{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,3]],"date-time":"2026-06-03T06:10:51Z","timestamp":1780467051195,"version":"3.54.1"},"reference-count":42,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2021,11,8]],"date-time":"2021-11-08T00:00:00Z","timestamp":1636329600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Pediatr."],"abstract":"<jats:p><jats:bold>Introduction:<\/jats:bold>Few studies in the literature discuss the benefits of compliance with sepsis bundles in hospitals in low- and middle-income countries, where resources are limited and mortality is high.<\/jats:p><jats:p><jats:bold>Methods:<\/jats:bold>This is a retrospective cohort study conducted at a public hospital in a low-income region in Brazil. We evaluated whether completion of a sepsis bundle is associated with reduced in-hospital mortality for sepsis, severe sepsis, and septic shock, as well as prevention of septic shock and organ dysfunction. Bundle compliance required the completion of three items: (1) obtaining blood count and culture, arterial or venous blood gases, and arterial or venous lactate levels; (2) antibiotic infusion within the first hour of diagnosis; and (3) infusion of 10\u201320 ml\/kg saline solution within the first hour of diagnosis.<\/jats:p><jats:p><jats:bold>Results:<\/jats:bold>A total of 548 children with sepsis, severe sepsis, or septic shock who were treated at the emergency room from February 2008 to August of 2016 were included in the study. Of those, 371 patients were included in the protocol group and had a lower median length of stay (3 days vs. 11 days;<jats:italic>p<\/jats:italic>&amp;lt; 0.001), fewer organ dysfunctions during hospitalization (0 vs. 2,<jats:italic>p<\/jats:italic>&amp;lt; 0.001), and a lower probability of developing septic shock. According to a propensity score analysis, mortality was lower during the post-implementation period [2.75 vs. 15.4% (RR 95%IC 0.13 (0.06, 0.27);<jats:italic>p<\/jats:italic>&amp;lt; 0.001)].<\/jats:p><jats:p><jats:bold>Conclusions:<\/jats:bold>A simple and low-cost protocol was feasible and yielded good results at a general hospital in a low-income region in Brazil. Protocol use resulted in decreased mortality and progression of dysfunctions and was associated with a reduced probability of developing septic shock.<\/jats:p>","DOI":"10.3389\/fped.2021.757721","type":"journal-article","created":{"date-parts":[[2021,11,8]],"date-time":"2021-11-08T08:07:35Z","timestamp":1636358855000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":8,"title":["A Pediatric Sepsis Protocol Reduced Mortality and Dysfunctions in a Brazilian Public Hospital"],"prefix":"10.3389","volume":"9","author":[{"given":"Daniela Nasu Monteiro","family":"Medeiros","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ana Carolina Cintra Nunes","family":"Mafra","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Joseph Anthony","family":"Carcillo","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Eduardo Juan","family":"Troster","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2021,11,8]]},"reference":[{"key":"B1","doi-asserted-by":"publisher","first-page":"793","DOI":"10.1542\/peds.112.4.793","article-title":"Early reversal of pediatric-neonatal septic shock by community physicians is associated with improved outcome","volume":"112","author":"Han","year":"2003","journal-title":"Pediatrics"},{"key":"B2","doi-asserted-by":"publisher","first-page":"2409","DOI":"10.1097\/CCM.0000000000000509","article-title":"Delayed antimicrobial therapy increases mortality and organ dysfunction duration in pediatric sepsis","volume":"42","author":"Weiss","year":"2014","journal-title":"Crit Care Med."},{"key":"B3","doi-asserted-by":"publisher","first-page":"2","DOI":"10.1097\/SHK.0000000000000699","article-title":"The epidemiology of sepsis in childhood","volume":"47","author":"de Souza","year":"2017","journal-title":"Shock."