ROLE OF SYSTEMIC INFLAMMATORY INDICES IN IDENTIFYING SEPSIS IN PICU PATIENTS IN A TERTIARY HEALTHCARE CENTRE OF INDIA

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Early diagnosis has been shown to improve patient prognosis. The objective of this study was to understand the role of systemic inflammatory indices as predictors of sepsis in children admitted to the PICU. Methods A prospective observational study was conducted to compare systemic inflammatory indices between two groups: one with sepsis and another without sepsis. Of the 138 PICU patients, 69 had sepsis and 69 were grouped under non-sepsis. Systemic inflammatory indices were calculated for NLR, PLR, MLR, SII, SIRI, and PIV in both groups and compared. ROC analysis was conducted to measure the predictive value. Results NLR, PLR, MLR, SII, SIRI, and PIV were significant predictors of sepsis among PICU patients. NLR was the best predictor, with an AUC of 1.000 at a cut-off of 1.957, with 100% sensitivity and specificity. SIRI and SII had predictive powers, with AUCs of 0.950 and 0.944, respectively. With a sensitivity of 92.8% and specificity of 89.9%, the optimal cut-off for the SII was found to be 571727.208. Conclusion Systemic inflammatory indices are accurate predictors of sepsis in patients in The PICU, enabling them to diagnose and intervene at an early stage. Their use may reduce pediatric sepsis-related morbidity and mortality by enabling bedside diagnoses. " } { "@context": "http://schema.org", "@type": "BreadcrumbList", "itemListElement": [ { "@type": "ListItem", "position": "1", "item": { "@id": "https://f1000research.com/", "name": "Home" } }, { "@type": "ListItem", "position": "2", "item": { "@id": "https://f1000research.com/browse/articles", "name": "Browse" } }, { "@type": "ListItem", "position": "3", "item": { "@id": "https://f1000research.com/articles/15-179/v1", "name": "ROLE OF SYSTEMIC INFLAMMATORY INDICES IN IDENTIFYING SEPSIS IN PICU..." } } ] } Home Browse ROLE OF SYSTEMIC INFLAMMATORY INDICES IN IDENTIFYING SEPSIS IN PICU... ALL Metrics - Views Downloads Get PDF Get XML Cite How to cite this article Srikanth S, Renganathan G, Kamath L et al. ROLE OF SYSTEMIC INFLAMMATORY INDICES IN IDENTIFYING SEPSIS IN PICU PATIENTS IN A TERTIARY HEALTHCARE CENTRE OF INDIA [version 1; peer review: 1 not approved] . F1000Research 2026, 15 :179 ( https://doi.org/10.12688/f1000research.173741.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Research Article ROLE OF SYSTEMIC INFLAMMATORY INDICES IN IDENTIFYING SEPSIS IN PICU PATIENTS IN A TERTIARY HEALTHCARE CENTRE OF INDIA [version 1; peer review: 1 not approved] Sahajanya Srikanth https://orcid.org/0000-0001-5271-5006 1 , Gayathri Renganathan https://orcid.org/0009-0009-0116-6858 2 , Laxmi Kamath https://orcid.org/0000-0002-2379-155X 2 , [...] Nishank Gowda 1 , Sowmini P Kamath https://orcid.org/0000-0001-7902-1012 2 , Jayashree K 2 , Smitha Sharlette D’Sa 2 , Venkat Tarun Dungigalla 3 Sahajanya Srikanth https://orcid.org/0000-0001-5271-5006 1 , Gayathri Renganathan https://orcid.org/0009-0009-0116-6858 2 , [...] Laxmi Kamath https://orcid.org/0000-0002-2379-155X 2 , Nishank Gowda 1 , Sowmini P Kamath https://orcid.org/0000-0001-7902-1012 2 , Jayashree K 2 , Smitha Sharlette D’Sa 2 , Venkat Tarun Dungigalla 3 PUBLISHED 03 Feb 2026 Author details Author details 1 Kasturba Medical College Mangalore, Mangaluru, Karnataka, 575001, India 2 Department of Pediatrics, Kasturba Medical College Mangalore, Mangaluru, Karnataka, India 3 Department of Surgery, Kasturba Medical College Mangalore, Mangaluru, Karnataka, India Sahajanya Srikanth Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Resources, Writing – Original Draft Preparation Gayathri Renganathan Roles: Conceptualization, Formal Analysis, Supervision, Validation, Writing – Original Draft Preparation Laxmi Kamath Roles: Supervision, Validation, Writing – Original Draft Preparation, Writing – Review & Editing Nishank Gowda Roles: