Postdischarge mortality in children with acute infectious diseases: derivation of postdischarge mortality prediction models

Wiens, Matthew O.; Kumbakumba, Elias; Larson, Charles P.; Ansermino, J. Mark; J, Singer; Kissoon, Niranjan; Wong, Hubert; Ndamira, Andrew; Kabakyenga, Jerome; Kiwanuka, Julius; Zhou, Guohai

doi:10.1136/bmjopen-2015-009449

Cited by 68 publications

(91 citation statements)

References 22 publications

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“…The methods have been previously described in detail. 6 Briefly, this was a two-site, hospital-based cohort study in Mbarara, Uganda. All children between 6 months and 5 years of age who were admitted to either site with a suspected or proven infection were screened for eligibility.…”

Section: Methodsmentioning

confidence: 99%

Application of Sepsis Definitions to Pediatric Patients Admitted With Suspected Infections in Uganda*

Wiens

Larson

Kumbakumba

et al. 2016

Pediatric Critical Care Medicine

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Objectives Acute infectious diseases are the most common cause of under-5 mortality. However, the hospital burden of non-neonatal pediatric sepsis has not previously been described in the resource poor setting. The objective of this study was to determine the prevalence of sepsis among children 6 months to 5 years of age admitted with proven or suspected infection and to evaluate the presence of sepsis as a predictive tool for mortality during admission. Design In this Prospective cohort study we used the pediatric International Consensus Conference definition of sepsis to determine the prevalence of sepsis among children admitted to the pediatric ward with a proven or suspected infection. The diagnosis of sepsis, as well as each individual component of the sepsis definition, were evaluated for capturing in-hospital mortality. Setting The pediatric ward of two hospitals in Mbarara, Uganda Patients Admitted children between 6 months and 5 years with a confirmed or suspected infection. Interventions None Measurements and Main Results One thousand three hundred and seven (1307) subjects with a confirmed or suspected infection were enrolled and 65 children died (5.0%) during their admission. One thousand one hundred and twenty-one (85.9%) met the systemic inflammatory response syndrome criteria, and therefore were defined as having sepsis. The sepsis criteria captured 61 deaths, demonstrating a sensitivity and specificity of 95% (95% CI 90% – 100%) and 15% (95% CI 13% – 17%), respectively. The most discriminatory individual component of the SIRS criteria was the leukocyte count which alone had a sensitivity of 72% and a specificity of 56% for the identification of mortality in hospital. Conclusions This study is among the first to quantify the burden of non-neonatal pediatric sepsis in children with suspected infection, using the international consensus sepsis definition, in a typical resource constrained setting in Africa. This definition was found to be highly sensitive in identifying those who died, but had very low specificity as most children who were admitted with infections had sepsis. The SIRS-based sepsis definition offers little value in identification of children at high risk of in-hospital mortality in this setting.

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Section: Methodsmentioning

confidence: 99%

Application of Sepsis Definitions to Pediatric Patients Admitted With Suspected Infections in Uganda*

Wiens

Larson

Kumbakumba

et al. 2016

Pediatric Critical Care Medicine

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“…This is likely to be because children with severe signs more often died during the inpatient phase. However, in Uganda, in a study where severe pneumonia was not strictly defined according to WHO criteria, two features of severity, oxygen saturation and coma score were associated with post‐discharge mortality after adjustment for HIV and nutritional status …”

Section: Commentmentioning

confidence: 99%

“…[11][12][13] Two of these studies included hospitalised children with a diagnosis of pneumonia, but not necessarily severe pneumonia according to World Health Organization (WHO) guidelines, from The Gambia (n = 2725) 11 and Uganda (n = 389). 12 Only the Ugandan study 12 examined the effect of HIV status. One other study, from Bangladesh (n = 369) 13 used WHO diagnostic criteria for severe pneumonia, but only included HIV-uninfected children with Severe Acute Malnutrition (SAM).…”

mentioning

confidence: 99%

Mortality after Inpatient Treatment for Severe Pneumonia in Children: a Cohort Study

