Viral-associated septic shock in pediatric pneumonia: a retrospective analysis of pathogen-specific risks and comparative clinical features with bacterial sepsis

Background This study aimed to determine the incidence of septic shock in hospitalized children with viral pneumonia, identify high-risk viral pathogens, and compare the clinical features between viral- and bacterial-associated septic shock cases. Methods A retrospective study on viral respiratory infections in children hospitalized with pneumonia at two hospitals between 2022 and 2024 was conducted, with logistic regression used to assess the pathogen-specific risks. Results Among 5,956 children with viral pneumonia, the incidence of septic shock was 1.06%, varying significantly by pathogen ( p < 0.001). Influenza A (FluA) showed the highest incidence (3.70%) and was the strongest predictor of shock [odds ratio (OR) = 7.506], followed by respiratory syncytial virus (RSV) (2.24%; OR = 4.559). Compared to bacterial shock cases ( n = 46), viral shock cases showed higher respiratory failure/acute respiratory distress syndrome (ARDS) rates (88.9% vs. 52.2%, p < 0.001) but they had shorter hospital stays (17.3 vs. 24.2 days, p = 0.026). FluA cases were more likely to have less infant involvement ( p = 0.023), more neurologic compromise (35.7% vs. 8.7%, p = 0.040), and develop refractory shock (42.9% vs. 8.7%, p = 0.007) compared to bacterial cases. RSV showed higher respiratory failure (75.9% vs. 52.2%, p = 0.040) and lower coagulopathy (34.5% vs. 60.9%, p = 0.026) rates. Conclusions FluA and RSV are the key viral pathogens that predispose pediatric pneumonia patients to septic shock. Rapid viral polymerase chain reaction testing enables early pathogen identification, facilitating antibiotic de-escalation when bacterial coinfection is unlikely and promoting precise, safe antimicrobial stewardship.