowing better knowledge of its epidemiologic data and outcome (3). This is the first step on the way to reducing differences in health care. In this issue of the Pediatric Critical Care Medicine, Jaramillo-Bustamante et al (4) describe 1,051 patients admitted with sepsis to 19 pediatric intensive care units of ten Colombian cities during a 1-yr period. The children included were mostly <2 yrs of age (56%), of a low social condition (76%), and from urban areas (56%). They were admitted in a critically ill condition (septic shock or severe sepsis) in 73% of the cases; 70% required mechanical ventilation and 43% presented with multiple organ dysfunction. The mortality rate was high reaching 18% with a length of stay of 9.75 days. Approximately 50% of patients had some comorbidity. One of the limitations of this study is the impossibility to distinguish between community-acquired infection and infection associated to health care or use of dispositives. There is not a description about the origin of the patients before pediatric intensive care unit admission. The incidence of Gram-negative bacteria (43.5%) and the type of micro-organisms that were isolated (Klebsiella, Escherichia coli, and Pseudomona) suggest that the incidence of nosocomial infection could be an important condition and it could be related to the mortality rate. This difference is of importance at the time of choosing strategies aimed at reducing mortality. For community-acquired sepsis, these strategies should include better accessibility to primary and emergency care, educational initiatives for healthcare workers and the general population, expanding the use of the new vaccines, and improving sanitary conditions such as the provision of potable water and sewer services. On the other hand, nosocomial infections could be reduced by the use of efficient evidence-based strategies (5). The most frequent source of infection found in this study was the respiratory tract (54%) followed by the abdomen (18.27%). This finding supports the definition of pneumonia as the principal killer of children in the world. One could speculate that a fraction of these could be ventilator-associated pneumonias. A high incidence of 11.1 episodes every 1000 days of mechanical ventilation has been reported in units of South America (6). The Surviving Sepsis Campaign has contributed to improve the management of sepsis in adult patients, especially by means of diffusing educational tools. The adhesion to some of the therapeutic goals of this campaign is high; however, other goals are not routinely used. In the pediatric population, the global sepsis initiative sponsored by the World Federation of Pediatric Intensive Care and Critical Care Societies is an online educational and research resource created with the purpose of contributing to reduce the burden of sepsis in children around the world by means of disseminating quality improvement strategies (7). The responsibility of intensive care physicians is to question what could be done to prevent children from dying of sepsis by evaluating the whole spectrum of possibilities, including failure in prevention, accessibility, function of the health system, low educative level of healthcare workers, inappropriate skill training or low professionalism, and to make a personal commitment with possible solutions. Eduardo Schnitzler, MD Thomas Iolster, MD Hospital Universitario Austral Buenos Aires, Argentina