},{"key":"B4","doi-asserted-by":"publisher","first-page":"348","DOI":"10.1136\/adc.2008.153064","article-title":"Emergency management of children with severe sepsis in the United Kingdom: the results of the Paediatric Intensive Care Society sepsis audit","volume":"94","author":"Inwald","year":"2009","journal-title":"Arch Dis Child."},{"key":"B5","doi-asserted-by":"publisher","first-page":"7","DOI":"10.1186\/2110-5820-3-7","article-title":"Management of children with sepsis and septic shock: a survey among pediatric intensivists of the Reseau Mere-Enfant de la Francophonie","volume":"3","author":"Santschi","year":"2013","journal-title":"Ann Intensive Care."},{"key":"B6","doi-asserted-by":"publisher","first-page":"352","DOI":"10.1001\/jamapediatrics.2018.4839","article-title":"Global case-fatality rates in pediatric severe sepsis and septic shock: a systematic review and meta-analysis","volume":"173","author":"Tan","year":"2019","journal-title":"JAMA Pediatr."},{"key":"B7","doi-asserted-by":"publisher","first-page":"17","DOI":"10.1371\/journal.pone.0181160","article-title":"Clinical outcomes and mortality before and after implementation of a pediatric sepsis protocol in a limited resource setting: a retrospective cohort study in Bangladesh","volume":"12","author":"Kortz","year":"2017","journal-title":"PLoS ONE."},{"key":"B8","doi-asserted-by":"publisher","first-page":"2","DOI":"10.1097\/01.PCC.0000149131.72248.E6","article-title":"International pediatric sepsis consensus conference: definitions for sepsis and organ dysfunction in pediatrics","volume":"6","author":"Goldstein","year":"2005","journal-title":"Pediatr Crit Care Med."},{"key":"B9","doi-asserted-by":"publisher","first-page":"580","DOI":"10.1007\/s00134-012-2769-8","article-title":"Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: (2012)","volume":"41","author":"Dellinger","year":"2013","journal-title":"Crit Care Med."},{"key":"B10","doi-asserted-by":"crossref","first-page":"205","DOI":"10.1542\/peds.106.S1.205","article-title":"Pediatric deaths attributable to complex chronic conditions: a population-based study of Washington State, 1980-1997","volume":"106","author":"Feudtner","year":"2000","journal-title":"Pediatrics"},{"key":"B11","doi-asserted-by":"publisher","first-page":"702","DOI":"10.1093\/aje\/kwh090","article-title":"A modified Poisson regression approach to prospective studies with binary data","volume":"159","author":"Guangyong","year":"2004","journal-title":"Amer J Epidemiol"},{"key":"B12","doi-asserted-by":"publisher","first-page":"1","DOI":"10.18637\/jss.v016.i09","article-title":"Object-oriented computation of sandwich estimators","volume":"16","author":"Achim","year":"2006","journal-title":"J Stat Softw"},{"key":"B13","doi-asserted-by":"publisher","first-page":"129","DOI":"10.1007\/s10182-010-0141-2","article-title":"A new heteroskedasticity-consistent covariance matrix estimator for the linear regression model","volume":"95","author":"Cribari-Neto","year":"2011","journal-title":"Adv Stat Anal."},{"key":"B14","unstructured":"PaulaGA Instituto de Matem\u00e1tica e Estat\u00edstica da Universidade de S\u00e3o PauloModelos de Regress\u00e3o Com Apoio Computacional2013"},{"key":"B15","doi-asserted-by":"publisher","first-page":"1","DOI":"10.18637\/jss.v042.i07","article-title":"Multivariate and propensity score matching software with automated balance optimization: the matching package for R","volume":"42","author":"Sekhon","year":"2011","journal-title":"J Stat Softw"},{"key":"B16","doi-asserted-by":"publisher","first-page":"932","DOI":"10.1162\/REST_a_00318","article-title":"Genetic matching for estimating causal effects: a general multivariate matching method for achieving balance in observational studies","volume":"95","author":"Diamond","year":"2013","journal-title":"Rev Econ Stat"},{"key":"B17","doi-asserted-by":"publisher","first-page":"1","DOI":"10.18637\/jss.v067.i01","article-title":"Fitting linear mixed-effects models using lme4","volume":"67","author":"Bates","year":"2015","journal-title":"J Stat Softw"},{"key":"B18","author":"Knowles","year":"2019","journal-title":"merTools: Tools for Analyzing Mixed Effect Regression Models"},{"key":"B19","doi-asserted-by":"publisher","first-page":"278","DOI":"10.3389\/fped.2017.00278","article-title":"Clinical presentation and outcomes among children with sepsis presenting to a public tertiary hospital in Tanzania","volume":"5","author":"Kortz","year":"2017","journal-title":"Front Pediatr."