Formal Analysis, Investigation, Writing – Original Draft Preparation, Writing – Review & Editing Sowmini P Kamath Roles: Supervision, Writing – Review & Editing Jayashree K Roles: Supervision, Writing – Review & Editing Smitha Sharlette D’Sa Roles: Supervision, Writing – Review & Editing Venkat Tarun Dungigalla Roles: Supervision, Writing – Review & Editing OPEN PEER REVIEW DETAILS REVIEWER STATUS This article is included in the Manipal Academy of Higher Education gateway. Abstract Background Sepsis is a major cause of morbidity and mortality in children, predominantly among critically ill patients admitted to the pediatric intensive care unit (PICU). Early diagnosis has been shown to improve patient prognosis. The objective of this study was to understand the role of systemic inflammatory indices as predictors of sepsis in children admitted to the PICU. Methods A prospective observational study was conducted to compare systemic inflammatory indices between two groups: one with sepsis and another without sepsis. Of the 138 PICU patients, 69 had sepsis and 69 were grouped under non-sepsis. Systemic inflammatory indices were calculated for NLR, PLR, MLR, SII, SIRI, and PIV in both groups and compared. ROC analysis was conducted to measure the predictive value. Results NLR, PLR, MLR, SII, SIRI, and PIV were significant predictors of sepsis among PICU patients. NLR was the best predictor, with an AUC of 1.000 at a cut-off of 1.957, with 100% sensitivity and specificity. SIRI and SII had predictive powers, with AUCs of 0.950 and 0.944, respectively. With a sensitivity of 92.8% and specificity of 89.9%, the optimal cut-off for the SII was found to be 571727.208. Conclusion Systemic inflammatory indices are accurate predictors of sepsis in patients in The PICU, enabling them to diagnose and intervene at an early stage. Their use may reduce pediatric sepsis-related morbidity and mortality by enabling bedside diagnoses. READ ALL READ LESS Keywords Sepsis in PICU, Prevention, Inflammatory markers, Early diagnosis Corresponding Author(s) Gayathri Renganathan ( [email protected] ) Close Corresponding author: Gayathri Renganathan Competing interests: No competing interests were disclosed. Grant information: The author(s) declared that no grants were involved in supporting this work. Copyright: © 2026 Srikanth S et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Srikanth S, Renganathan G, Kamath L et al. ROLE OF SYSTEMIC INFLAMMATORY INDICES IN IDENTIFYING SEPSIS IN PICU PATIENTS IN A TERTIARY HEALTHCARE CENTRE OF INDIA [version 1; peer review: 1 not approved] . F1000Research 2026, 15 :179 ( https://doi.org/10.12688/f1000research.173741.1 ) First published: 03 Feb 2026, 15 :179 ( https://doi.org/10.12688/f1000research.173741.1 ) Latest published: 03 Feb 2026, 15 :179 ( https://doi.org/10.12688/f1000research.173741.1 ) Introduction Sepsis is a global public health issue owing to its high prevalence and associated mortality, morbidity, and economic burden. It is a leading cause of PICU admission; both incidence and mortality remain high even with improvements in diagnosis and management in low- and middle-income countries. 1 The incidence of pediatric sepsis is approximately 22 per 100,000 person-years, and that of neonatal sepsis is approximately 2202 cases per 100,000 live births worldwide, totalling 1.2 million cases of pediatric sepsis annually. 2 The case-fatality rate for pediatric sepsis following diagnosis is estimated to be 25%. 3 Most of the fatalities caused by sepsis are due to refractory shock or multiple organ dysfunction syndrome, and many die during the first 48–72 h of treatment. 4 , 5 This suggests that early diagnosis of sepsis can contribute to the mitigation of the burden of the disease. Recent evidence strongly suggests that systemic immune responses are of primary importance in the etiology and course of sepsis. 6 A positive blood culture result is the current gold standard for the diagnosis of pediatric sepsis. 