Genotypes and Phenotypes in Pediatric SIRS and Sepsis (GAPPSS)

Genotypes and Phenotypes in Pediatric SIRS and Sepsis (GAPPSS)

The aim of this investigation is to longitudinally quantify host gene expression and serum proteins in children with infectious and non-infectious SIRS. The investigators hypothesize that children with non-infectious SIRS, with bacterial infection associated SIRS, or with viral infection associated SIRS will exhibit distinct patterns of host gene expression and serum proteins. The investigators further hypothesize that it should be possible to discover sets of mRNA or protein biomarkers that will permit unambiguous diagnosis of non-infectious SIRS, SIRS associated with bacterial infection, and SIRS associated with viral infection.

Study Overview

• Status: Completed
• Conditions: Sepsis; Systemic Inflammatory Response Syndrome (SIRS)

Detailed Description

The investigators will undertake a proof-of-concept, pilot, prospective, observational trial that aims to recruit ~90 children from the Seattle Children's Hospital Pediatric Intensive Care Unit (PICU) and Cardiac Intensive Care Unit (CICU). The study will plan to recruit 30 children who are scheduled for surgery to repair congenital cardiac malformations, 15 - 25 immunocompetent children with culture positive sepsis, and 15 - 25 immunocompromised children with culture positive sepsis, and 30-40 children who are polymerase chain reaction (PCR) positive for viral respiratory pathogens (RSV, influenza, parainfluenza, rhinovirus, etc), and who meet the eligibility criteria. In total, accounting for culture negative bacterial sepsis (estimated 40%), the investigators plan to enroll 50 children with sepsis, 30-40 with viral sepsis, and 20 children undergoing surgery for congenital heart disease.

Demographic data will be collected at the time of ICU admission. Illness severity will be quantified by PRISM III and day 1 PELOD scores. Additional measures of sepsis severity will include oxygenation index, saturation index and duration of mechanical ventilation, vasoactive inotropic score and duration of vasoactive-inotropic support and highest serum creatinine on day 1. Resource utilization will be measured as PICU and hospital duration of stay.

For all children enrolled in the study, blood samples will be obtained on study days 1, 2 and 3. For children with sepsis, if cultures remain sterile or PCR negative, no additional research blood samples will be obtained. For children with sepsis and a positive culture or positive PCR by study day 3, additional blood samples will be obtained on the day of PICU discharge.

• Study Type: Observational
• Enrollment (Actual): 104

Contacts and Locations

Study Locations

• United States
  • Washington
    • Seattle, Washington, United States, 98105
      • Seattle Children's Hospital

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 8 months to 18 years (Child, Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

• Sampling Method: Non-Probability Sample

Study Population

INSI group: children who had congenital cardiac defect corrective surgery requiring cardiopulmonary bypass, known to induce an INSI response for ~24 hours thereafter. All children in this group were immune competent and culture negative.

CSSS group: children with confirmed or highly suspected infection (microbial culture orders, antimicrobial prescription), SIRS criteria (including fever/hypothermia and leukocytosis/leukopenia), and at least cardiovascular ± pulmonary organ dysfunction.

Viral Infection group: children with severe respiratory dysfunction in the presence of PCR -documented viral infection.

Description

A. INSI group: systemic inflammation, in the absence of culture positive infection. Cardiac surgery patients, n=30.

Inclusion Criteria:

• Admission to the CICU AND
• Age ~1-18 years AND
• Weight exceeding 10 kg
• Vascular catheter capable of providing the blood draw or anticipated orders for venipuncture for clinical labs AND
• Status post open heart surgery requiring cardiopulmonary bypass AND
• Parents speak English AND
• Not previously enrolled in the GAPPSS investigation

Exclusion Criteria:

• Pre- or post-operative culture positive infection OR
• Not expected to survive the CICU stay OR
• Ward of the state OR
• Concurrent malignancy or autoimmune disorder

B. CSSS (Clinical Severe Sepsis Syndrome) group: systemic inflammation, in the presence of highly suspected or documented bacterial infection. Children with clinical severe sepsis, n = 40. In this group, the investigators will enroll children who are immunocompetent as well as children who are immunocompromised.

Inclusion Criteria:

• Admitted to the PICU AND
• Age newborn (>38 weeks EGA)-18 years AND
• Weight equal to or greater than 4 kg AND
• Vascular catheter capable of providing the blood draw or anticipated orders for venipuncture for clinical labs AND
• At least one organ dysfunction (severe sepsis) AND
• Parents speak English AND
• SIRS (systemic inflammatory response syndrome) AND
• Strongly suspected or documented source of infection
• Not previously enrolled in the GAPPSS investigation

Exclusion Criteria:

• PICU nosocomial primary infection accounting for the sepsis event
• Not expected to survive the PICU stay
• Ward of the state

C. Viral Infection group. Severe respiratory dysfunction in the presence of PCR -documented viral infection. Children with clinical severe viral sepsis, n=6. In this group, the investigators will enroll children who are immunocompetent as well as children who are immunocompromised.

Inclusion Criteria:

• Admitted to the PICU AND
• Age newborn (>38 weeks EGA)-18 years AND
• Weight equal to or greater than 4 kg AND
• Vascular catheter capable of providing the blood draw or anticipated orders for venipuncture for clinical labs AND
• Parents speak English AND
• Severe respiratory dysfunction requiring invasive or non-invasive positive pressure mechanical ventilation support AND
• Positive PCR verifying a viral infection
• Not previously enrolled in the GAPPSS investigation

Exclusion Criteria:

• PICU nosocomial primary infection accounting for the sepsis event
• Not expected to survive the PICU stay
• Ward of the state

Study Plan

How is the study designed?