},{"key":"B20","doi-asserted-by":"publisher","first-page":"82","DOI":"10.1007\/s00134-018-5213-x","article-title":"The ten pitfalls of lactate clearance in sepsis","volume":"45","author":"Hernandez","year":"2019","journal-title":"Intensive Care Med."},{"key":"B21","doi-asserted-by":"publisher","first-page":"249","DOI":"10.1001\/jamapediatrics.2016.3681","article-title":"Association between early lactate levels and 30-day mortality in clinically suspected sepsis in children","volume":"171","author":"Scott","year":"2017","journal-title":"JAMA Pediatr."},{"key":"B22","doi-asserted-by":"publisher","first-page":"4","DOI":"10.1016\/j.jpeds.2015.11.071","article-title":"Lactate clearance and normalization and prolonged organ dysfunction in pediatric sepsis","volume":"170","author":"Scott","year":"2016","journal-title":"J Pediatr."},{"key":"B23","doi-asserted-by":"publisher","first-page":"1295.e4","DOI":"10.1016\/j.jpeds.2015.09.027","article-title":"Identifying pediatric severe sepsis and septic shock: accuracy of diagnosis codes","volume":"167","author":"Balamuth","year":"2015","journal-title":"J Pediatr."},{"key":"B24","doi-asserted-by":"publisher","first-page":"695","DOI":"10.1164\/rccm.200207-682OC","article-title":"The epidemiology of severe sepsis in children in the United States","volume":"167","author":"Watson","year":"2003","journal-title":"Am J Respir Crit Care Med."},{"key":"B25","doi-asserted-by":"publisher","first-page":"487","DOI":"10.1542\/peds.2006-2353","article-title":"Patient and hospital correlates of clinical outcomes and resource utilization in severe pediatric sepsis","volume":"119","author":"Odetola","year":"2007","journal-title":"Pediatrics."},{"key":"B26","doi-asserted-by":"publisher","first-page":"727","DOI":"10.1097\/PCC.0000000000000847","article-title":"Epidemiology of sepsis in children admitted to PICUs in South America","volume":"17","author":"de Souza","year":"2016","journal-title":"Pediatr Crit Care Med."},{"key":"B27","doi-asserted-by":"publisher","first-page":"e758","DOI":"10.1542\/peds.2010-2895","article-title":"Implementation of goal-directed therapy for children with suspected sepsis in the emergency department","volume":"127","author":"Cruz","year":"2011","journal-title":"Pediatrics."},{"key":"B28","doi-asserted-by":"publisher","first-page":"483","DOI":"10.1016\/S1553-7250(11)37061-4","article-title":"Kaiser Permanente's performance improvement system, part 3: multisite improvements in care for patients with sepsis","volume":"37","author":"Whippy","year":"2011","journal-title":"Jt Comm J Qual Patient Saf."},{"key":"B29","doi-asserted-by":"publisher","first-page":"1301.e1","DOI":"10.1016\/j.jpeds.2015.08.044","article-title":"Resuscitation bundle in pediatric shock decreases acute kidney injury and improves outcomes","volume":"167","author":"Akcan Arikan","year":"2015","journal-title":"J Pediatr."},{"key":"B30","doi-asserted-by":"publisher","first-page":"e273","DOI":"10.1542\/peds.2012-0094","article-title":"Adherence to PALS sepsis guidelines and hospital length of stay","volume":"130","author":"Paul","year":"2012","journal-title":"Pediatrics."},{"key":"B31","doi-asserted-by":"publisher","first-page":"358","DOI":"10.1001\/jama.2018.9071","article-title":"Association between the New York sepsis care mandate and in-hospital mortality for pediatric sepsis","volume":"320","author":"Evans","year":"2018","journal-title":"Jama."