Severe bacterial infections requiring PICU admission in previously healthy children – Insights from a structured pediatric intensive care follow-up program

doi:10.21203/rs.3.rs-8155821/v1

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Severe bacterial infections requiring PICU admission in previously healthy children – Insights from a structured pediatric intensive care follow-up program

https://doi.org/10.21203/rs.3.rs-8155821/v1

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Objective

This study aimed to evaluate physical, cognitive, and psychosocial outcomes in previously healthy children admitted to the Pediatric Intensive Care Unit (PICU) with severe complications arising from initially common community-acquired infections, and to describe the first-year experience of a structured post-intensive care follow-up program at a tertiary care hospital in Germany. Currently Germany lacks standardized follow-up structures for PICU survivors, despite growing recognition of long-term morbidity.

Design:

Clinical and follow-up data were obtained retrospectively from in- and outpatient medical records of all PICU patients meeting inclusion criteria during the study period. Demographic, clinical, and follow-up data were extracted anonymously. Multidomain outcomes were assessed at 4 weeks, 3, 6, and 12 months after discharge, including physical, neurocognitive, and psychosocial parameters.

Setting:

Tertiary care University center in Germany.

Patients:

All previously healthy children (n = 37, age > 28 days and < 18 years) admitted to the PICU in 2023 due to severe infectious complications, including intracranial abscess or meningitis (43%), orbital abscesses (27%), septic shock (14%), osteomyelitis (11%), and necrotizing fasciitis (5%).

Interventions:

None.

Measurements and Main Results:

Despite appropriate acute management during the PICU stay, 25 children (68%) developed prolonged neurological, somatic, or psychosocial impairments, including motor deficits, neurocognitive dysfunction, and anxiety. Many sequelae emerged around 5 months after discharge. The heterogeneous recovery trajectories emphasize the clinical relevance of Pediatric Post-Intensive Care Syndrome (PICS-p).

Conclusions

Our findings highlight the need for multidisciplinary post-PICU follow-up, particularly for previously healthy children. Early recognition and targeted interventions may reduce long-term morbidity and improve quality of life for affected children and their families.

Pediatrics

Invasive streptococcal infections

pediatric post-intensive care syndrome (PICS-p)

post-intensive care syndrome family (PICS-F)

neurocognitive outcome

multidisciplinary care

Over the past decades, advances in pediatric intensive care medicine have led to a substantial decline in mortality rates (1). As survival rates continue to improve, clinical and research attention has shifted towards the long-term morbidity and health-related quality of life of survivors. Up to 80% of children discharged from the PICU develop new or persistent physical, cognitive, psychological, or social impairments (2, 3).

The Pediatric Post-Intensive Care Syndrome (PICS-p) describes newly acquired or worsening impairments after PICU admission, while PICS-F affects parents and siblings (4). These concepts suggest the importance of structured, multidisciplinary follow-up (5).

While most bacterial infections in childhood are benign and self-limiting, life-threatening complications such as sepsis, intracranial abscess, necrotizing fasciitis, or osteomyelitis can arise even in previously healthy children (6–8). They may experience substantial long-term sequelae after PICU discharge (4, 9).

This brief report presents a single-center assessment of structured follow-up in children admitted to the PICU in 2023 due to severe complications from bacterial infections.

This was a retrospective, single-center study conducted at a tertiary care children’s hospital. Children > 28 days and < 18 years admitted to the PICU in 2023 due to complications of community-acquired ENT or soft-tissue infections were included. Anonymized findings following the implementation of a structured post-intensive care follow-up program were included, covering the entire inpatient course, including known risk factors for PICS-p (e.g. length of stay, sepsis, vasoactive agents, ventilation, sedation and delirium) (Fig. 1). Multidomain outcomes were assessed at 4 weeks, 3 months, 6 months, and 12 months after hospital discharge and included physical, neurocognitive, and psychosocial aspects (using among others Bayley Scales of Infant Development testing, Wechsler Intelligence Scale for Children-V (WISC-V)), via somatic follow up (specialist pediatric comprehensive examination with neuro-pediatric focus) as well as standardized questionnaires using published cut-off scores (Inventory for the Assessment of Quality of Life in Children and Adolescents (ILK), Beck Anxiety Inventory for Youth (BAI-Y), Body Self-Perception Inventory for Youth (BSCI-Y), physiotherapeutic evaluations, and psychological assessments (Table 2).

