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132 Original article

The role of measurement of serum mannose‑binding lectin in diagnosis of and prediction of prognosis among children admitted into the pediatric Fady M. El Gendya, Muhammad S. El‑Mekkawya, Ahmed A. Sonbolb, Osama A. R. Diabc

Departments of aPediatrics and bClinical Objectives Pathology, Faculty of , Menoufia To evaluate validity of serum mannose‑binding lectin (MBL) measurement in diagnosis and University, Menoufia, cDepartment of , Benha Children Hospital, Benha, Egypt prognosis of sepsis among critically ill children. Background Correspondence to Osama A. R. Diab, MBBCh, MBL is a part of the innate immune system with a potential role in sepsis susceptibility. Shebin El‑Kom, Menoufia 32717, Egypt Fax: 0482088039; Patients and methods Tel: +20 109 908 2959; A prospective observational study was conducted that included 50 critically ill children admitted e‑mail: [email protected] into the pediatric intensive care unit. Another group of 38 healthy children served as a control Received 21 August 2019 group. Serum MBL level was measured for all patients (within 24 h) and controls. Patients Revised 12 September 2019 were monitored till hospital discharge to determine the diagnosis of sepsis and occurrence Accepted 14 September 2019 of morbidity and mortality. Published 25 March 2020 Results Menoufia Medical Journal 2020, 33:132–137 No significant difference in MBL level was noted between septic patients and controls [median and range = 2.1 (1.2–298) vs. 2.25 (1.4–134); P = 0.45] or between survivors and nonsurvivors [median and range = 2.4 (1.1–298) vs. 10.95 (1.3–244); P = 0.75]. MBL had a

significant negative correlation with C‑reactive protein (rs=−0.33; P = 0.021) but not with pediatric risk of mortality, pediatric index of mortality 2, or sequential organ failure assessment score. MBL had a poor area under receiver operating characteristic (area under the curve) curve for prediction of mortality compared with pediatric risk of mortality, sequential organ failure assessment, and pediatric index of mortality 2 (area under the curve = 0.54, 0.91, 0.90, and 0.75, respectively). No significant correlation was found between MBL and length of pediatric intensive care unit stay or duration. Conclusion MBL is neither useful for sepsis diagnosis nor prediction of mortality or morbidity. The routinely available markers and prognostic scores are much more powerful compared with an expensive marker like MBL.

Keywords: C‑reactive protein, critically ill children, mannose‑binding lectin, pediatric, prognosis, sepsis

Menoufia Med J 33:132–137 © 2020 Faculty of Medicine, Menoufia University 1110‑2098

Introduction prolonged . The use of antibiotics may be helpful in preventing health care‑associated infections, Sepsis still represents a major cause of morbidity and but their unnecessary and irrational use has a few mortality in critically ill patients despite the use of serious disadvantages. Prolonged and inappropriate use modern antibiotics and therapies. There of antibiotics has resulted in emergence of is a lack of early diagnosis and timely intervention resistance, which is an important clinical, economic, for sepsis in pediatric intensive care unit (PICU), and public health problem [2]. and recent interest has focused on biomarkers for early diagnosis, risk stratification, and evaluation of The innate immune system is the first line of defense prognosis of sepsis [1]. against invasive pathologic organisms, and its role is essential in controlling infection in the first 24–48 h Children admitted to PICU have life‑threatening before the adaptive immune system is able to mount an illnesses. They either already have infection when adequate response. One of the primary innate immune admitted or are at high risk of acquiring infections

because of different procedures, use of invasive This is an open access journal, and articles are distributed under the terms devices, and extended length of stay. Antibiotics are of the Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0 the most commonly used in the ICUs. The License, which allows others to remix, tweak, and build upon the work critical nature of the illness of patients admitted to non‑commercially, as long as appropriate credit is given and the new PICU often leads to the prescription of multiple and creations are licensed under the identical terms. 1110-2098 © 2020 Faculty of Medicine, Menoufia University DOI: 10.4103/mmj.mmj_260_19 [Downloaded free from http://www.mmj.eg.net on Thursday, January 14, 2021, IP: 156.204.184.20]

