Abstract
IntroductionSuboptimal 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.MethodsA 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.ResultsSuboptimal 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.ConclusionsSuboptimal 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.
Highlights
Suboptimal care is frequent in the management of severe bacterial infection
The consequences of suboptimal care in pediatric patients with severe bacterial infection (SBI) have been examined in 4 studies. [4,5,6,7] All found clinically meaningful and statistically significant associations between suboptimal care and morbidity and mortality. [4,5,6,7] the results were limited by methodological concerns such as selection bias related to hospital-based recruitment, [6] classification bias related to arbitrary definition of diagnosis delay as consultation more than once before hospitalisation, [5] nonindependent evaluation of the optimality of care, [7] non-justified use of continuous variables in multivariable models, [4,5,7] and/or selection of non-appropriate variables for adjustment. [8,9] No study examined the determinants of this suboptimal care to inform corrective actions for parents and healthcare workers
The first medical contact was a general practitioners (GPs) in 66% of cases, an emergency physician in 25%, and a mobile medical unit in 9%; 60% of children were hospitalized after this first medical contact
Summary
We aimed to evaluate the consequences of suboptimal care in the early management of severe bacterial infection in children and study the determinants. [2] In 2010, we published a population-based study evaluating optimality of care for 21 children who died due to SBI: the initial medical management was suboptimal in 76% of cases, with a delay in seeking medical care in 33%. [8,9] No study examined the determinants of this suboptimal care to inform corrective actions for parents and healthcare workers. The aim of the present study was to evaluate the determinants and consequences of suboptimal care in the initial management of SBI in children, using appropriate methodological approaches, to evaluate the relevance of future targeted corrective actions for parents and healthcare workers The consequences of suboptimal care in pediatric patients with SBI have been examined in 4 studies. [4,5,6,7] All found clinically meaningful and statistically significant associations between suboptimal care and morbidity and mortality. [4,5,6,7] the results were limited by methodological concerns such as selection bias related to hospital-based recruitment, [6] classification bias related to arbitrary definition of diagnosis delay as consultation more than once before hospitalisation, [5] nonindependent evaluation of the optimality of care, [7] non-justified use of continuous variables in multivariable models, [4,5,7] and/or selection of non-appropriate variables for adjustment (without using a causal diagram that could help deal with co-variables that could be confounders or intermediate variables). [8,9] No study examined the determinants of this suboptimal care to inform corrective actions for parents and healthcare workers.
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