Descriptive analyses were performed. Continuous variables are presented as median (IQR) and categorical variables as n (%).

A total of 37 children fulfilled the inclusion criteria. The median age at admission was 8 years (IQR 1–11.5), and 61% were female. All patients had been previously healthy before PICU admission.

The primary infectious foci were ENT infections (n = 27; 73%) and soft-tissue infections (n = 10; 27%). The most common complications leading to PICU admission were intracranial abscess or bacterial meningitis (n = 17; 43%), retro-orbital abscess (n = 10; 27%), septic shock (n = 5; 14%; including three toxic shock syndromes), osteomyelitis (n = 4; 11%), and necrotizing fasciitis (n = 1; 5% (Table 1, Fig. 1).

Pathogen detection revealed Streptococcus spp. in 18 (29%), Staphylococcus aureus in 9 (24%), and other bacteria in 10 (27%) cases, including atypical Mycobacteria (n = 2; 5%), Klebsiella spp. (n = 1; 3%), Mycoplasma (n = 1, 3%), and six cases without an identified pathogen. Targeted antimicrobial therapy was received by 95% and 32 (87%) required surgical source control (Table 1).

The median PICU stay was 4 days (Interquartile range (IQR) 2–5). Mechanical ventilation was performed in 30 (81%) patients for a median duration of 1 day (IQR 1–2). Vasoactive support was administered in 14 (38%), and sedation was administered in 30 (81%), half of which showed signs of delirium.

All patients survived, with long-term sequelae affecting 25 (68%). The most frequent neurological or functional impairments included motor deficits (27%), hearing impairment (27%), migraine requiring new long-term medication (27%), and visual impairment (22%). Seizures, developmental regression, and attention deficits each occurred in one-quarter of cases (Table 2). The Pediatric Cerebral Performance Category Scale (PCPC) worsened by a median of 1 (IQR 0–1).

Beyond physical impairment, psychological and cognitive difficulties also became evident during follow-up. Depression or anxiety was documented in 9 (24%) children, and 8 (22%) received support for attention or concentration problems, leading to school-related difficulties such as a decline in grades by at least one level, repetition of a school year, transfer to a different type of school, or even the need for an integration assistant. Inpatient rehabilitation was initiated in 17 (46%) and many required outpatient therapies like occupational therapy (49%), physiotherapy (38%), referral to a psychologist (32%), and speech therapy (22%). Medication after discharge was needed in 13 (35%) (Table 2).

The attendance at 4 weeks, 3 months, 6 months, and 12 months (Fig. 1) declined from 81% at Visit 1 to 62% after 1 year. The main reasons for missed visits were ongoing inpatient rehabilitation (n = 3), no further need for follow-up (n = 4), family relocation (n = 3), and non-attendance (n = 4). Additional follow-up visits were required in 11 (30%) patients to address ongoing issues (Table 2).

In 22 children (59%), difficulties in diagnostic coding led to delays or denials in reimbursement for required therapies, particularly affecting access to specialized inpatient rehabilitation (13/17; 45%), where the absence of a specific ICD-10 code for PICS-p frequently necessitated additional justification (Table 2).

This single-center analysis found that initially benign bacterial infections that progress to severe or even life-threatening complications can cause long-term morbidity in previously healthy children.

The predominance of Streptococcus spp. corresponds to the surge of invasive streptococcal infections reported in 2023 across Europe and North America, likely reflecting post-pandemic changes in population immunity and pathogen transmission dynamics (10).

A large proportion of children surviving intensive care develop persistent sequelae despite short PICU stays and often mild organ dysfunction. These include motor and sensory deficits, neurocognitive changes, and psychosocial difficulties, consistent with the multidimensional concept of pediatric Post-Intensive Care Syndrome (PICS-p) (2). A recent meta-analysis showed reduced cognitive performance and post-traumatic stress even without primary neurological injury (3). It is assumed that post-critical illness morbidity is common, under-recognized, and influenced by factors such as sedation, delirium, pain, and stress during the PICU stay (11).

Emerging frameworks, like that described by Manning et al., conceptualize PICS-p as encompassing physical, cognitive, and psychosocial domains (12). Our findings support this model: many psychosocial and cognitive sequelae emerged months after hospital discharge, typically between three and six months, showing limits of early outcome assessments. Similar findings support structured follow-up, yet its implementation remains inconsistent (13).