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processes is activation of the complement system for Investigations included venous blood gas, complete direct pathogen killing and for opsonization, which blood count, C‑reactive protein (CRP), blood glucose, marks pathogens for destruction by phagocytes. sodium, potassium, urea, creatinine, serum glutamic A critical antimicrobial protein in this pathway is pyruvic transaminase, serum glutamic oxaloacetic mannose‑binding lectin (MBL) which recognizes transaminase, , and other cultures if mannose sugars on the periphery of bacteria, viruses, needed. Additionally, serum MBL level was performed and fungi, and on damaged human cells. Binding of for controls and patients within 24 h of PICU this protein to cell membranes causes conformational admission. The clinical and laboratory parameters changes that activate directed complement deposition were used to calculate two mortality predictive scores, for the invading microbe to be opsonized and killed [3]. namely, pediatric risk of mortality (PRISM) (within 24 h of PICU admission), pediatric index of mortality MBL is produced continuously in the ; serum 2 (PIM2) (within 1 h of PICU admission) and levels in healthy individuals have been shown to be SOFA (within 24 h of admission). Patients were closely influenced by host genetic makeup [4]. It is worth monitored till hospital discharge. mentioning that MBL deficiency is often associated with an increased risk of infection or worse prognosis Laboratory methods in immunocompromised patients [5]. For all patients, serum MBL was measured within 24 h of PICU admission. MBL was also measured Aim for all controls. Two milliliters of venous blood was The aim of this study was to evaluate the validity of taken under complete aseptic conditions in sterile serum MBL level in diagnosis and prognosis of sepsis vacutainer tube. Serum sample was coagulated in PICU of Benha Children Hospital. at room temperature for 10–20 min and then centrifuged at the speed of 3000 rpm for 10 min to collect supernatant. This kit was based on standard sandwich enzyme‑linked immunosorbent assay Patients and methods technology. The purified anti‑MBL antibody (Cat No. This was a prospective observational study conducted BYLK1089; Chongqing Biospes Co. Ltd, Chongqing, in Benha Children Hospital from April 2017 to China) was precoated onto 96‑well plates, and the March 2018. The study protocol was approved by the HRP‑conjugated anti‑MBL antibody was used as ethical committee of Faculty of Medicine, Menoufia detection antibodies. The standard test samples and University. The study was conducted from April 2017 HRP‑conjugated detection antibody were added to to March 2018 in PICU of Benha Children Hospital. the wells subsequently, mixed, and incubated, and then A total of 86 children were included. These consisted unbound conjugates were washed away with wash of 50 patients and 36 age‑matched and sex‑matched buffer. TMB substrates (A and B) were used to visualize healthy children who served as a control group. HRP enzymatic reaction, and then the concentration of MBL was calculated. Critically ill children with an expected length of PICU stay of 48 h or more were consecutively enrolled. The exclusion criteria included (a) children younger than Statistical analysis 1 month or older than 18 years, (b) known immune The collected data were tabulated and analyzed using deficiency, (c) anticipated short PICU stay (>48 h), and SPSS, version 23, software (SPSS Inc., Chicago, Illinois, (d) failure to obtain parental informed consent. Patients USA). Categorical data were presented as number and were subgrouped according to the presence of infection percentages. 2 or Fisher’s exact test was used to analyze and systemic inflammatory response syndrome (SIRS) categorical variables. Quantitative data were tested for into the following: (a) patients with sepsis, (b) patients normality using Kolmogorov–Smirnov test, assuming with noninfectious SIRS, and (c) patients without normality at P value more than 0.05. Quantitative SIRS. A patient was considered as having sepsis if he data were expressed as mean ± SD, median, and range. or she fulfilled at least two SIRS criteria (one of which Student t test was used to analyze normally distributed is temperature or leukocytic count change) in the quantitative variables among two independent presence of proven or suspected infection [6]. Another groups, whereas Mann–Whitney U test was used for method to diagnose sepsis was based on the recent comparing the means of non‑normally distributed sepsis‑3 adult guidelines that require the presence of variables. Spearman’s correlation coefficient (rs) was sequential organ failure assessment (SOFA) score of at used to assess correlation between nonparametric least two with suspected infection [7]. variables. Receiver operating characteristic curve was used to detect cutoff values with optimum sensitivity The diagnostic workup performed to patients included and specificity for prediction of sepsis. A P value less history, physical examination, and investigations. than 0.05 was considered statistically significant. [Downloaded free from http://www.mmj.eg.net on Thursday, January 14, 2021, IP: 156.204.184.20]

