Pediatric Sepsis Criteria Focus on Organ Dysfunction Indicators

By Dorothy Brooks

While initiatives such as the Centers for Disease Control and Prevention’s (CDC) new Core Measures program seek to highlight and promote quality improvement in the evidence-based care of patients with sepsis, much of the work in recent years has been focused on adult patients.¹ However, sepsis also is a major public health burden in pediatric patients.

“Sepsis is a leading cause of death worldwide among children and accounted for an estimated 25 million pediatric cases and 3 million deaths of children worldwide in 2017,” explains Scott Watson, MD, MPH, associate chief in the division of pediatrics at Seattle Children’s Hospital in Seattle.² “Many survivors experience long-term physical and psychological morbidity, including family members.”

Watson served as co-chair of an interdisciplinary group of clinician experts who were tasked by the Society of Critical Care Medicine (SCCM) with creating and validating new, data-based criteria for sepsis and septic shock. The resulting work was presented at SCCM’s Critical Care Congress held in Phoenix in January 2024, and also detailed in two published articles.^3,4

Notably, the new criteria mark the first update to pediatric sepsis criteria in nearly two decades, and they present a major shift in focus, according to Jerry Zimmerman, MD, an attending physician in the pediatric intensive care unit at Seattle Children’s and a member of the SCCM task force focused on developing the new criteria. “As compared to previous criteria derived by expert consensus in 2005 that focused on describing a systemic inflammatory response to infection, the pragmatic, data-driven Phoenix Criteria emphasize the importance of organ dysfunction resulting from the host response to infection,” he tells EDM.

In particular, Zimmerman notes that the Phoenix Criteria are intended to identify life-threatening organ dysfunction due to documented or highly suspected infection in children. “It is hoped that these updated criteria for pediatric sepsis will improve clinical care, epidemiological assessment, quality improvement, and research in addressing pediatric sepsis and septic shock around the world,” he says.

To develop the Phoenix Criteria, SCCM task force members used data and analysis of more than 3 million pediatric healthcare encounters from 10 hospitals located in diverse locations around the world, including some low-resource settings, according to L. Nelson Sanchez-Pinto, MD, MBI, a critical care physician at Lurie Children’s Hospital of Chicago and an SCCM task force member who presented at the SCCM Congress in Phoenix.

Sanchez-Pinto noted that members of the data group of the SCCM task force used a machine learning approach to key in on the elements that were most effective at identifying children at high risk of dying from organ dysfunction in the setting of an infection. He stated that the resulting criteria relate to four systems: cardiovascular, respiratory, neurological, and coagulation. Further, the task force members found that these criteria do a better job of identifying children with infections that are at higher risk of poor outcomes than the old criteria, he said. Sanchez-Pinto also shared that the criteria are globally applicable, even in lower-resource settings.

What this means for care providers is that documentation of a Phoenix Pediatric Sepsis Score greater than 2 in a child with a suspected infection that is bacterial, fungal, or viral in nature denotes an increased risk for mortality and the need for intensive care, if available, observes Zimmerman. “The Phoenix Criteria will hopefully increase the specificity of sepsis diagnosis in children and ultimately enhance antimicrobial stewardship,” he says.

Zimmerman emphasizes that the Phoenix Sepsis Score was not designed to be used as a screening or early warning tool for sepsis, although he notes that the SCCM task force recognizes the importance of pursuing this aspect of the work as a next step. “Clinicians should continue to utilize the systemic inflammatory response syndrome criteria in assessing children for infection,” he says. “The purpose of the Phoenix Score is to assist clinicians in identifying children with both infection and life-threatening organ dysfunction.”

While the Phoenix Criteria require additional prospective validation, Zimmerman states that clinicians should have confidence in the work for multiple reasons, including:

• The Pediatric Sepsis Definition Task Force proactively identified all relevant stakeholders for the work.

• In addition to the data-driven identification of pediatric sepsis operational criteria, the task force also undertook an international survey and systematic review, all of which contributed to the Phoenix Pediatric Sepsis Definition.

• National Institutes of Health funding, along with associated peer review, supported the data science identification of the pediatric sepsis operational criteria.

• The process recognized the importance of an internationally applicable definition.

• Both clinicians and researchers contributed to the derivation of the new definition.

Watson explains that the task force is planning several additional articles in peer-reviewed journals to discuss various aspects of the criteria and their development. Clinicians also can anticipate podcasts and webinars that will review this work. “The data team is developing clinical decision support tools that can be embedded in electronic medical records, an app that can be used in lower-resource settings, and additional work to develop tools to screen children at risk of developing sepsis,” he says.

Watson also notes that the CDC has funded a separate project that includes and is co-led by several task force members to develop a pediatric sepsis surveillance tool using the Phoenix Criteria to assess the rate of pediatric sepsis nationwide.

REFERENCES

1. Centers for Disease Control and Prevention. Sepsis. Hospital Sepsis Program Core Elements. https://www.cdc.gov/sepsis/core-elements.html
2. Evans IVR, Watson RS, Carcillo J, et al. Epidemiology of sepsis among adolescents at community hospital emergency departments: Implications of Rory’s Regulations. JAMA Pediatr 2017;171:1011-1012.
3. Schlapbach LJ, Watson RS, Sorce LR, et al. International Consensus Criteria for Pediatric Sepsis and Septic Shock. JAMA 2024;331:665-674.
4. Sanchez-Pinto LN, Bennett TD, DeWitt PE, et al. Development and validation of the Phoenix Criteria for pediatric sepsis and septic shock. JAMA 2024;331:675-686.