title: A retrospective cohort study of prognostic factors associated with outcome in pediatric severe sepsis: what is the role of steroids?
abstract: OBJECTIVE
  Systemic corticosteroids remain controversial in the treatment of pediatric patients with severe sepsis. Recent studies in septic adults have shown decreased mortality with the use of hydrocortisone in patients with relative adrenal insufficiency. We conducted this large retrospective cohort study to further characterize severe sepsis in infants and children and correlates of outcome, including the use of steroids.
  
  
  METHODS
  Retrospective cohort study.
  
  
  METHODS
  The Pediatric Health Information System (PHIS), an administrative database of the Child Health Corporation of America (CHCA), was queried for inpatients 0-17 yrs of age with severe sepsis (defined here as an International Classification of Disease 9th edition code for infection with use of simultaneous mechanical ventilation and vasoactive infusions) from 2001 to 2002. In addition to demographic information, use of systemic corticosteroids (hydrocortisone, methylprednisolone, or dexamethasone) concurrent with the ventilatory and vasoactive support was collected.
  
  
  METHODS
  Data from PHIS.
  
  
  METHODS
  None.
  
  
  RESULTS
  Patients (n = 6693) were identified at 27 PHIS-participating CHCA member hospitals. Overall mortality was 24%; univariate predictors of death included use of steroids (odds ratio [OR], 1.9; 95% confidence interval (CI), 1.7, 2.2), older age (e.g., 13-17 yrs vs. neonates; OR, 1.6; 95% CI, 1.3, 2.0), a hematologic-oncologic diagnosis (OR, 5.87; 95% CI, 4.19, 8.23), and moderate vs. high case volume (OR, 1.25; 95% CI, 1.09, 1.44). Age, hematologic-oncologic diagnosis, case volume, and use of steroids remained independent predictors of mortality in multivariable analysis.
  
  
  CONCLUSIONS
  From this administrative database analysis, there is no evidence that steroids are associated with improved outcome in critically ill infants and children with sepsis. Although steroids may be given preferentially to more severely ill children, their use was associated with increased mortality. Clinicians should maintain equipoise on this topic pending prospective randomized clinical trials.
authors.affiliation: Washington University School of Medicine, St. Louis Children's Hospital, St. Louis, MO, USA.
authors.forename: Barry P
authors.initials: BP
authors.lastname: Markovitz
authors.forename: Denise M
authors.initials: DM
authors.lastname: Goodman
authors.forename: R Scott
authors.initials: RS
authors.lastname: Watson
authors.forename: David
authors.initials: D
authors.lastname: Bertoch
authors.forename: Jerry
authors.initials: J
authors.lastname: Zimmerman
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D016638:Critical Illness; D005260:Female; D005938:Glucocorticoids / Q000627:therapeutic use*; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D011379:Prognosis; D012121:Respiration, Artificial; D012189:Retrospective Studies; D018805:Sepsis / Q000175:diagnosis / Q000188:drug therapy*; D012720:Severity of Illness Index; D016896:Treatment Outcome
chemical_list: D005938:Glucocorticoids