7 The typical turnaround time for blood culture results is 48–72 h after sample collection, and early detection of sepsis is difficult due to the lack of certain clinical signs. 8 , 9 Therefore, to identify sepsis early, a sensitive and user-friendly bedside diagnostic tool is required. Zhu et al. revealed that the neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), and systemic immune-inflammatory index accurately predict pediatric sepsis. 10 Systemic Inflammation Response Index (SIRI), Pan immune Inflammation Value (PIV), and Monocyte to Lymphocyte Ratio (MLR) values in the sepsis group of neonates were reported to be greater than those in the control group in a study by U Cakir et al. 11 In this study, we established that SII, SIRI, PIV, NLR, MLR, and PLR are useful markers in the early diagnosis of sepsis among PICU patients in the Indian population. Summary of evidence Zhu et al. conducted a thorough investigation. SII had the highest predictive value, while the neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio could also accurately predict pediatric sepsis. SII yielded the highest AUC value at 0.82, with a sensitivity of 78% and specificity of 87% at optimal cutoff concentrations of approximately 936. The AUC value was 0.74, with an optimal cut-off concentration of 4.2, sensitivity of 75%, and specificity of 72% for NLR. PLR yielded an AUC value of 0.66 with an optimal cut-off concentration of 59.6, exhibiting a sensitivity of 73% and 63% specificity. 10 An accessible and credible systemic inflammatory index for the diagnosis of Early Onset Sepsis in very low birth weight preterm newborns is SIRI when combined with other indicators, as per a study by Cakir et al. The AUC value of SIRI for predicting EOS was 0.803. 11 A study by Seda Aydogan et al. found that SII and NLR have predictive power to identify neonatal sepsis in infants with CHD. The AUC for SII was 0.76 (70% sensitivity, 70.5% specificity). 12 Güngör et al. showed that SII is a predictor of UTIs in babies. AUC for SII was 0.84 (95% CI: 0.78-0.89). 13 Research by Runqiang Liang et al. found that the SII was crucial for diagnosing serious bacterial infections in newborns. The AUC was 0.805 (95%CI: 0.759–0.852). At a cutoff value of 0.082, the maximum specificity and sensitivity were 0.809 (95%CI: 0.787–0.831) and 0.719 (95%CI: 0.641–0.797), respectively. 14 Cakir et al. found that a higher SII level (≥78.2) may be a predictor of the development of RDS in premature infants. The AUC value of the SII was 0.842. 15 It was found that SII, SIRI, PIV, and NLR were significantly increased in infants with hypoxic-ischemic encephalopathy when compared to the control group in a study by Burak Ceran et al. The areas under the curve for NLR, PLR, MLR, SII, SIRI, and PIV to predict HIE were 0.808, 0.597, 0.653, 0.763, 0.686, and 0.663, respectively. 16 Another study by Kawalec et al. showed that the SII and NLR were promising prognostic markers in children with burns, and higher NLR and SII values were related to longer hospitalization. 17 A study by Mathews et al. showed that the SII has been used frequently as a biomarker to determine the load of inflammation in certain illnesses, like diabetic kidney injury and severe COVID-19. It was observed that the non-The survivor group had a higher SII than the survivor group. Interestingly, the pattern of the SII was consistent with that of the NLR and PLR. These are believed to provide more comprehensive assessment of patient inflammatory status. NLR increase predicted mortality of 61.1%, and a PLR increase of 77.8%. Decreasing trends in the NLR and PLR were both closely related to better survival. Rise in PLR had higher sensitivity, specificity, PPV, NPV, and an overall accuracy of 72.73% (p < 0.001) for predicting mortality. 