Re: Suspected sepsis: summary of NICE guidance and the potential impact to paediatrics
Sepsis is a leading cause of avoidable death (NCEPOD, 2013 Ombudsman) with 62% of children with shock receiving sub-optimal management.1 Early recognition of paediatric sepsis is difficult but can lead to reductions in morbidity and mortality.3,4 Combinations of physiological parameters are comparable to triage tools (80% sensitivity, 39% specific5) for sepsis screening but as yet no nationally recognized UK paediatric early warning system exists. We welcome the publication of NICE sepsis guidelines in 2016,4 however it leaves practitioners facing the challenge of balancing overly sensitive screening with early recognition and the need to treat all cases.
We conducted a prospective cohort study over two months (May- June 2016) to describe current practice and model the new sepsis guideline-based practice based on these parameters. 285 consecutive patients presenting to a tertiary centre emergency department with fever >/=38·5 0C were included; 174 male (61·1%), age range 0 - 15·2 years (median 2·1 years), comorbidity present in 45 (13·8%). Sepsis was defined as SIRS criteria plus proven infection.
21 patients (7·4%) had full sepsis screens (blood tests, chest X-ray, lumbar puncture and intravenous (IV) antibiotics). Diagnoses included, two sepsis, seven viral meningitis, three urinary tract infection, one lower respiratory tract infection (LRTI), three viral illness, two fever post-immunisation, one skin infection and two fever unknown origin (FUO). No sepsis occurred in the 264 patients (92·6%) not screened. 206 (72·3%) would have been eligible for sepsis screens according to new NICE guidelines (“red flags”), a ten-fold increase. 27 (9·5%) children received IV antibiotics and one intramuscular (IM) (21 for possible sepsis, two tonsillitis, four LRTI and one FUO). All survived. Median length of stay for the 21 patients screened for sepsis was 2 days (range 1-10).
Modelling the NICE sepsis guidelines to actual data, demonstrates a potential tenfold increase in investigation and treatment of sepsis, equivalent to an estimated increase of 2220 bed days/year (6.1 beds/year), resulting in unnecessary harm, poor antibiotic stewardship, and a major burden on the health system over winter.
Current available diagnostics lack sensitivity and specificity to accurately identify children with bacterial sepsis which has led to the development of guidelines. We believe that current protocols, particularly those including physiological parameters triggering escalation require robust underpinning with data. The new NICE guidelines would benefit from validation and adjustment. We call for a national database to enable shared learning and evidence based algorithms aiding but not replacing clinical judgment.
ME and EL have received funding from the European Union’s Horizon 2020 research and innovation programme under grant agreement No. 668303
1. Just Say Sepsis, A Review Of The Process Of Care Received By Patients With Sepsis. National Confidential Enquiry into Patient Outcome and Death, 2015. Web. 11 Aug. 2016.
2. Inwald D, Tasker R, Peters M, Nadel S. Emergency management of children with severe sepsis in the United Kingdom: the results of the Paediatric Intensive Care Society sepsis audit. Archives of Disease in Childhood. 2009;94(5):348-353.
3. Plunkett ATong J. Sepsis in children. BMJ. 2015;350(jun09 10):h3017-h3017.
4. Freitag A, Constanti M, O'Flynn N, Faust S. Suspected sepsis: summary of NICE guidance. British Medical Journal. 2016 Aug 11;354(i4030):1-3.
5. Thompson M, Coad N, Harnden A, Mayon-White R, Perera R, Mant D. How well do vital signs identify children with serious infections in paediatric emergency care?. Archives of Disease in Childhood. 2009;94(11):888-893.
Competing interests: No competing interests