The present nationwide retrospective study provides compelling insights into the epidemiology and management outcomes of paediatric septic shock in Thailand from 2015 to 2022, highlighting its persistent severity and impact on health care systems globally. Paediatric septic shock remains a critical concern worldwide because of its high mortality rates and the significant health care resources required for management [2, 10, 11, 13]. This condition is particularly burdensome in low- to middle-income countries where resource constraints and variability in health care practices can exacerbate outcomes [3,4,5, 16].

In Thailand, the prevalence of paediatric septic shock has shown an increasing trend, with rates peaking at 280 per 100,000 people in 2020. This number is considerably higher than that reported in several other countries, where systematic adherence to guidelines and better health care infrastructure may lead to more favourable epidemiological figures [17]. This disparity underscores the need for continuous monitoring and adaptation of health care practices in Thailand to address the rising trends effectively.

The mortality rate for septic shock in Thailand markedly declined from 30.7% in 2015 to 20.2% in 2022. However, this rate is still higher than recent findings from European and American studies, which often report mortality rates below 20% due to strong health care systems and effective implementation of clinical guidelines [10, 18]. Notably, our study highlights significant regional disparities in the prevalence and outcomes of paediatric septic shock. Compared with the other regions, the Northeast region, which accounted for the highest burden of cases, presented the lowest mortality rate over the study period. This discrepancy may be attributed to factors such as inconsistency in protocol adherence and the variability in health care delivery noted in general physician practices across Thailand [12]. Previous data suggest that adherence to the surviving sepsis campaign guidelines can significantly reduce the mortality rate [4]. This emphasizes that rapid identification and management are crucial and that enhancing protocol awareness and education among health care providers could be instrumental in further reducing mortality.

Our study also revealed that children under one year of age and those with comorbidities exhibited a significantly high mortality rate, underscoring the vulnerability of these groups. The supporting literature indicates that younger patients, especially those with cardiovascular and respiratory comorbidities, are at increased risk of poor outcomes in septic shock [19,20,21]. These findings suggest that age-specific treatment protocols and more aggressive management strategies may be necessary to increase survival in this high-risk group. Additionally, in our analysis, most paediatric septic shock patients had an unknown infection source, which is consistent with previous studies indicating that unidentified infection sources are common in paediatric sepsis patients [22]. This uncertainty can lead to inadequate or delayed source control, which may contribute to higher mortality rates [23, 24]. Among cases with an identified infection source, respiratory infections were the most frequent, mirroring other studies that reported the respiratory tract as a predominant site for invasive bacterial infections in septic shock, which is often associated with increased mortality [22].

Previous studies conducted within Thailand, particularly those involving multicentre analyses at tertiary care hospitals, reported better outcomes but were unable to reflect the situation at the primary and secondary care levels[4]. Our study adds substantial value by encompassing comprehensive data across all hospital levels, presenting a true representation of septic shock management and outcome disparities across the health care spectrum in Thailand. These real-world data underscore the need for tailored interventions at each health care level to address identified gaps and unify treatment standards.

The associated health care burden remains significant, with over one-third of affected children requiring mechanical ventilation and nearly one-quarter needing renal replacement therapy, which are treatments typically provided in secondary and tertiary hospitals equipped with advanced facilities. These interventions highlight the severity of septic shock and the critical need for resource allocation, particularly in underresourced settings. Additionally, the higher mortality rates observed in these hospitals, which manage over 80% of cases, reflect the aggregation of more severe cases in higher-level health care institutions. In Thailand, ECMO is utilized in only a small fraction of refractory paediatric septic shock cases, as it is not covered under the Universal Coverage Scheme, and few centres are equipped to provide this treatment. Despite its limited use, the mortality rate for patients receiving ECMO exceeds 50%, which aligns with findings from a previous study [25]. Given the complexity and resource-intensive nature of care for these patients, it would be wise for future studies to investigate the specific factors contributing to mortality and unfavourable outcomes, which could guide the development of targeted strategies aimed at early intervention and prevention.

Despite the observed decline in mortality rates, the enduring high demand for mechanical ventilation and renal replacement therapy underscores the ongoing health care burden associated with managing severe septic shock cases. Remarkably, our findings indicate that nearly half of the patients requiring prolonged mechanical ventilation and renal replacement therapy succumb to their conditions. This observation is consistent with previous research indicating that mortality rates are significantly high among patients with septic shock who develop acute kidney injury, volume overload, and multiorgan failure during treatment, necessitating continuous renal replacement therapy (CRRT) and extended mechanical ventilation [26,27,28]. Furthermore, existing studies have shown that multiorgan dysfunction, which is prevalent among paediatric patients undergoing CRRT, is correlated with mortality rates exceeding 50% [29]. These findings emphasize the importance of enhancing paediatric critical care capacities and developing region-specific interventions to manage septic shock effectively at earlier stages to achieve favourable outcomes [30]. Importantly, this study highlights significant health care disparities across regions and hospital levels, suggesting that improvements in the health care system could further reduce morbidity and mortality in paediatric septic shock patients.

Our study has certain limitations. Its retrospective design makes it susceptible to potential coding errors, whereas the absence of a control group limits comparative insights. Septic shock cases or the burden of septic shock patients in terms of the need for prolonged mechanical ventilation and renal replacement therapy may be underreported. The reliance on hospital data could distort the actual incidence rates. Although the database contains minimal amounts of missing data, the classification of certain items via the ICD-10 may be inaccurate. Moreover, the use of ICD-10 codes for classifying conditions may not accurately reflect the clinical severity or distinct characteristics of septic shock as defined by current guidelines. This limitation restricts the precise tracking of administered therapies such as fluid boluses, vasoactive and inotropic agents, and steroids and complicates the correlation of specific infections with septic shock outcomes. These factors highlight the need for future studies to address these gaps and improve the generalizability and applicability of findings across various regions and settings.