18 Frans et al. used NLR, PLR, MLR, and MPV as indicators of mortality in sepsis in the pediatric population. This study indicated that NLR was the best indicator of sepsis-related mortality. The cut-off value of NLR as a diagnostic marker for sepsis was 3.52 with a sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and odds ratio (OR) of 82.50%, 47.50%, 61.11%, 73.08%, and 4.26 (p < 0.004), respectively. 19 Need for study The early identification of sepsis is key to managing and reducing morbidity and mortality. The extent of sepsis also aids treatment modalities and provides insights into the course of antibiotics required. Bedside parameters will also help reduce the need to wait for a culture report before starting the course of treatment. Methods Study design and setting This prospective, observational study was conducted in the pediatric intensive care unit (PICU) at the Regional Advanced Pediatric Care Center, Mangalore, a tertiary care referral hospital. This study was conducted between November 2024 and March 2025 after obtaining approval from institutional ethics committee at Kasturba Medical College in Mangalore granted ethical clearance on 21/11/24 (Protocol No: IECKMCMLR-11/2024/644). The study is done as per STROBE guidelines for observational study ( Figure 1 ). We adhered to all ethical parameters as per Declaration of Helsinki. Figure 1. Strobe flow diagram. Study population Participants who fulfilled the following criteria were included in the study: (1) admission to the PICU during the study period and (2) diagnosis of sepsis or septic shock according to the Third International Consensus Definitions (2016). Patients were excluded if they had (1) severe non-infectious life-threatening conditions (e.g., trauma, congenital malformations), (2) were on long-term medications such as antibiotics or immunosuppressants, or if (3) they were not willing to participate. Sample size Based on previous research, it was found that the mean PLR in the sepsis group was 62.5, with a standard deviation of 37.3, whereas for the non-sepsis group, the average PLR was 80.4 with a Standard deviation of 26.2. Considering the same 80% power and 95% confidence interval, the sample size was estimated to be 69 patients in each group. Thus, there were 138 PICU patients, 69 patients with sepsis, and 69 patients without sepsis. Consecutive sampling was used to select the participants from the sepsis group. Open Epi Version 3.01 was used to calculate the sample size. 10 Figure 1 shows the STROBE flow diagram for recruitment of cases. Data collection and laboratory assays Data were collected at the time of PICU admission after obtaining written informed consent from parents/guardians. Blood tests, including a complete blood count (CBC) which were sent as part of the PICU protocol, were considered for the study. CBC was calculated using the Sysmex XN 1000 automator used in our laboratory. For patients who had multiple CBC reports within 24 hours, only the first value was considered for consistency. The collected data included demographic information (age and sex) and clinical diagnosis. All tests were performed in the hospital’s central diagnostic laboratory following standardized protocols. From the collected data, the SII, SIRI, PIV, NLR, MLR, and PLR were calculated using the following formulae: 1. Systemic Immune Inflammatory Index (SII) = neutrophil * platelet/lymphocyte 17 2. Systemic Inflammation Response Index (SIRI) = neutrophil * monocyte/lymphocyte 18 3. Pan Immune Inflammation Value (PIV) = neutrophil × platelet × monocyte/lymphocyte 19 4. Neutrophil to Lymphocyte Ratio (NLR) 10 5. Platelet to Lymphocyte Ratio (PLR) 10 6. Monocyte to Lymphocyte Ratio (MLR) 11 Operational definitions Sepsis and septic shock were defined according to the 3 rd International Consensus Definition of 2016. Sepsis is defined as a suspected or documented infection with an acute increase of ≥ 2 Sequential Organ Failure Assessment (SOFA) points. Septic Shock is diagnosed when sepsis and vasopressor therapy are needed to elevate MAP ≥ 65 mmHg and lactate >2 mmol/L (18 mg/dL) after