Staphylococcal Sepsis in Children
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《新英格兰医药杂志》
To the Editor: The article by Adem and colleagues (Sept. 22 issue)1 described three patients with severe sepsis caused by Staphylococcus aureus who had, at autopsy, bilateral adrenal hemorrhage. Two of the patients had elevated serum cortisol levels. Is it possible that clinical deterioration was associated with a sudden decrease in the plasma cortisol level, which is expected after bilateral adrenal hemorrhage? In patients with severe sepsis, the use of corticosteroids may improve the clinical course. Current evidence suggests that corticosteroids improve outcome in adults for whom the results of a corticotropin stimulation test are abnormal (despite an elevated baseline cortisol level).2 Whether corticosteroids have this effect in children is unknown. The current clinical guidelines of the American College of Critical Care Medicine for the treatment of sepsis in children, and the pediatric considerations in the guidelines of the Surviving Sepsis Campaign,3,4 recommend the use of corticosteroids in children with purpura fulminans, as was seen in the cases reported by Adem et al. We would be interested to know whether corticosteroids were used in these patients, and if so, at what time in the disease course?
Ricardo G. Branco, M.D.
Robert C. Tasker, M.D.
University of Cambridge
Cambridge CB2 2QQ, United Kingdom
brancori@terra.com.br
References
Adem PV, Montgomery CP, Husain AN, et al. Staphylococcus aureus sepsis and the Waterhouse-Friderichsen syndrome in children. N Engl J Med 2005;353:1245-1251.
Annane D, Sebille V, Charpentier C, et al. Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. JAMA 2002;288:862-871.
Parker MM, Hazelzet JA, Carcillo JA. Pediatric considerations. Crit Care Med 2004;32:Suppl:S591-S594.
Carcillo JA, Fields AI, American College of Critical Care Medicine Task Force Committee Members. Clinical practice parameters for hemodynamic support of pediatric and neonatal patients in septic shock. Crit Care Med 2002;30:1365-1378.
The authors reply: We agree with Drs. Branco and Tasker that preliminary data show that the early use of corticosteroids may improve the outcome in children with sepsis and bilateral adrenal hemorrhage. Patients 2 and 3 in our study did receive corticosteroids. Patient 2 was started on stress doses of hydrocortisone on the first evening after an arrest, and Patient 3 received dexamethasone in the emergency department and continued to receive corticosteroids during his brief hospitalization. Patient 1 did not receive corticosteroids. We have been initiating stress-dose corticosteroid therapy in children who have evidence of severe sepsis and hemodynamic instability, and we hope that additional data will help to determine definitively the merits of this approach.
Tracy K. Koogler, M.D.
Christopher P. Montgomery, M.D.
Robert S. Daum, M.D.
University of Chicago
Chicago, IL 60637
Ricardo G. Branco, M.D.
Robert C. Tasker, M.D.
University of Cambridge
Cambridge CB2 2QQ, United Kingdom
brancori@terra.com.br
References
Adem PV, Montgomery CP, Husain AN, et al. Staphylococcus aureus sepsis and the Waterhouse-Friderichsen syndrome in children. N Engl J Med 2005;353:1245-1251.
Annane D, Sebille V, Charpentier C, et al. Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. JAMA 2002;288:862-871.
Parker MM, Hazelzet JA, Carcillo JA. Pediatric considerations. Crit Care Med 2004;32:Suppl:S591-S594.
Carcillo JA, Fields AI, American College of Critical Care Medicine Task Force Committee Members. Clinical practice parameters for hemodynamic support of pediatric and neonatal patients in septic shock. Crit Care Med 2002;30:1365-1378.
The authors reply: We agree with Drs. Branco and Tasker that preliminary data show that the early use of corticosteroids may improve the outcome in children with sepsis and bilateral adrenal hemorrhage. Patients 2 and 3 in our study did receive corticosteroids. Patient 2 was started on stress doses of hydrocortisone on the first evening after an arrest, and Patient 3 received dexamethasone in the emergency department and continued to receive corticosteroids during his brief hospitalization. Patient 1 did not receive corticosteroids. We have been initiating stress-dose corticosteroid therapy in children who have evidence of severe sepsis and hemodynamic instability, and we hope that additional data will help to determine definitively the merits of this approach.
Tracy K. Koogler, M.D.
Christopher P. Montgomery, M.D.
Robert S. Daum, M.D.
University of Chicago
Chicago, IL 60637