The structured post-PICU follow-up in our cohort achieved high overall attendance, with 81% attendance at four weeks and 62% at one year, demonstrating its clinical feasibility. Approximately 30% of patients required additional visits between scheduled visits or after the 12-month assessment, underscoring the need for flexible follow-up intervals.

Integrating psychological, physiotherapeutic, and educational support proved crucial for early detection and intervention in our follow-up program. Our data suggest that even children with severe but non-life-threatening illness benefit from systematic follow-up, as subtle morbidity often became apparent only after school or social reintegration. This aligns with international calls to shift the focus from short-term survival to long-term functional and psychosocial outcomes (13).

Limitations include the retrospective, single-center design and modest sample size, which limit generalizability. Moreover, a detailed characterization of this patient population is essential from both a health-services and health-economics perspective. Although a dedicated ICD-10/ICD-10-CM or ICD-10-GM diagnostic code for PICS in children is currently under discussion (in Germany), it has not yet been introduced. Consequently, long-term sequelae are frequently captured only through non-specific symptom codes or general “Z-codes,” complicating standardized reporting and resource planning (14).

At the same time, international studies show that children surviving critical illness frequently experience persistent physical, cognitive, psychosocial, and educational impairments, yet remain insufficiently integrated into rehabilitation and support services. A recent narrative review on pediatric post-intensive care syndrome (PICS-p) highlights that, although such impairments are well documented, “no standardized or evidence-based approach to long-term follow-up in the PICU exists” (5). These findings underscore that PICS-p extends beyond medical recovery and requires coordinated care across multiple systems. The lack of a specific ICD-10 code for pediatric PICS, may have contributed to funding and reimbursement challenges for multidisciplinary rehabilitation. As a result, families frequently encountered administrative delays, highlighting the urgent need for standardized coding and better integration of post-PICU care pathways to prevent loss to follow-up and unmet care needs.

Our findings therefore support the development of a multiprofessional post-ICU follow-up model to address these structural gaps and to ensure that children and families receive appropriate, continuous and equitable care across the entire recovery trajectory.

This single-center analysis demonstrates that structured follow-up for pediatric intensive care survivors is both feasible and valuable. Even previously healthy children admitted for short PICU stays due to common infections may face relevant long-term sequelae. Multidisciplinary post-PICU care enabled early detection of neurological, functional, and psychosocial impairments and was well accepted. These findings support systematic follow-up to all PICU survivors, while multicenter prospective studies should define optimal screening strategies to identify PICS-p and improve long-term outcomes.

Ethical approval

This study was conducted in accordance with the Declaration of Helsinki. The study protocol was approved by the Ethics Committee of the University of Duisburg-Essen (approval number 25-12803-BO), which waived the requirement for informed consent due to the retrospective nature of the study. The study is registered in the German Clinical Trials Register (DRKS) under the identifier DRKS00038522.

Acknowledgment

We would like to express our sincere gratitude to all patients and their families for putting their trust in our care. We thank the nursing and medical staff of the Department of Pediatrics I at the University Hospital Essen for their dedicated support in patient care and sample collection.

Conflicts of interest / funding:

The authors declare no conflict of interest.

Author Contributions:

N.B., C.D.S. and S.C.G. conceptualized the study. S.G., C.H., S.T., H.K., A.D.M., N.S., A.G., M.K., H.R., S.B collected data. S.C.G. performed data curation and analysis. S.C.G., C.H., S.T. and S.B. helped by literature review, C. D.-S., S.B., U. S.-S., U. F.-M, and N.B. supervised the project. S.C.G. drafted the manuscript, and all authors reviewed and approved the final version