},{"key":"B32","doi-asserted-by":"publisher","first-page":"231","DOI":"10.5935\/0103-507X.20210030","article-title":"Prevalence and outcomes of sepsis in children admitted to public and private hospitals in Latin America: a multicenter observational study","volume":"33","author":"De Souza","year":"2021","journal-title":"Rev Bras Ter Intensiva."},{"key":"B33","doi-asserted-by":"publisher","first-page":"469","DOI":"10.1097\/PCC.0b013e3181ce752e","article-title":"Suboptimal care in the initial management of children who died from severe bacterial infection: a population-based confidential inquiry","volume":"11","author":"Launay","year":"2010","journal-title":"Pediatr Crit Care Med."},{"key":"B34","doi-asserted-by":"publisher","first-page":"703","DOI":"10.7727\/wimj.2013.326","article-title":"Systems for paediatric sepsis: a global survey","volume":"63","author":"Kang","year":"2014","journal-title":"West Indian Med J."},{"key":"B35","doi-asserted-by":"publisher","first-page":"e20180299","DOI":"10.1590\/1983-1447.2019.20180299","article-title":"Sepsis and AMI: knowledge of the population visiting parks and patient companions","volume":"40","author":"Moretti","year":"2019","journal-title":"Rev Gaucha Enferm."},{"key":"B36","doi-asserted-by":"publisher","first-page":"945","DOI":"10.1136\/archdischild-2015-310234","article-title":"A prospective quality improvement study in the emergency department targeting paediatric sepsis","volume":"101","author":"Long","year":"2016","journal-title":"Arch Dis Child."},{"key":"B37","doi-asserted-by":"publisher","first-page":"501","DOI":"10.1097\/PCC.0b013e31823c980f","article-title":"Epidemiology of sepsis in pediatric intensive care units: first Colombian multicenter study","volume":"13","author":"Jaramillo-Bustamante","year":"2012","journal-title":"Pediatr Crit Care Med."},{"key":"B38","doi-asserted-by":"publisher","first-page":"e43639","DOI":"10.1371\/journal.pone.0043639","article-title":"Low socioeconomic status is associated with prolonged times to assessment and treatment, sepsis and infectious death in pediatric fever in El Salvador","volume":"7","author":"Gavidia","year":"2012","journal-title":"PLoS ONE."},{"key":"B39","doi-asserted-by":"publisher","first-page":"298","DOI":"10.1097\/MOP.0000000000000222","article-title":"Quality improvement in pediatric sepsis","volume":"27","author":"Melendez","year":"2015","journal-title":"Curr Opin Pediatr."},{"key":"B40","doi-asserted-by":"publisher","first-page":"e051","DOI":"10.1097\/pq9.0000000000000051","article-title":"A quality improvement collaborative for pediatric sepsis: lessons learned","volume":"3","author":"Paul","year":"2018","journal-title":"Pediatr Qual Saf."},{"key":"B41","doi-asserted-by":"publisher","first-page":"e321","DOI":"10.1097\/PCC.0000000000001536","article-title":"Effect of a sepsis educational intervention on hospital stay","volume":"19","author":"Fernandez-Sarmiento","year":"2018","journal-title":"Pediatr Crit Care Med."},{"key":"B42","doi-asserted-by":"publisher","first-page":"e0186210","DOI":"10.1371\/journal.pone.0186210","article-title":"Intravenous fluid prescribing errors in children: mixed methods analysis of critical incidents","volume":"12","author":"Conn","year":"2017","journal-title":"PLoS ONE."}],"container-title":["Frontiers in Pediatrics"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fped.2021.757721\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2023,1,14]],"date-time":"2023-01-14T17:09:08Z","timestamp":1673716148000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fped.2021.757721\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2021,11,8]]},"references-count":42,"alternative-id":["10.3389\/fped.2021.757721"],"URL":"https:\/\/doi.org\/10.3389\/fped.2021.757721","relation":{},"ISSN":["2296-2360"],"issn-type":[{"value":"2296-2360","type":"electronic"}],"subject":[],"published":{"date-parts":[[2021,11,8]]},"article-number":"757721"}}