title: Why children with severe bacterial infection die: a population-based study of determinants and consequences of suboptimal care with a special emphasis on methodological issues.
abstract: BACKGROUND
  Suboptimal care is frequent in the management of severe bacterial infection. We aimed to evaluate the consequences of suboptimal care in the early management of severe bacterial infection in children and study the determinants.
  
  
  METHODS
  A previously reported population-based confidential enquiry included all children (3 months- 16 years) who died of severe bacterial infection in a French area during a 7-year period. Here, we compared the optimality of the management of these cases to that of pediatric patients who survived a severe bacterial infection during the same period for 6 types of care: seeking medical care by parents, evaluation of sepsis signs and detection of severe disease by a physician, timing and dosage of antibiotic therapy, and timing and dosage of saline bolus. Two independent experts blinded to outcome and final diagnosis evaluated the optimality of these care types. The effect of suboptimal care on survival was analyzed by a logistic regression adjusted on confounding factors identified by a causal diagram. Determinants of suboptimal care were analyzed by multivariate multilevel logistic regression.
  
  
  RESULTS
  Suboptimal care was significantly more frequent during early management of the 21 children who died as compared with the 93 survivors: 24% vs 13% (p = 0.003). The most frequent suboptimal care types were delay to seek medical care (20%), under-evaluation of severity by the physician (20%) and delayed antibiotic therapy (24%). Young age (under 1 year) was independently associated with higher risk of suboptimal care, whereas being under the care of a paediatric emergency specialist or a mobile medical unit as compared with a general practitioner was associated with reduced risk.
  
  
  CONCLUSIONS
  Suboptimal care in the early management of severe bacterial infection had a global independent negative effect on survival. Suboptimal care may be avoided by better training of primary care physicians in the specifics of pediatric medicine.
authors.affiliation: CHU Nantes, Hôpital de la Mère et de l'Enfant, Clinique médicale pédiatrique, Faculté de médecine de Nantes, Nantes, France; Inserm U1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team, Research Center for Epidemiology and Biostatistics Sorbonne Paris Cité (CRESS), Paris Descartes University, Paris, France.
authors.forename: Elise
authors.initials: E
authors.lastname: Launay
authors.affiliation: CHU Nantes, Hôpital de la Mère et de l'Enfant, Clinique médicale pédiatrique, Faculté de médecine de Nantes, Nantes, France; CHU Nantes, Hôpital de la Mère et de l'Enfant, Urgences pédiatriques, Faculté de médecine de Nantes, Nantes, France.
authors.forename: Christèle
authors.initials: C
authors.lastname: Gras-Le Guen
authors.affiliation: CHU de Lille, Hôpital R. Salengro, Unité d'urgences pédiatriques et de maladies infectieuses, Université de Lille-Nord de France, Lille, France.
authors.forename: Alain
authors.initials: A
authors.lastname: Martinot
authors.affiliation: Association pour le Recherche et l'Enseignement en Pédiatrie Générale (AREPEGE); Association Française de Pédiatrie Ambulatoire (AFPA), Cabinet de Pédiatrie, Issy-les-Moulineaux, France.
authors.forename: Rémy
authors.initials: R
authors.lastname: Assathiany
authors.affiliation: CHU Nantes, Hôpital de la Mère et de l'Enfant, Clinique médicale pédiatrique, Faculté de médecine de Nantes, Nantes, France.
authors.forename: Elise
authors.initials: E
authors.lastname: Martin
authors.affiliation: CHU Nantes, Hôpital de la Mère et de l'Enfant, Clinique médicale pédiatrique, Faculté de médecine de Nantes, Nantes, France.
authors.forename: Thomas
authors.initials: T
authors.lastname: Blanchais
authors.affiliation: Inserm U1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team, Research Center for Epidemiology and Biostatistics Sorbonne Paris Cité (CRESS), Paris Descartes University, Paris, France.
authors.forename: Catherine
authors.initials: C
authors.lastname: Deneux-Tharaux
authors.affiliation: CHU Nantes, Hôpital de la Mère et de l'Enfant, Réanimation pédiatrique et néonatale, Faculté de médecine de Nantes, Nantes, France.
authors.forename: Jean-Christophe
authors.initials: JC
authors.lastname: Rozé
authors.affiliation: Inserm U1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team, Research Center for Epidemiology and Biostatistics Sorbonne Paris Cité (CRESS), Paris Descartes University, Paris, France; Hôpital Necker Enfants Malades, AP-HP, Service de pédiatrie générale, Paris Descartes University, Paris, France.
authors.forename: Martin
authors.initials: M
authors.lastname: Chalumeau
mesh_terms: D000293:Adolescent; D001424:Bacterial Infections / Q000401:mortality* / Q000628:therapy*; D002648:Child; D002675:Child, Preschool; D019468:Disease Management; D005260:Female; D005602:France / Q000453:epidemiology; D006801:Humans; D007223:Infant; D016015:Logistic Models; D008297:Male; D011787:Quality of Health Care; D012307:Risk Factors; D012720:Severity of Illness Index