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Results useful. Hemoglobin and alanine transaminase were also superior to MBL in this regard. Characteristics of the study participants A total of 86 individuals were enrolled in the study. MBL had low sensitivity and specificity to detect Their demographic and clinical data are shown in mortality, whereas PIM2 and pediatric SOFA Table 1. Patients and controls were age and sex matched. score had high sensitivity and specificity to detect However, weight and length were significantly lower mortality (Table 4). among patients compared with controls. The most frequent primary reason for PICU admission was Correlation between mannose‑binding lectin and other respiratory diseases, and then neurological diseases. clinical and laboratory variables There was no statistically significant difference between There was a significant negative weak correlation patients and controls regarding age and male sex. There between MBL and CRP. However, there were no was a statistically significant decrease in weight and significant correlations between MBL and other length among patients than controls (Table 1). Table 1 Demographic and clinical characteristics of patients and controls The diagnostic value of systemic inflammatory Patients Controls P response syndrome (n=50) (n=38) There was no significant difference between patients Age (months) 6 (1.3‑105) 36 (4‑108) <0.001* Male sex 23 (46) 18 (47.4) 0.89 with sepsis (based on SIRS or SOFA score) and Weight (kg) 5.18 (2.3‑17) 14.5 (7‑37) <0.001* controls regarding MBL (Table 2). Length (cm) 62 (51‑120) 94.5 (65‑127) <0.001* Category according to SIRS There was no statistically significant difference between Sepsis 22 (44) NA NA sepsis, noninfectious SIRS, and non‑SIRS regarding Noninfectious SIRS 22 (44) MBL (Fig. 1). Non‑SIRS 6 (12) Positive blood culture 18 (36) NA NA There was no statistically significant difference between PICU stay (days) 14 (3‑36) NA NA survivors and nonsurvivors regarding MBL (Fig. 2). Length of hospital 14 (3‑36) NA NA stay (days) MBL and platelets had poor area under the curve MODS 24 (48) NA NA (AUC) for prediction of sepsis, whereas white blood MV use 17 (34) NA NA cells (WBCs) had the highest AUC for prediction of PICU mortality 10 (20) NA NA PRISM mortality risk (%) 1.5 (0.6‑57.3) NA NA sepsis (Table 3). PIM2 mortality risk (%) 6.1 (0.2‑91.7) NA NA Pediatric SOFA score 2.5 (0‑11) NA NA The prognostic value of mannose‑binding lectin CRP (mg/dl) 36 (10‑96) NA NA WBC (1000/µl) 16.24±4.37 NA NA MBL had a poor AUC for prediction of mortality. Hemoglobin (g/dl) 9.59±0.99 NA NA whereas PRISM, SOFA, and PIM were much more Platelets (1000/µl) 347.9±209.2 NA NA ALT 70 (19‑232) NA NA Figure 1 Creatinine (mg/dl) 0.7 (0.3‑1.2) NA NA MBL 2.4 (1.3‑298) 2.25 (1.4‑134) 0.74 *Means statistically significant result. Data are presented as n (%) and median and range. ALT, alanine transaminase; CRP, C‑reactive protein; MBL, mannose‑binding lectin; PICU, pediatric intensive care unit; PIM2, pediatric index of mortality 2; PRISM, pediatric risk of mortality; SIRS, systemic inflammatory response syndrome; SOFA, sequential organ failure assessment; WBC, white blood cell; MODS, multiple syndrome.

Table 2 Comparison between mannose‑binding lectin in patients with sepsis (based on systemic inflammatory response syndrome and sequential organ failure assessment score) and controls Sepsis (SIRS) (n=22) Controls (n=38) P MBL 2.1 (1.2‑298) 2.25 (1.4‑134) 0.73 Sepsis (SOFA) (n=30) Controls (n=38) P MBL 6 (1.1‑298) 2.25 (1.4‑134) 0.45 Median MBL in patients with sepsis, noninfectious SIRS, and non‑SIRS. MBL, mannose‑binding lectin; SIRS, systemic inflammatory Data are presented as median and range. MBL, mannose‑binding response syndrome. lectin; SIRS, systemic inflammatory response syndrome; SOFA, sequential organ failure assessment. [Downloaded free from http://www.mmj.eg.net on Thursday, January 14, 2021, IP: 156.204.184.20]