Procter C, Morrow B, Pienaar G, Shelton M, Argent A (2021) Outcomes following admission to paediatric intensive care: a systematic review. J Paediatr Child Health 57(3):328–358. 10.1111/jpc.15381
Manning JC, Pinto NP, Rennick JE et al (2020) Conceptualizing post intensive care syndrome in children: the PICS-p framework. Pediatr Crit Care Med 21(7):e491–e498
Ko MSM, Poh PF, Heng KYC et al (2022) Assessment of long-term psychological outcomes after pediatric intensive care unit admission: a systematic review and meta-analysis. JAMA Pediatr 176(3):e215767. 10.1001/jamapediatrics.2021.5767
Smith AC, Ferguson HN, Russell RM, Savsani P, Wang S (2025) Post-Intensive Care Syndrome Family. Crit Care Clin 41(1):73–88. 10.1016/j.ccc.2024.08.008
Quadir A, Festa M, Gilchrist M, Thompson K, Pride N, Basu S (2024) Long-term follow-up in pediatric intensive care: a narrative review. Front Pediatr 12:1430581. 10.3389/fped.2024.1430581
Cress VJ, Green KJ, Jain A, Viaud-Murat EM, Patel PA, Wiedermann JP (2024) A scoping review of the intracranial complications of pediatric sinusitis. Otolaryngol Head Neck Surg 171(4):937–945. 10.1002/ohn.862
Shinnawi S, Khoury M, Cohen-Vaizer M, Cohen JT, Gordin A (2024) Intracranial complications of acute mastoiditis: surgery not always necessary. Am J Otolaryngol 45(4):104299. 10.1016/j.amjoto.2024.104299
Peltola H, Pääkkönen M (2014) Acute osteomyelitis in children. N Engl J Med 370(4):352–360. 10.1056/NEJMra1213956
Pollack MM, Holubkov R, Funai T et al (2014) Pediatric intensive care outcomes: development of new morbidities during pediatric critical care. Pediatr Crit Care Med 15(9):821–827
Valcarcel Salamanca B, Cyr PR, Bentdal YE, Watle SV, Wester AL, Strand ÅMW, Bøås H (2024) Increase in invasive group A streptococcal infections (iGAS) in children and older adults, Norway, 2022 to 2024. Euro Surveill 29(20):2400242. 10.2807/1560-7917.ES.2024.29.20.2400242
Woodruff AG, Choong K (2021) Long-term outcomes and the post-intensive care syndrome in critically ill children: a North American perspective. Child (Basel) 8(4):254. 10.3390/children8040254
Tang M, Xu M, Su S, Huang X, Zhang S (2021) Post-intensive care syndrome in children: a concept analysis. J Pediatr Nurs 61:417–423. 10.1016/j.pedn.2021.10.007
Mortamet G, Birsan S, Zini J et al (2024) Pediatric intensive care unit follow-up: thinking before acting. Anaesth Crit Care Pain Med 43(4):101401. 10.1016/j.accpm.2024.101401
Peach BC, Valenti M, Sole ML et al (2021) A Call for the World Health Organization to Create International Classification of Disease Diagnostic Codes for Post-Intensive Care Syndrome in the Age of COVID-19. World Med Health Policy 13(2):373–382. 10.1002/wmh3.401

