Bundle Adherence of Intravenous Antibiotic Fluid Resuscitation and Vasopressor in Children with Severe Sepsis or Septic Shock
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RESEARCH ARTICLE
Bundle Adherence of Intravenous Antibiotic Fluid
Resuscitation and Vasopressor in Children with Severe Sepsis
or Septic Shock
Clarice L Barboza1, Cristina OS Valete2, André RA da Silva3
A b s t r ac t
Objective: The aim of this study was to measure the effects of a bundle of interventions in children admitted with severe sepsis or septic shock
in the first hour after diagnosis on mortality.
Materials and methods: A retrospective study was conducted at a pediatric intensive care unit (PICU) between January 2014 and January 2016.
Three interventions (intravenous [IV] antibiotic, fluid boluses, and vasopressor administration) applied in the first hour of severe sepsis or septic
shock diagnosis were analyzed according to their adherence rates. The main outcome was mortality. Odds ratios were calculated.
Results: Of a total of 530 PICU admissions, 105 patients met the criteria for sepsis, 53 (50.5%) with severe sepsis and 52 (49.5%) with septic
shock. Seventy-two (68.6%) patients received IV antibiotic within the first hour, 65 (61.9%) received IV fluid bolus, and 55 (53.3%) received
a vasopressor drug. Fifty-two (49.5%) patients received concomitant IV antibiotics and fluid bolus. Blood cultures were collected before IV
antibiotic administration in 87 (82.9%) out of 105 patients. Thirteen (12.4%) patients died, 1 with severe sepsis and 12 with septic shock. In a
univariate analysis, the odds ratios for death and IV antibiotic were 6.39 (p value = 0.081, 95% CI = 0.795–51.465), 4.77 for fluid bolus between
21 and 40 mL/kg (p value = 0.013, 95% CI = 1.395–16.336), and 3.23 for vasopressor administration (p value < 0.0001, 95% CI = 1.734–6.018).
In a multivariate analysis, the odds ratio of fluid bolus between 21 and 40 mL/kg was 42.66 (p value = 0.005, 95% CI = 3.117–583.841) and
noradrenaline use was 23.93 (p value = 0.010, 95% CI = 2.124–269.750).
Conclusion: Adherence was observed for more than half of the single interventions as IV antibiotic, fluid resuscitation, and vasopressor
administration in the first hour. The antibiotic administration alone was not associated with high mortality. Vasopressor administration was
related to higher mortality but moderate fluid bolus was a protective factor associated with lower mortality.
Keywords: Antibiotic, Bundle, Fluid resuscitation, Pediatric intensive care unit, Sepsis.
Indian Journal of Critical Care Medicine (2020): 10.5005/jp-journals-10071-23336
I n t r o d u c t i o n 1
Federal Fluminense University, Brazil
2,3
Severe sepsis and septic shock are critical conditions and important Materno-Infantil Department, Federal Fluminense University, Brazil
causes of death in children worldwide.1 The management and Corresponding Author: André RA da Silva, Materno-Infantil
evolution of pediatric sepsis were assessed by Weiss et al., in a Department, Federal Fluminense University, Brazil, Phone: +55 21
point prevalence study conducted in 26 different countries. In 99854 1950, e-mail: aricardo@id.uff.br
this report, common therapies for the sepsis treatment included How to cite this article: Barboza CL, Valete COS, da Silva ARA.
antibiotic therapy (98%), mechanical ventilation (74%), vasoactive Bundle Adherence of Intravenous Antibiotic Fluid Resuscitation and
infusions (55%), and corticosteroids (45%). Hospital mortality was Vasopressor in Children with Severe Sepsis or Septic Shock. Indian J
25% and did not differ by age or between developed and resource- Crit Care Med 2020;24(2):128–132.
limited countries. 2 Source of support: Nil
The Survival Sepsis Campaign (SSC) is one of the initiatives Conflict of interest: None
to standardize procedures and interventions with the purpose of
reducing mortality in adult patients with sepsis, using the best available included early disease diagnosis, optimum hemodynamic
evidence. Some of these interventions were also recommended for resuscitation, and timely antibiotic administration.4
children, although with different grade of evidence.3 Immediate Although the benefits are observed in adults, clinical studies
recognition and treatment within the first hour after diagnosis with have shown that only 8–30% of pediatricians have implemented
antimicrobials, fluid, and vasopressor administration are the core a systematized approach to sepsis in their practice.5,6 Knowledge
interventions that may change the prognosis.2,3 about the adherence to a bundle of early interventions in children
In an interventional, multicenter trial conducted in children with sepsis could provide substantial information to identify
from seven different large academic centers in Thailand who had gaps in the initial approach and to evaluate the impact of these
been diagnosed with severe sepsis or septic shock, SSC bundles interventions on morbidity and mortality.
were applied and sepsis mortality was compared before and after The aim of this study is to measure the effects of three
intervention. Mortality was reduced significantly from 37% ± interventions (intravenous antibiotic, fluid resuscitation, and
20.7%, during the preintervention period, to 19.4% ± 14.3%, during vasopressor administration) in children admitted with severe sepsis
the postintervention period (p < 0.001). The set of components or septic shock in the first hour after the diagnosis on mortality.
© The Author(s). 2020 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.
org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and non-commercial reproduction in any medium, provided you give appropriate credit to
the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain
Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Bundle Adherence of Intravenous Antibiotic Fluid Resuscitation and Vasopressor in Children with Severe Sepsis or Septic Shock
M at e r ia l s a n d M e t h o d s Data Analysis
Study Design and Patients First a descriptive variable analysis was performed using Excel
files. It was assumed that the data were not normally distributed
A retrospective descriptive study was performed in a cohort
(Kolmogorov–Smirnov test). Medians, interquartile range, 95%
of children admitted in a pediatric intensive care unit (PICU),
confidence intervals (CIs), Chi-square, Mann–Whitney tests, and
with severe sepsis or septic shock. The study was conducted in
odds ratios were calculated when required. Kappa coefficient
Prontobaby Children’s Hospital, a private pediatric hospital in Rio
was calculated to determine agreement among the categorical
de Janeiro city, Brazil, with ten-bed capacity. Patients were admitted
data: antibiotic administration and fluid bolus, septic shock and
from own emergency service or wards or referred from other
vasopressor administration. We used univariate analysis to explain
hospitals, with clinical or surgical diseases. Until 2017, the hospital
the outcome: death/survival. The variables that presented a p value
did not have a formalized protocol to treat patients with sepsis.
ofBundle Adherence of Intravenous Antibiotic Fluid Resuscitation and Vasopressor in Children with Severe Sepsis or Septic Shock
Table 3: Intravenous antibiotic, fluid bolus, vasopressor administration during the first hour in children with
severe sepsis or septic shock (n = 105)
Interventions during Severe sepsis (n = 53) Septic shock (n = 52)
the first hour Yes No p value Yes No p value
Intravenous 30 23 0.176 42 10Bundle Adherence of Intravenous Antibiotic Fluid Resuscitation and Vasopressor in Children with Severe Sepsis or Septic Shock
the first hour, in four different PICUs from Shanghai, China.12–14 Efforts need to be put to improve bundle adherence and confirm
Although early administration of antibiotics has been associated the best moment for antibiotic administration.
with better outcomes in adult studies, this association was not
found in our cohort.15 It seems that antibiotics administration in
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