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Year : 2020  |  Volume : 66  |  Issue : 2  |  Page : 63-64

Predictors of outcomes of severe sepsis in children in the Indian subcontinent – What's the big picture?

Director of Pediatric Critical Care Medicine Research, The Children's Hospital of San Antonio, Texas, USA

Date of Submission06-Nov-2019
Date of Decision02-Dec-2019
Date of Acceptance03-Dec-2019
Date of Web Publication01-Apr-2020

Correspondence Address:
U S Bhalala
Director of Pediatric Critical Care Medicine Research, The Children's Hospital of San Antonio, Texas
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jpgm.JPGM_619_19

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How to cite this article:
Bhalala U S. Predictors of outcomes of severe sepsis in children in the Indian subcontinent – What's the big picture?. J Postgrad Med 2020;66:63-4

How to cite this URL:
Bhalala U S. Predictors of outcomes of severe sepsis in children in the Indian subcontinent – What's the big picture?. J Postgrad Med [serial online] 2020 [cited 2023 Feb 2];66:63-4. Available from:

In determining management strategies and resource allocation, especially, in resource-limited countries, it is imperative to study the predictors of outcomes of disease. With increased awareness about the global impact of sepsis and a renewed interest in fighting the sepsis,[1] the recent report by Shah et al. is quite timely.[2] It focuses on predictors of outcomes of sepsis in children in India. Evaluation of prognostic factors that determine outcomes of sepsis, allows appropriate preventive measures to decrease overall mortality related to sepsis.

In the report published by Shah et al., the majority were infants who progressed to sepsis and presented with infective etiology of sepsis. Children, who were severely malnourished, presented late with sepsis, and multi-organ dysfunction succumbed to severe sepsis.[2] It is reasonable to comment that the patient population studied was representative of the pediatric sepsis population managed in most pediatric intensive care units in the Indian subcontinent. Surprisingly, in a similar study conducted prior by Kaur et al. from another PICU in India suggested that mortality among children with sepsis, severe sepsis, and septic shock were not predicted by any individual factors including the time lag to PICU transfer, duration of PICU stay, presence of multiorgan dysfunction, and PRISM score at admission.[3] The study by Kaur et al. had a much smaller sample size (n = 50) as compared to the study conducted by Shah et al. (n = 200).

In the study by Shah et al., multivariate analysis showed that severe acute malnutrition, multi-organ dysfunction, and delayed presentation to the hospital were associated with poor outcomes of sepsis in children. Severe, acute malnutrition and delayed presentation are quite common in developing countries.[4],[5]

The occurrence of malnutrition and delay in the presentation are related to multiple factors such as poverty, undereducation, lack of resources, and overpopulation. National and international institutions and agencies need to continue to put in the efforts to minimize these risk factors. Moreover, simultaneous efforts of local government in implementing programs and policies, which might be aligned with the World Health Organization (WHO) agenda on preventive health are important in controlling risk factors related to poor outcomes of sepsis in the developing world. The article by Shah et al. which describes the risk factor for the outcomes and progress of sepsis in children in India will add substantial evidence to support guidelines and policies directed towards the prevention and management of sepsis in the eastern world.

The article by Shah et al. describes the occurrence of multi-organ dysfunction as an important risk factor determining progression and poor outcome of sepsis in children. This emphasizes the importance of appropriate supportive care in the emergency room as well as intensive care to minimize multi-organ dysfunction. It is important to conduct future studies focused on outcomes following measures to prevent and manage multiple organ dysfunction following sepsis. This particular information also emphasizes the importance of early referral to tertiary level pediatric intensive care units in which technologic resources, expertise and the appropriate team might be available to support vital organs to change the outcome.

This article represents a significant advance in elucidating the key drivers of sepsis outcomes. Most important, the authors reveal the considerable effect of individual factors and external factors on the outcome of sepsis. It is important to note that the primary outcome in this study was in-hospital mortality. However, as care is being increasingly continued outside of acute care hospitals (e.g., long-term acute care), failure to account for outcomes occurring after discharge to these facilities could lead to an underestimation of true mortality rates.

In summary, Shah and colleagues have provided a timely and important examination of the predictors of outcomes related to sepsis in children in India. These results highlight the fact that individual and external factors drive the outcomes of sepsis in children. Rigorous efforts are needed to make resources available and implement protocols and policies at the national and international levels to alter risk factors associated with poor outcomes of sepsis in children in the developing world. Consequently, there is a huge need for further research related to interventions to minimize risk factors such as malnutrition, delayed presentation and multi-organ dysfunction, and outcomes of sepsis.

 :: References Top

Rudd KE, Kissoon N, Limmathurotsakul D, Bory S, Mutahunga B, Seymour CW, et al. The global burden of sepsis: Barriers and potential solutions. Crit Care 2018;22:232.  Back to cited text no. 1
Shah S, Deshmukh CT, Tullu MS. The predictors of outcome and progression of pediatric sepsis and septic shock: A prospective observational study from Western India. J Postgrad Med 2020; 66:67-72.  Back to cited text no. 2
[PUBMED]  [Full text]  
Kaur G, Vinayak N, Mittal K, Kaushik JS, Aamir M. Clinical outcome and predictors of mortality in children with sepsis, severe sepsis, and septic shock from Rohtak, Haryana: A prospective observational study. Indian J Crit Care Med 2014;18:437-41.  Back to cited text no. 3
[PUBMED]  [Full text]  
Müller O, Krawinkel M. Malnutrition and health in developing countries. CMAJ 2005;173:279-86.  Back to cited text no. 4
Papali A, McCurdy MT, Calvellow EJ. A “three delays” model for severe sepsis in resource-limited countries. J Crit Care 2015;30:861.e9-14.  Back to cited text no. 5


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