Risk of Mortality in Immunocompromised Children With Severe Sepsis and Septic Shock
Risk of Mortality in Immunocompromised Children With Severe Sepsis and Septic Shock
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DOI：
10.1097/ccm.0000000000004329
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发表时间：
2020-07-01
影响因子：
8.8
通讯作者：
Fitzgerald, Julie C.
中科院分区：
文献类型：
--
作者：
Lindell, Robert B.;Nishisaki, Akira;Fitzgerald, Julie C.
目的：评估严重脓毒症和脓毒性休克儿童中免疫功能低下诊断的患病率，并在调整人口统计学和疾病严重程度后确定免疫功能低下诊断与临床结局之间的相关性。设计：回顾性多中心队列研究。设置：虚拟儿科系统数据库中的83个中心。患者：2012年1月1日至2016年12月31日期间入住参与研究的PICU的严重脓毒症或脓毒性休克儿童。干预措施：无。测量和主要结果：在83个中心中，我们确定了10，768例PICU入院患者，国际疾病分类，第9版，严重脓毒症或脓毒性休克的临床修改代码;其中3，021例患者（28%）诊断为免疫功能低下。为了评估各中心之间的差异并确定与PICU死亡率相关的因素，我们使用了混合效应logistic回归模型。在未进行造血细胞移植的患者中，先天性免疫缺陷（校正比值比，1.90; 95% CI，1.24-2.92），多种既往恶性肿瘤（校正比值比，1.86; 95% CI，1.15-2.99），和噬血细胞性淋巴组织细胞增生症（调整后的比值比，3.09; 95%CI，1.91-4.98）与PICU死亡率的增加有关。在既往接受过造血细胞移植的患者中，（校正比值比，3.15; 95% CI，2.09-4.74），先天性免疫缺陷（校正比值比，6.94; 95% CI，3.84-12.53），多种既往恶性肿瘤（校正比值比，3.54; 95%CI，1.80-6.95）和噬血细胞性淋巴组织细胞增生症（校正比值比，2.79; 95%CI，1.36-5.71）与PICU死亡率的增加相关。PICU死亡率因中心而异，中心每月平均脓毒症患者数较高与PICU死亡率较低相关（校正比值比，0.94; 95%CI，0.90-0.98）。PICU资源利用因免疫功能低下诊断和造血细胞移植史而异，在存活的免疫功能低下患者中，与未诊断免疫功能低下的患者相比，PICU中位住院时间较短（p < 0.001）。结论：28%的严重脓毒症或脓毒性休克患儿存在免疫功能低下诊断。多种既往恶性肿瘤、噬血细胞性淋巴组织细胞增生症、先天性免疫缺陷和造血细胞移植与严重脓毒症或脓毒性休克儿童的PICU死亡率增加独立相关。尽管对免疫功能低下诊断、脓毒症相关死亡率的已知危险因素和中心水平脓毒症量进行了调整，但各中心的PICU死亡率仍存在显著差异。
Objectives: To assess the prevalence of immunocompromised diagnoses among children with severe sepsis and septic shock, and to determine the association between immunocompromised diagnoses and clinical outcomes after adjustment for demographics and illness severity.Design: Retrospective multicenter cohort study.Setting: Eighty-three centers in the Virtual Pediatric Systems database.Patients: Children with severe sepsis or septic shock admitted to a participating PICU between January 1, 2012, and December 31, 2016.Interventions: None.Measurements and Main Results: Across 83 centers, we identified 10,768 PICU admissions with an International Classification of Diseases, 9th Revision, Clinical Modification code for severe sepsis or septic shock; 3,021 of these patients (28%) had an immunocompromised diagnosis. To evaluate variation across centers and determine factors associated with PICU mortality, we used mixed-effect logistic regression models. Among patients without hematopoietic cell transplant, congenital immunodeficiency (adjusted odds ratio, 1.90; 95% CI, 1.24-2.92), multiple prior malignancies (adjusted odds ratio, 1.86; 95% CI, 1.15-2.99), and hemophagocytic lymphohistiocytosis (adjusted odds ratio, 3.09; 95% CI, 1.91-4.98) were associated with an increased odds of PICU mortality. Among patients with prior hematopoietic cell transplant, liquid malignancy (adjusted odds ratio, 3.15; 95% CI, 2.09-4.74), congenital immunodeficiency (adjusted odds ratio, 6.94; 95% CI, 3.84-12.53), multiple prior malignancies (adjusted odds ratio, 3.54; 95% CI, 1.80-6.95), and hemophagocytic lymphohistiocytosis (adjusted odds ratio, 2.79; 95% CI, 1.36-5.71) were associated with an increased odds of PICU mortality. PICU mortality varied significantly by center, and a higher mean number of sepsis patients per month in a center was associated with lower PICU mortality (adjusted odds ratio, 0.94; 95% CI, 0.90-0.98). PICU resource utilization varied by immunocompromised diagnosis and history of hematopoietic cell transplant, and among survivors immunocompromised patients have shorter median PICU length of stay compared with patients without immunocompromised diagnoses (p < 0.001).Conclusions: Immunocompromised diagnoses are present in 28% of children with severe sepsis or septic shock. Multiple prior malignancies, hemophagocytic lymphohistiocytosis, congenital immunodeficiency, and hematopoietic cell transplant are independently associated with an increased odds of PICU mortality in children with severe sepsis or septic shock. Significant variation exists in PICU mortality among centers despite adjustment for immunocompromised diagnoses, known risk factors for sepsisrelated mortality, and center-level sepsis volume.