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Table 3 Receiver operating characteristic curve analysis for prediction of prediction of sepsis by mannose‑binding lectin among critically ill children by mannose‑binding lectin Variables AUC (95% CI) Cutoff level Sensitivity (%) Specificity (%) P MBL 0.57 (0.41‑0.73) ≤71.5 86.4 35.7 0.41 CRP (mg/dl) 0.57 (0.41‑0.74) ≥14 68.2 53.6 0.38 WBC (1000/ml) 0.72 (0.57‑0.87) ≥15.55 72.7 71.4 0.008* Platelets (1000/ml) 0.57 (0.4‑0.74) ≤231.5 40.9 85.7 0.41 *Means statistically significant result. AUC, area under the curve; CI, confidence interval; CRP, C‑reactive protein; MBL, mannose‑binding lectin; WBC, white blood cell.

Table 4 Receiver operating characteristic curve analysis for prediction of mortality by mannose‑binding lectin among critically ill children by mannose‑binding lectin Variables AUC (95% CI) Cutoff level Sensitivity (%) Specificity (%) P MBL 0.54 (0.3‑0.77) ≤1.55 40 82.5 0.73 CRP 0.63 (0.43‑0.83) ≥14 80 50 0.19 WBC 0.45 (0.24‑0.66) ≥13.75 70 42.5 0.64 Platelets 0.667 (0.45‑0.88) ≤344 80 57.5 0.10 Hemoglobin 0.71 (0.56‑0.85) ≤10.3 100 42.5 0.044* PRISM 0.91 (0.81‑1.00) ≥3 70 95 <0.001* PIM2 0.75 (0.57‑0.94) ≥8.9 60 90 0.016* Pediatric SOFA score 0.90 (0.78‑1.00) ≥7.5 70 100 <0.001* Creatinine 0.66 (0.45‑0.88) ≥0.78 50 82.5 0.11 ALT 0.77 (0.61‑0.92) ≥42.5 90 55 0.009* *Means statistically significant result. ALT, alanine transaminase; AUC, area under the curve; CI, confidence interval; CRP, C‑reactive protein; MBL, mannose‑binding lectin; PIM2, pediatric index of mortality 2; PRISM, pediatric risk of mortality; SOFA, sequential organ failure assessment; WBC, white blood cell.

Figure 2 No significant difference was found among patients with sepsis, noninfectious SIRS, and non‑SIRS either. Noteworthy, the lack of significant difference between septic patients and controls was demonstrated when sepsis was defined classically based on SIRS and when it was defined following the recent adult guidelines (sepsis‑3). Undoubtedly, the small sample size in the present study hinders us from drawing firm conclusions about the diagnostic value of MBL, and certainly, larger studies are needed.

Although our current research provides no solid conclusions, principally owing to the small sample size, it should be borne in mind that a small study is not without value as it can be later included in a meta‑analysis which Median MBL level in survivors and nonsurvivors. MBL, mannose‑binding can give more clear‑cut answers to the questions related lectin. to the role of MBL in pediatric sepsis. In addition, a small study can serve as a stimulus for performing a larger or multicenter study which can be more conclusive. numerical data (WBCs, platelets, hemoglobin, creatinine, age, weight, length, PRISM score, PIM2 We also noticed that there was no significant difference score, and pediatric SOFA score). between patients with sepsis and controls regarding MBL and no significant difference between sepsis, noninfectious SIRS, and non‑SIRS regarding MBL Discussion level. In the present study, critically ill children were evaluated In line with our current findings, previous studies in for the possibility of having sepsis depending on serum adults have detected no role for MBL in diagnosis of MBL level as well as the routine sepsis markers and sepsis. Similarly, Madsen et al. [8] found no association prognostic scores. MBL demonstrated no diagnostic between MBL level and infection status on admission value. No significant difference in serum MBL level or with progression from SIRS to sepsis or septic was found between patients with sepsis and controls. in pediatric patients. Although MBL haplotypes [Downloaded free from http://www.mmj.eg.net on Thursday, January 14, 2021, IP: 156.204.184.20]