adequate fluid resuscitation. The definitions of the systemic inflammatory indices were based on previously validated formulas. Statistical analysis The data was entered and analysed using IBM SPSS (Statistical Package for Social Sciences) Statistics for Windows Version 29.0. Armonk, NY: IBM Corp. Descriptive statistics were presented as medians and standard deviations. The scores between the case and control arms were compared using an independent-sample t-test. Statistical significance was set at P < 0.05. to assess the predictive ability of the diagnostic markers ROC analysis was done. Additionally, the optimum cut-off values were determined using the Youden Index. Results A total of 138 patients in the PICU were included in the study. Fifty percent of the patients belonged to the sepsis group. Table 1 shows participants’ demographic details. The median age was significantly higher in the sepsis group than in the non-sepsis group (P < 0.001). Of the 69 participants in the sepsis group, 56.52% were male, whereas in the non-sepsis group, 46.37% were male. Table 1. Basic demographic details of patients included in the study. SEPSIS GROUP (n = 69) (n (%)) NON- SEPSIS GROUP (n = 69) (n (%)) Age (Median (SD)) 8.00 (5.108) 2.00 (4.414) Gender of patient Male 39 (56.52) 32 (46.37) Female 30 (43.47) 37 (53.62) Table 2 shows laboratory parameters of the patients. Compared to the sepsis group the non-sepsis group had lower total WBC counts and neutrophil counts. Values of total WBC count (p < 0.001), Neutrophil count (p < 0.001) and Lymphocyte count(p < 0.001) were found to be statistically significant. Values of Monocyte count (p = 0.649) and Platelet count (p = 0.472) were not found to be statistically significant. Table 2. Laboratory parameters. CBC VALUES SEPSIS GROUP (Median (IQR)) NON-SEPSIS GROUP (Median (IQR)) p value Total WBC Count 13410 (10970-17610) 9930 (7480-13530) < 0.001 Neutrophil Count 10767 (7716-14130) 3823 (2694-5475) <0.001 Lymphocyte Count 2066 (1183-2636) 4465 (2922-6729) <0.001 Monocyte Count 774 (530-1212) 790 (510-1205) 0.649 Platelet Count 289000 (230000-428000) 351000 (219000-458000) 0.472 Table 3 shows systemic inflammatory indictors of the patients. Values of NLR (p < 0.001), PLR (p < 0.001), MLR (p < 0.001), SII (p < 0.001), SIRI (p < 0.001), PIV (p < 0.001) were all found to be statistically significant. This indicates that each of the six inflammatory markers were able to accurately predict the incidence of sepsis. Table 3. Systemic inflammatory indicators. INDICATORS SEPSIS GROUP (Median (IQR)) NON-SEPSIS GROUP (Median (IQR)) p value NLR (Neutrophil to Lymphocyte Ratio) 4.675 (3.3925-8.048) 0.950 (0.5091-1.387) <0.001 PLR (Platelet to Lymphocyte Ratio) 162.784 (106.3254-229.090) 68.917 (37.5550-102.802) <0.001 MLR (Monocyte to Lymphocyte Ratio) 0.440 (0.2951-0.570) 0.163 (0.0909-0.263) <0.001 SII (Systemic Immune Inflammatory Index) 1514870.69 (897641.5094-2579412.698) 303732.143 (144218.7500-452600.423) <0.001 SIRI (Systemic Inflammation Response Index) 3881.723 (2238.0429-7129.421) 726.282 (325.5444-1151.569) <0.001 PIV (Pan Immune Inflammation Value) 1.37*10 9 (6.9*10 8 -2.31*10 9 ) 2.63*10 8 (7.43*10 7 -4.45*10 8 ) <0.001 To evaluate the predictive power of NLR, PLR, MLR, SII, SIRI, and PIV for sepsis, the area under the curve (AUC) values were computed using receiver operating characteristic (ROC) curves. The Youden index was used to determine the cutoff points ( Tables 4 & 5 ). Table 4. ROC analysis to assess predictive ability of diagnostic markers to predict sepsis in PICU. INDICATORS AUC p VALUE 95% CI Lower bound Upper Bound NLR 1.000 <0.001 1.000 1.000 PLR 0.827 <0.001 0.756 0.898 MLR 0.858 <0.001 0.795 0.920 SII 0.944 <0.001 0.902 0.986 SIRI 0.950 <0.001 0.916 0.985 PIV 0.880 <0.001 0.823 0.937 Table 5. Cut offs for indicators. INDICATORS CUT OFF VALUE SENSITIVITY SPECIFICITY NLR 1.957 100% 100% PLR 96.158 84.1% 73.9% MLR 0.2285 76.8% 81.2% SII 571727.20760 92.8% 