Phoenix Sepsis Score may identify children with differing hydrocortisone outcomes

An observational cohort study and target trial emulation across 15 US pediatric intensive care units included 48,345 children with suspected or confirmed community-acquired infection. Early hydrocortisone was associated with lower mortality among children with high Phoenix Sepsis Scores, but higher mortality among those with low scores; the authors say prospective validation is needed.

PSS ≥4 identified children with substantially higher mortality.
Hydrocortisone associations differed by PSS risk group.
Findings came from observational target trial emulation.
Prospective validation is needed before practice changes.

Researchers analyzed children younger than 18 years admitted to 15 US pediatric intensive care units from 2010 to 2019 with suspected or confirmed community-acquired infection. The observational cohort study used a target trial emulation to compare patients given systemic stress-dose hydrocortisone within 24 hours of admission with untreated patients. The analysis included 48,345 children and assessed in-hospital mortality across Phoenix Sepsis Score (PSS) risk groups, with findings evaluated in development and validation cohorts.

A PSS of 4 or higher in the first 12 hours identified a group with about 10 times the mortality of children with lower scores. In the development cohort, early hydrocortisone was associated with lower mortality in the high-risk group (adjusted risk ratio [aRR] 0.72, 95% CI 0.65–0.80) and higher mortality in the low-risk group (aRR 1.90, 95% CI 1.66–2.16). The pattern was replicated in the validation cohort: aRRs were 0.79 (95% CI 0.68–0.92) and 2.95 (95% CI 2.43–3.59), respectively; interaction p<0.001 in both cohorts.

These findings suggest the score may help identify treatment-effect differences, but they do not establish that hydrocortisone causes the observed outcomes. Treatment was not randomized, and the authors call for further external and prospective validation before the strategy can guide care.

In practice

For critically ill children with suspected or confirmed community-acquired sepsis, this study suggests that early hydrocortisone outcomes may differ by Phoenix Sepsis Score: treatment was associated with lower in-hospital mortality at scores of 4 or higher and higher mortality below 4. The evidence is observational, despite use of target trial emulation, so residual confounding and treatment-selection effects cannot be excluded. These findings do not establish a treatment rule; external and prospective validation is warranted before using the score to select children for hydrocortisone.

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Source

Critical Care: Enrichment using the Phoenix Sepsis Score in children: heterogeneous treatment effects in a hydrocortisone target trial emulation ↗

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