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strongly influenced MBL levels in the predicted addition to lack of significant correlations with other relationship, low MBL‑producing haplotypes were not clinical and laboratory variables, including the sepsis associated with increased risk of infection. biomarkers WBC and platelet count. These findings are in line with our previous findings showing no Likewise, another pediatric study, Liu and Ning [9], association of MBL with sepsis. failed to detect a lower MBL level among PICU patients with infection versus PICU patients without A further demonstration of the lack of the diagnostic infection. power of MBL came from receiver operating characteristic curve analysis where MBL have a Specifically in pediatrics, six studies have demonstrated poor AUC, whereas WBC had a high AUC for an association between lower MBL levels, or low discriminating children with sepsis from controls. In MBL‑producing haplotypes, and increased severity contrast, other pediatric studies reported a high AUC of infection‑related disease [10] whereas five studies as well as a better sensitivity and specificity of MBL for have showed similar findings to ours with a lack of prediction of sepsis [17,18]. association [11], and two studies concluded a possible protective role for low‑producing MBL genotypes or Besides the diagnostic value, we evaluated a potential levels [12]. prognostic value of MBL. MBL was found to have a very poor performance for prediction of mortality On the contrary, Garred et al. [13] and Gordon et al. [14] compared with PRISM, SOFA, PIM2, hemoglobin, reported that MBL polymorphisms were associated and alanine transaminase. Of note, these mortality with lower level of serum MBL and increasing risk predictive scores are freely available and require of sepsis in critically ill adult populations. However, parameters that are routinely obtained for all PICU other studies in adults have not found MBL to be patients. The excellent performance of these scores has associated with risk for sepsis [15] or have reported a been demonstrated in previous studies [20–22]. It is more nuanced picture that includes a mixture of both thus prudent to carefully evaluate new biomarkers, as proinflammatory and anti‑infection effects, which routinely available prognostic tools can be much more may be beneficial or detrimental in varying disease useful. states [9]. In fact, a point of controversy that is frequently raised, There are likely several etiologies behind the lack of particularly in resource‑limited countries, is related association between MBL levels, low‑producing MBL the high cost of almost all new sepsis biomarkers. haplotypes, and increased susceptibility to severe Undoubtedly, MBL is much more expensive compared infection. The redundancy in complement activation with the more routinely available diagnostic (e.g. CRP) within the innate immune system may provide relative and prognostic (e.g., platelet count and WBC) markers resilience [16]. as well as clinical severity scores, for example, PRISM and SOFA score. However, new researches are supposed In other words, the relation between MBL and the to be targeting, not only national medical problems whole immune system can be likened to the relation but also medical problems of concern to the whole between one fighter and a whole army; loss of one scientific community all over the world. Moreover, if a fighter is not expected to have a significant influence new biomarker proves to be clinically useful, it will be on the performance of the whole army. inevitably produced commercially on a large scale, with a consequent fall of its price. In contrast, Amer et al. [17] reported a significantly lower MBL levels in neonates with sepsis compared Limitations of the present study include the small with controls. sample which made it difficult to assess MBL role with great confidence. Furthermore, the mortality rate Likewise, El Gendy et al. [18] found that the mean in the present study was high, and our result might not MBL serum level was lower in the septic neonates hold in centers with lower mortality rates. compared with healthy controls.

Another neonatal study [19] demonstrated that MBL level was significantly lower in infants with sepsis than Conclusion in the control group. The lowest MBL levels were Our current findings suggest a lack of utility of MBL detected in those infants with . for diagnosis of sepsis or prediction of mortality and morbidity. Furthermore, the routinely available Another finding in the present study was the significant markers and prognostic scores proved to be much weak negative correlation between CRP and MBL in more powerful compared with an expensive marker [Downloaded free from http://www.mmj.eg.net on Thursday, January 14, 2021, IP: 156.204.184.20]