89.9% SIRI 1284.4100 94.2% 84.1% PIV 774006913.47 73.9% 94.2% ROC curve analysis demonstrated that the NLR had an unprecedented predictive value for sepsis, with an AUC of 1.000 (p < 0.001), indicating perfect discrimination between septic and non-septic patients ( Figure 2 ). Although such exceptional diagnostic performance is rare in clinical practice, this result may be attributed to the study population, where patients with sepsis likely had a severe inflammatory response characterized by profound neutrophilia and lymphopenia. Extreme elevation in NLR suggests that septic patients may have had fulminant infections, leading sharply to distinct immune profiles, differentiating them from the non-sepsis group. SIRI and SII also showed remarkably high predictive ability with AUC values of 0.950 and 0.944, respectively, in highly significant tests (p < 0.001), reinforcing their status as robust markers of systemic inflammation. PIV exhibited robust prognostic capability with an AUC equal to 0.880 and p value less than 0.001, while PLR and MLR displayed considerable discriminatory ability between patients with sepsis and those without sepsis, with AUC values of 0.827 and 0.858, respectively, with p values less than 0.001. Systemic inflammatory indices, particularly the NLR, may serve as highly effective biomarkers for sepsis in critically ill pediatric patients in resource-scarce settings. Figure 2. ROC curve analysis. Critical reflection Systemic inflammatory indices play a significant role in predicting sepsis in critically ill pediatric patients. These findings highlight a peculiar inflammatory signature in sepsis patients with grossly elevated NLR, PLR, MLR, SII, SIRI, and PIV underscoring the immune system dysregulation inherent in sepsis. NLR’s strikingly high AUC value of 1.000 suggests extremely severe infection and systemic inflammation in septic patients, reflective of an extreme immune response. Such perfect discriminatory power may be largely attributed to the inclusion of patients with advanced or fulminant sepsis, in which neutrophilia and lymphopenia manifest quite pronouncedly. SIRI with an AUC of 0.950 and SII with an AUC value of 0.944 showed remarkably excellent predictive ability beyond the NLR, reinforcing their role as robust markers. The predictive strength of PLR, MLR, and PIV further supports their potential utility in sepsis diagnosis quite early on. The cut-off values identified here provide actionable thresholds aiding clinical decision-making, thereby facilitating prompt intervention and resulting in markedly improved outcomes. These findings underscore the potential of systemic inflammatory indices to serve as swiftly deployable biomarkers for early sepsis detection in pediatric ICU settings. Implementation of their diagnostics could facilitate earlier treatment initiation in critically ill pediatric patients, thereby significantly improving survival rates and markedly reducing morbidity. Discussion Sepsis persists as a substantial morbidity and mortality factor in gravely ill pediatric patients, necessitating the early identification of reliable diagnostic markers. Systemic inflammatory indices have emerged as bedside markers for sepsis detection, largely because of the inherent limitations of blood culture. NLR, PLR, MLR, SII, SIRI, and PIV are markedly elevated in patients with sepsis, reinforcing their putative role as indicators of systemic inflammation. Systemic inflammatory indices were significantly higher in septic patients than in the non-sepsis group, consistent with the findings of Shanshan Zhu et al. 10 The significant elevation of SII in the sepsis group supports the findings of Liang et al. , who identified its crucial role in detecting serious bacterial infections in neonates. 14 Similarly, Cakir et al. found that systemic inflammatory markers such as SII and PIV were valuable in diagnosing neonatal conditions, which aligns with our results, where PIV demonstrated strong predictive potential. 