Design Details

• Observational Models: Cohort
• Time Perspectives: Prospective

Number of groups / cohorts

3

Cohorts and Interventions

Group / Cohort
INSI; Infection-negative systemic inflammation (INSI). The INSI group consists of children who have undergone congenital cardiac defect corrective surgery requiring cardiopulmonary bypass, known to induce an INSI response for ~24 hours thereafter; all children in this cohort are culture negative. This group is demarcated further by inclusion & exclusion criteria (see Eligibility section below).
CSSS; Clinical severe sepsis syndrome (CSSS). Children assigned to the CSSS group had confirmed or highly suspected infection (microbial culture orders, antimicrobial prescription), exhibited 2 or more systemic inflammatory response syndrome criteria (including temperature and leukocyte criteria), and demonstrated at least cardiovascular ± pulmonary organ dysfunction. This group is demarcated further by inclusion & exclusion criteria (see Eligibility section below).
Viral; The Viral Infection group consists of children who displayed signs and symptoms of severe viral infection, and who tested positive for respiratory viral infection(s) by a molecular virus panel test. These children were clinically evaluated to not have bacterial sepsis. This group is demarcated further by inclusion & exclusion criteria (see Eligibility section below).

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Gene Expression Levels	Gene expression levels (quantitative) will be compared between CSSS, INSI and viral infection groups, in a search for signatures that can discriminate these groups	Day 1 of admission to the pediatric intensive care unit (PICU)

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Serum Protein Expression Profiles	Serum protein expression profiles (semi-quantitative) will be compared between CSSS and INSI groups, in a search for signatures that can discriminate the two groups	Day 1 of admission to the pediatric intensive care unit (PICU)

Collaborators and Investigators

• Sponsor: Seattle Children's Hospital
• Collaborators: Immunexpress
• Investigators: Principal Investigator: Jerry J Zimmerman, MD, PhD, Seattle Children's Hospital

Publications and helpful links

General Publications

• Mathias B, Mira JC, Larson SD. Pediatric sepsis. Curr Opin Pediatr. 2016 Jun;28(3):380-7. doi: 10.1097/MOP.0000000000000337.
• Weiss SL, Fitzgerald JC, Pappachan J, Wheeler D, Jaramillo-Bustamante JC, Salloo A, Singhi SC, Erickson S, Roy JA, Bush JL, Nadkarni VM, Thomas NJ; Sepsis Prevalence, Outcomes, and Therapies (SPROUT) Study Investigators and Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network. Global epidemiology of pediatric severe sepsis: the sepsis prevalence, outcomes, and therapies study. Am J Respir Crit Care Med. 2015 May 15;191(10):1147-57. doi: 10.1164/rccm.201412-2323OC. Erratum In: Am J Respir Crit Care Med. 2016 Jan 15;193(2):223-4.
• Zimmerman J, Sullivan E, Sampson D, McHugh L, Yager T, Seldon T. 1024: Sensitive and Specific Diagnosis of Sepsis in Critically Ill Children Utilizing Host Gene Expression. Critical Care Medicine 2015; 43 (12), 258. doi: 10.1097/01.ccm.0000474855.13970.46
• McHugh L, Seldon TA, Brandon RA, Kirk JT, Rapisarda A, Sutherland AJ, Presneill JJ, Venter DJ, Lipman J, Thomas MR, Klein Klouwenberg PM, van Vught L, Scicluna B, Bonten M, Cremer OL, Schultz MJ, van der Poll T, Yager TD, Brandon RB. A Molecular Host Response Assay to Discriminate Between Sepsis and Infection-Negative Systemic Inflammation in Critically Ill Patients: Discovery and Validation in Independent Cohorts. PLoS Med. 2015 Dec 8;12(12):e1001916. doi: 10.1371/journal.pmed.1001916. eCollection 2015 Dec.
• Zimmerman JJ, Sullivan E, Yager TD, Cheng C, Permut L, Cermelli S, McHugh L, Sampson D, Seldon T, Brandon RB, Brandon RA. Diagnostic Accuracy of a Host Gene Expression Signature That Discriminates Clinical Severe Sepsis Syndrome and Infection-Negative Systemic Inflammation Among Critically Ill Children. Crit Care Med. 2017 Apr;45(4):e418-e425. doi: 10.1097/CCM.0000000000002100.

Study record dates

Study Major Dates

• Study Start (Actual): May 1, 2013
• Primary Completion (Actual): December 31, 2017
• Study Completion (Actual): December 31, 2017

Study Registration Dates

• First Submitted: March 30, 2016
• First Submitted That Met QC Criteria: March 30, 2016
• First Posted (Estimate): April 5, 2016

Study Record Updates

• Last Update Posted (Actual): April 19, 2018
• Last Update Submitted That Met QC Criteria: April 17, 2018
• Last Verified: April 1, 2018

More Information

Terms related to this study

• Keywords: pediatric; inflammation; sepsis; cardiopulmonary bypass; transcripts; serum proteins
• Additional Relevant MeSH Terms: Pathologic Processes; Infections; Inflammation; Shock; Sepsis; Toxemia; Systemic Inflammatory Response Syndrome
• Other Study ID Numbers: 14761

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: Yes
• IPD Plan Description: The investigators plan to publish the results of the GAPPSS study in a peer-reviewed scientific journal. A supplemental digital file associated with this paper will be made publicly available through a web link, and will contain relevant clinical data (with all patients de-identified).