Ngari

Fegan

Mwangome

et al. 2017

Paediatric Perinatal Epid

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BackgroundAlthough pneumonia is a leading cause of inpatient mortality, deaths may also occur after discharge from hospital. However, prior studies have been small, in selected groups or did not fully evaluate risk factors, particularly malnutrition and HIV. We determined 1‐year post‐discharge mortality and risk factors among children diagnosed with severe pneumonia.MethodsA cohort study of children aged 1–59 months admitted to Kilifi County Hospital with severe pneumonia (2007–12). The primary outcome was death <1 year after discharge, determined through Kilifi Health and Demographic Surveillance System (KHDSS) quarterly census rounds.ResultsOf 4184 children (median age 9 months) admitted with severe pneumonia, 1041 (25%) had severe acute malnutrition (SAM), 267 (6.4%) had a positive HIV antibody test, and 364 (8.7%) died in hospital. After discharge, 2279 KHDSS‐resident children were followed up; 70 (3.1%) died during 2163 child‐years: 32 (95% confidence interval (CI) 26, 41) deaths per 1000 child years. Post‐discharge mortality was greater after admission for severe pneumonia than for other diagnoses, hazard ratio 2.5 (95% CI 1.2, 5.3). Malnutrition, HIV status, age and prolonged hospitalisation, but not signs of pneumonia severity, were associated with post‐discharge mortality. Fifty‐two per cent (95% CI 37%, 63%) of post‐discharge deaths were attributable to low mid‐upper arm circumference and 11% (95% CI 3.3%, 18%) to a positive HIV test.ConclusionsAdmission with severe pneumonia is an important marker of vulnerability. Risk stratification and better understanding of the mechanisms underlying post‐discharge mortality, especially for undernourished children, are needed to reduce mortality after treatment for pneumonia.

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“…Current guidelines recommend that children admitted with cSAM are discharged and transferred to community care when their medical complications, including oedema, are resolving, they are clinically well and alert, and have good appetite, rather than hospital discharge being based on anthropometric criteria (WHO, 2019). However, children with cSAM experience a high rate of mortality and readmission in the months following hospital discharge especially in sub-Saharan Africa (Berkley et al, 2016;Chhibber et al, 2015;Dubray et al, 2008;Kerac et al, 2009;Moisi et al, 2011;Ngari et al, 2017;Trehan et al, 2013;Veirum, Sodeman, Biai, Hedegård, & Aaby, 2007;Wiens et al, 2013;Wiens et al, 2015). Recent systematic reviews reported paediatric post-discharge mortality rates in resource-poor countries of up to 18% that may exceed in-hospital mortality rates in many settings (Nemetchek et al, 2018;Wiens et al, 2013).…”

Section: Introductionmentioning

confidence: 99%

Phenotype is sustained during hospital readmissions following treatment for complicated severe malnutrition among Kenyan children: A retrospective cohort study

Gonzales

Ngari

Njunge

et al. 2019

Maternal & Child Nutrition

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Hospital readmission is common among children with complicated severe acute malnutrition (cSAM) but not well‐characterised. Two distinct cSAM phenotypes, marasmus and kwashiorkor, exist, but their pathophysiology and whether the same phenotype persists at relapse are unclear. We aimed to test the association between cSAM phenotype at index admission and readmission following recovery. We performed secondary data analysis from a multicentre randomised trial in Kenya with 1‐year active follow‐up. The main outcome was cSAM phenotype upon hospital readmission. Among 1,704 HIV‐negative children with cSAM discharged in the trial, 177 children contributed a total of 246 readmissions with cSAM. cSAM readmission was associated with age<12 months (p = .005), but not site, sex, season, nor cSAM phenotype. Of these, 42 children contributed 44 readmissions with cSAM that occurred after a monthly visit when SAM was confirmed absent (cSAM relapse). cSAM phenotype was sustained during cSAM relapse. The adjusted odds ratio for presenting with kwashiorkor during readmission after kwashiorkor at index admission was 39.3 [95% confidence interval (95% CI) [2.69, 1,326]; p = .01); and for presenting with marasmus during readmission after kwashiorkor at index admission was 0.02 (95% CI [0.001, 0.037]; p = .01). To validate this finding, we examined readmissions to Kilifi County Hospital, Kenya occurring at least 2 months after an admission with cSAM. Among 2,412 children with cSAM discharged alive, there were 206 readmissions with cSAM. Their phenotype at readmission was significantly influenced by their phenotype at index admission (p < .001). This is the first report describing the phenotype and rate of cSAM recurrence.

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Postdischarge mortality in children with acute infectious diseases: derivation of postdischarge mortality prediction models

Cited by 68 publications

References 22 publications

Application of Sepsis Definitions to Pediatric Patients Admitted With Suspected Infections in Uganda*

Application of Sepsis Definitions to Pediatric Patients Admitted With Suspected Infections in Uganda*

Mortality after Inpatient Treatment for Severe Pneumonia in Children: a Cohort Study

Phenotype is sustained during hospital readmissions following treatment for complicated severe malnutrition among Kenyan children: A retrospective cohort study

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