Table 1
Patient Characteristics, Sequalaes and PICU-Follow-Up
Variable	n (%) or Median (IQR)
Demographics
Age at admission, years, median (IQR)	8 (1–11, 5)
Female	22 (61%)
Previously healthy before infection	37 (100%)
Primary infectious focus
Ear-Nose-Throat-Infection	27 (73%)
Soft-Tissue-Infection (incl. cellulitis and phlegmone)	10 (27%)
Primary infectious complication leading to PICU admission
Intracranial abscess / bacterial meningitis	17 (43%)
Retro-orbital abscess	10 (27%)
Septic shock (incl. toxic shock syndrome)	5 (14%)
Osteomyelitis	4 (11%)
Necrotizing fasciitis	1 (5%)
Pathogens identified
Streptococcus spp.	18 (49%)
Streptococcus pyogens	13 (35%)
Streptococcus pneumoniae	1 (3%)
Streptococcus intermedius	4 (11%)
Staphylococcus aureus	9 (24%)
Other bacteria*	10 (27%)
PICU course
Antimicrobial therapy	35 (95%)
Surgical source control (drainage/debridement)	32 (87%)
Length of PICU stay, days, median (IQR)	4 (2–5)
Mechanical ventilation	30 (81%)
Length of mechanical ventilation, days, median (IQR)	1 (1–2)
Vasoactive support	14 (38%)
Duration of vasoactive support, days, median (IQR)	1 (1–3.5)
Sedative medication	30 (81%)
Sedation duration, days, median (IQR)	2 (1–4)
Delirium	12 (32%)
Overall Outcome
PCPC change (from admission to discharge), median (IQR)	1 (0–1)
PCPC before admission, median (IQR)	1 (1–1)
PCPC after admission, median (IQR)	2 (1–2)
Mortality	0 (0%)
Sequelae	25 (68%)
Time to diagnosis of sequelae, month, median (IQR)	5 (1–3)
Specific sequelae
Seizures (newly diagnosed after discharge)	8 (22%)
Newly diagnosed migraine (needing medication)	10 (27%)
Motor deficits (physiotherapeutic assessment, necessity of aids)	10 (27%)
Visual impairment (ophthalmologically confirmed)	8 (22%)
Hearing impairment (decrease in audiogram)	10 (27%)
Developmental regression or lack of developmental progress (psychological and pediatric assessment using among others Bayley Scales of Infant Development testing and WISC-V)	10 (27%)
Attention deficits (needing therapy/medication, school difficulties	8 (22%)
Depression, anxiety (psychological evaluated and need for therapy - previously screened using ILK, BAI-Y, TEX-Q)	9 (24%)
Therapies
Inpatient rehabilitation	17 (46%)
Referral to psychologist	12 (32%)
Referral to physiotherapy	14 (38%)
Referral to occupational therapy	18 (49%)
Referral to speech therapy	8 (22%)
Medication after discharge	13 (35%)
Others**	7 (19%)
Difficulties within coding resulting funding challenges
All therapies	22 (59%)
Inpatient rehabilitation	13 / 17 (45%)
Follow-up attendence and continuity***
Attended Post-PICU Visit 1 (≈ 4 weeks)	30 (81%)
Attended Post-PICU Visit 2 (≈ 3 months)	25 (68%)
Attended Post-PICU Visit 3 (≈ 6 months)	23 (62%)
Attended Post-PICU Visit 4 (≈ 12 months)	23 (62%)
Additional visits (between standard visits)	11 (30%)

*Others included atypical mycobacteria (n = 2), Klebsiella spp. (n = 1), mycoplasma (n = 1), unknown pathogen (n = 6); **Others: plastic issues (4), partial limp loss (2), chronic pain (1), Cochlea implant (1); *** Reasons for not attendance: still in inpatient rehabilitation (3), no further need for follow-up (4), family moved away (3), incompliance/missed appointments (4); Abbreviation: BAI-Y = Beck Anxiety Inventory for Youth; BSCI-Y = Body Self-Perception Inventory for Youth; ILK = Quality of Life in Children and Adolescents; PCPC = Pediatric Cerebral Performance Category Scale; PICU = Paediatric Intensive Care Unit; Streptococcus spp. = Streptococcus species; TEX-Q = Therapy Expectation Questionnaire; WISC-V = Wechsler Intelligence Scale for Children-V

Table 2
Overview of the standardized multidomain follow-up test battery used within the structured post-PICU follow-up program. Assessments were age-adapted and administered by trained pediatric neurologists, psychologists, and physiotherapists.
Domain	Assessment Tools / Methods	Purpose / Outcome Measured	Months After Discharge
Physical / Somatic Function	Comprehensive pediatric examination with neuro-pediatric focus; as well as physiotherapeutic assessment	Motor deficits, muscle tone, coordination, residual neurological impairment, pain, developmental state	1, 3, 6, 12
Neurocognitive Development	Bayley Scales of Infant and Toddler Development (for < 3 years); Wechsler Intelligence Scale for Children – V (WISC-V, for ≥ 6 years)	Global and domain-specific cognitive performance; developmental progress or regression	3, 6, 12
Psychological / Emotional Function	Beck Anxiety Inventory for Youth (BAI-Y); Inventory for the Assessment of Quality of Life in Children and Adolescents (ILK)	Anxiety symptoms, depression, health-related quality of life	3, 6, 12
Body Image / Self-Perception	Body Self-Perception Inventory for Youth (BSCI-Y)	Self-esteem, perception of physical changes after illness	6, 12
Therapy Motivation / Expectation	Therapy Expectation Questionnaire (TEX-Q)	Patient and family expectations and satisfaction regarding rehabilitation and follow-up care	3, 12
Family / Psychosocial Impact	Semi-structured family interviews and psychologist evaluation	Family functioning, parental stress, PICS-F screening	6, 12

The authors declare no competing interests.

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Severe bacterial infections requiring PICU admission in previously healthy children – Insights from a structured pediatric intensive care follow-up program

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