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10 Darton TC, Jack DL, Johnson M, Borrow R, Guiver M, Kaczmarski EB, like MBL. However, larger studies are required to et al. MBL2 deficiency is associated with higher genomic bacterial loads more fully assess the true value of MBL in managing during meningococcemia in young children. Clin Microbiol Infect 2014; :1337–1342. critically ill children. 20 11 Ingels C, Vanhorebeek I, Steffensen R, Derese I, Jensen L, Wouters PJ, et al. Lectin pathway of complement activation and relation with clinical complications in critically ill children. Pediatr Res 2014; 75:99–108. Financial support and sponsorship 12 Sprong T, Mollnes TE, Neeleman C, Swinkels D, Netea MG, van der Nil. Meer JW, et al. Mannose‑binding lectin is a critical factor in systemic complement activation during meningococcal septic shock. Clin Infect Dis 2009; 49:1380–1386. Conflicts of interest 13 Garred P, J Strøm J, Quist L, Taaning E, Madsen HO. Association of mannose‑binding lectin polymorphisms with sepsis and fatal outcome, There are no conflicts of interest. in patients with systemic inflammatory response syndrome. J Infect Dis 2003; 188:1394–1403. 14 Gordon AC, Waheed U, Hansen TK, Hitman GA, Garrard CS, Turner MW, et al. Mannose‑binding lectin polymorphisms in severe sepsis: relationship to levels, incidence, and outcome. Shock 2006; 25:88–93. References 15 Mills TC, Chapman S, Hutton P, Gordon AC, Bion J, Chiche JD, et al. 1 Liu B, Chen YX, Yin Q, Zhao YZ, Li CS. Diagnostic value and prognostic Variants in the mannose‑binding lectin gene MBL2 do not associate with evaluation of Presepsin for sepsis in an emergency department. Crit Care sepsis susceptibility or survival in a large European cohort. Clin Infect Dis 2013; 17:R244. 2015; 61:695–703. 2 Abbas Q, Haq AU, Kumar R, Ali SA, Hussain K, Shakoor S Evaluation 16 Eisen DP, Dean MM, Thomas P, Marshall P, Gerns N, Heatley S, et al. of antibiotic use in pediatric intensive care unit of a developing country. Low mannose‑binding lectin function is associated with sepsis in adult Indian J Crit Care Med 2016; 20:291–294. patients. FEMS Immunol Med Microbiol 2006; 48:274–282. 3 Fujita T, Matsushita M, Endo Y. The lectin‑complement pathway – Its role 17 Amer ESA, El‑Shaer OS, Mohamed IM. Evaluation of mannose‑binding in innate immunity and evolution. Immunol Rev 2004; 198:185–202. lectin serum level in prediction of neonatal sepsis. Benha Med J 2015; 4 Auriti C, Prencipe G, Inglese R, Azzari C, Ronchetti MP, Tozzi A, et al. 32:126–130. Role of mannose‑binding lectin in nosocomial sepsis in critically ill 18 El‑Gendy FM, Khodeer SA, Elsayed HM, Elsayed SA. Serum neonates. Hum Immunol 2010; 71:1084–1088. mannose‑binding lectin as a biomarker in neonatal sepsis. Menoufia Med 5 Frakking FN, Brouwer N, van de Wetering MD, Budde IK, Strengers PF, J 2018; 31:987–993. Huitema AD, et al. Safety and pharmacokinetics of plasma‑derived 19 Mohamed WA, Saeed MA. Mannose‑binding lectin serum levels in mannose‑binding lectin (MBL) substitution in children with neonatal sepsis and septic shock. J Matern Fetal Neonatal Med 2012; chemotherapy‑induced neutropaenia. Eur J Cancer 2009; 45:505–512. 25:411–414 6 Goldstein B, Giroir B, Randolph A. International pediatric sepsis consensus 20 Jones AE, Trzeciak S, Kline JA. The sequential organ failure assessment conference: definitions for sepsis and organ dysfunction in paediatrics. score for predicting outcome in patients with severe sepsis and evidence Pediatr Crit Care Med 2005; 6:2–8. of hypoperfusion at the time of emergency department presentation. Crit 7 Singer M, Deutschman CS, Seymour CW, Shankar‑Hari M, Annane D, Care Med 2009; 37:1649–1654. Bauer M, et al. The Third International Consensus Definitions for Sepsis 21 Craig DG, Reid TW, Martin KG, Davidson JS, Hayes PC, Simpson KJ, and Septic Shock (Sepsis‑3). JAMA 2016; 315:801–810. et al. The systemic inflammatory response syndrome and sequential 8 Madsen EC, Levy ER, Madden K, Agan AA, Sullivan RM, Graham DA, organ failure assessment scores are effective triage markers following et al. Mannose‑binding lectin levels in critically ill children with severe paracetamol overdose. Aliment Pharmacol Ther 2011; 34:219–228. infections. Pediatr Crit Care Med 2017; 18:103–111. 22 Matics TJ, Sanchez‑Pinto LN. Adaptation and validation of a pediatric 9 Liu L, Ning B. The role of MBL2 gene polymorphism in sepsis incidence. sequential organ failure assessment score and evaluation of the sepsis‑3 Int J Clin Exp Pathol 2015; 8:15123–15127. definitions in critically ill children. JAMA Pediatr 2017; 171:e172352.