Children With Congenital Heart Disease Who Develop Septicemia During Hospitalization Have Poor Outcomes

Deborah Brauser

January 22, 2010

January 21, 2010 (Miami Beach, Florida) — Complications from hospital-acquired infections, especially septicemia, significantly increase hospital costs and length of stay in children with disorders of the cardiovascular system, including sickle cell anemia (SCA), according to 2 new studies.

Dr. Veerajalandhar Allareddy

The results of both were presented during poster sessions here at the Society of Critical Care Medicine 39th Critical Care Congress by lead investigator Veerajalandhar Allareddy, MD, pediatric intensive care unit fellow in the Department of Pediatric Pharmacology and Critical Care at Rainbow Babies and Children's Hospital at University Hospitals (in partnership with Case Western Reserve University School of Medicine) in Cleveland, Ohio.

"Pediatric patients who have an underlying cardiovascular disorder have a higher morbidity when admitted to the hospital for acute care of any etiology, and those with SCA are at high risk of developing several complications," said Dr. Allareddy during his presentation. "Infection by itself is a major cause of morbidity and mortality in these children requiring in-hospital care."

He said that the purpose of these studies was to examine the association in the 2 patient populations between infectious complications and outcomes, such as in-hospital mortality, length of stay, and total charges during hospitalizations.

Septicemia Shows Poorest Outcomes

In the first study, Dr. Allareddy's team evaluated data from 45,968 children (mean age, 7.89 years; 54.6% male) hospitalized in 2006 for diseases and disorders of the circulatory system in the Kids' Inpatient Database (KID) of the Healthcare Cost and Utilization Project. The KID, which is run by the Agency for Healthcare Research and Quality, contains data from 28 states and more than 3700 hospitals.

Of the hospitalizations examined, 4207 patients developed septicemia (9.15%), 3655 patients developed bacterial infections (7.95%), and 1081 patients developed mycoses (2.35%).

"Patients who developed these infectious complications were matched with those who did not by factors such as age, sex, comorbid burden, insurance status, primary procedure performed during hospitalization, and hospital," Dr. Allareddy explained.

Results at the end of the study showed that the children who developed septicemia during hospitalization averaged 11.6 more days in the hospital (< .0001) and $64,969 more in hospital charges (< .0001) than the children who did not develop septicemia.

Those who developed mycoses averaged 7.8 more days (P < .0001) and $42,520 more in hospital charges (P < .0001), and those who developed bacterial infection averaged 3.9 more days (< .0001) and $23,412 more in hospital charges (< .0001) than the study matches who did not develop the infectious complications.

Although not statistically significant, higher in-hospital mortality was also associated with the children who developed septicemia (4.3% vs 1.8%; P = .03).

Overall, in-hospital mortality from all 3 of the infection groups was 2.18% (n = 1001 deaths).

"In other words, for any kid who is admitted to the hospital with a congenital heart disease and who develops an infection, the outcome is going to be poor," said Dr. Allareddy. "These results were a little surprising, in that the outcomes were worse than we expected."

Poor Outcomes Also for Children With SCA

In a second study, Dr. Allareddy and his colleagues looked specifically at the association between infectious complications and outcomes in children hospitalized with SCA.

Using the KID database again, they examined 15,445 hospitalized patients (mean age, 12.47 years; 50.1% male) with a primary diagnosis of SCA, including 285 who developed septicemia (1.84%), 351 who developed bacterial infections (2.27%), and 113 who developed mycoses (0.73%).

In this patient population, the children who developed septicemia spent an average of 5.7 more days in the hospital (P < .0001) and an extra $22,664 in hospital charges (< .0001); those who developed mycoses spent an average of 2.8 more days (P = .09) and $8,722 more in hospital charges (P = .03); and those who developed bacterial infection spent an average of 1.48 more days (= .001) and $8,554 more in hospital charges (P < .0001) than their respective matches who did not develop the infections.

"These studies underscore the importance of preventing and minimizing infectious complications to achieve better outcomes," said Dr. Allareddy. "Looking at these findings, we have a long way to go in treating these kids better."

He added that the findings are a national representation of the way things currently are. "We have a problem here. The key is to minimize these infections and to be really aggressive with antibiotics, etc., so that we can control them really fast."

Dr. Allareddy reported that previous studies that have looked at the effect of giving antibiotics within 2 hours of the appearance of an infection in an adult population have shown that that had a significant impact on mortality and length of stay. "So that's something I'm hoping we can examine soon in the pediatric population. I really believe that time is of the essence when it comes to treating these kids."

Robust Results

"Essentially, the first study bears out what we all suspected, which is that if you develop an underlying infection during hospitalization, not only does it increase the duration of hospital stay, it also increases morbidity," said session comoderator Emanuel Rivers, MD, MPH, vice-chair and research director for emergency medicine at Henry Ford Hospital in Detroit, Michigan.

"This has been fairly well known in adult patients. However, I don't know if this has ever been examined to this extent in children. And with almost 46,000 hospitalizations, it's a robust study with fairly robust results. I think it's an excellent paper," said Dr. Rivers, who was not involved with these studies.

He added that "a common feeling is that, with these types of sick patients, some of these infections are just par for the course, but I think there may be room for improvement. When you look at the overall mortality they found, some people will feel that's very low, compared with adults. But I think a 2% mortality rate in children is still significant, as we're talking about over a thousand deaths."

Dr. Rivers said that he isn't surprised that the second study had similar findings, because "sickle cell anemia is just a specific disease with an immunocompetency problem."

He said that he'd like to next see a good cohort study. "Overall, these are very good baseline data, but perhaps investigators could take this type of study, implement a preventing-sepsis program, and then look at a good cohort of patients after that implementation. That would be interesting because I think there are a lot of costs that could be avoided. Plus, if you could cut down overall mortality to less than 1%, that would be very significant," concluded Dr. Rivers.

Dr. Allareddy and Dr. Rivers have disclosed no relevant financial relationships.

Society of Critical Care Medicine (SCCM) 39th Critical Care Congress: Abstract 491, presented January 11, 2010; Abstract 282, presented January 10, 2010.