Challenges in pediatric post-sepsis care in resource limited settings: a narrative review

Abstract

Background: Morbidity and mortality secondary to sepsis disproportionately affects children, especially those in low-and middle-income countries (LMICs), where over 85% of global cases and deaths occur.These regions are plagued by poorly resilient health systems, widespread socio-economic deprivation and unique vulnerabilities such as malnutrition. Reducing the overall burden of sepsis will require a multipronged strategy that addresses all three important periods along the sepsis care continuum -pre-facility, facility and post-facility. Of these aspects, post-facility issues have been largely neglected in research, practice and policy, and are thus the focus of this review.Methods: Relevant data for this review was identified through a literature search using PubMed, through a review of the citations of select systematic reviews and from the personal repositories of articles collected by the authors. Data is presented within three sections. The first two sections on the short and long-term outcomes among sepsis survivors each outline the epidemiology as well as review relevant interventional research done. Where clear gaps exist, these are stated. The third section focuses on priorities for future research. This section highlights the importance of data (and data systems) and of innovative interventional approaches, as key areas to improve research of post-sepsis outcomes in children. Conclusions:During the initial post-facility period, mortality is high with as many children dying during this period as during the acute period of hospitalization, mostly due to recurrent illness (including infections) which are associated with malnutrition and severe acute disease. Long-term outcomes, often labelled as postsepsis syndrome (PSS), are characterized by a lag in developmental milestones and suboptimal quality of life (QoL). While long-term outcomes have not been well characterized in resource limited settings, they are well described in high-income countries (HICs), and likely are important contributors to long-term morbidity in resource limited settings. The paucity of interventional research to improve post-discharge outcomes (short-or long-term) is a clear gap in addressing its burden. A focus on the development of improved data systems for collecting routine data, standardized definitions and terminology and a healthsystems approach in research need to be prioritized during any efforts to improve outcomes during the postsepsis phase.

Study protocol for economic evaluation of probiotic intervention for prevention of neonatal sepsis in 0–2-month old low-birth weight infants in India: the ProSPoNS trial

“…Prevention of severe sepsis in the early neonates will prevent the long-term morbidity like neurodevelopmental disability risk associated with sepsis 13 and reduce mortality due to pneumonia, meningitis and neonatal sepsis and hospital admissions due to any infectious diseases. 14 We propose to use the short time horizon to assess the sepsis averted as a result of probiotics supplementation for 1 month and model the change in DALYs in the intervention group as a long-term measure.…”

“…Prevention of severe sepsis in the early neonates will prevent the long-term morbidity like neurodevelopmental disability risk associated with sepsis 13 and reduce mortality due to pneumonia, meningitis and neonatal sepsis and hospital admissions due to any infectious diseases. 14 …”

Prediction models for post-discharge mortality among under-five children with suspected sepsis in Uganda: A multicohort analysis

“…Reducing the overall sepsis burden requires a multi-pronged strategy that addresses three periods along the care continuum–pre-facility, facility and post-facility [ 2 ]. Of these, post-facility issues have been largely neglected in research, policy, and practice [ 3 ].…”

Post-discharge mortality among children under 5 years admitted with suspected sepsis in Uganda: a prospective multi-site study

“…2 A more granular understanding of events occurring during the post-discharge period is urgently required to guide interventions and policy decisions regarding resource allocation. 3…”