15 Our findings further emphasize the utility of PLR, which was significantly elevated in patients with sepsis, supporting the findings of Güngör et al., who found PLR to be an independent predictor of neonatal infections. 13 Additionally, the study by Mathews et al. suggested that a rise in PLR is closely associated with worsening inflammatory burden, which is consistent with our observation that PLR was significantly higher in the sepsis group. 18 NLR, which had the highest AUC in our study, was previously identified as a strong predictor of sepsis in pediatric patients. However, the exceptionally high predictive value observed in our study suggests that the included patients with sepsis may have had severe infections, with profound neutrophilia and lymphopenia. Pasaribu et al. previously identified the NLR as a strong marker of sepsis mortality, 19 and our findings suggest that its role in early diagnosis may be even more significant. Although Cakir et al. found that SIRI was a useful marker for diagnosing early onset sepsis, 11 our study did not find it to be as strong a predictor as the other indices. Similarly, while thrombocytopenia has been well documented in sepsis, our study found no significant difference in platelet counts between the sepsis and non-sepsis groups. This suggests that while platelet-related indices, such as PLR and SII, are reliable predictors, absolute platelet count alone may not be sufficient for early diagnosis. Overall, our findings indicate that systemic inflammatory indices, particularly the NLR, SII, PLR, and PIV, are effective predictors of sepsis in critically ill pediatric patients. Their accessibility and ease of calculation make them valuable bedside markers, potentially reducing delays in diagnosis and facilitating early interventions. Further multicenter studies are needed to validate these findings and establish standardized cutoff values for clinical applications. Limitations The generalizability of the findings may be limited because this study was conducted in a single center setting. Results may differ significantly between adult and neonatal populations, whereas study population populations may differ in spopulation, spopulation, spopulation, spopulation, spopulation, spopulation, spopulation, spopulation, and spopulation. Systemic inflammatory indices showed strong predictive ability, yet external validation with a fairly large multicenter cohort remains necessary to confirm clinical applicability. Future research should rigorously incorporate such indices into sepsis screening protocols and evaluate their effectiveness in real-world clinical settings. Conclusion The findings of this study underscore the potential of systemic inflammatory indices, particularly NLR and SII, as reliable markers for the early detection of sepsis. NLR shows remarkably high predictive accuracy, suggesting its huge potential as a primary diagnostic tool in patients at exceptionally high risk. These indices could enable prompt therapeutic interventions by facilitating early diagnosis, thereby markedly improving patient outcomes in the PICU setting. Further large-scale studies validating these findings and exploring their integration into routine clinical practice are urgently required. Patient and public involvement Patients and/or the public were not involved in the design, conduct, reporting, or dissemination of this research. Provenance and peer review Not commissioned. Ethics statements The Institutional Ethics Committee at Kasturba Medical College in Mangalore granted ethical clearance on 21/11/24 (Protocol No: IECKMCMLR-11/2024/644). Approval to conduct this research was received from the Regional Advanced Pediatric Care Center’s Medical Superintendent. Data availability statement Underlying data Repository name: Role of Systemic inflammatory indices in identifying sepsis in PICU patients in a tertiary healthcare centre of India. 20 https://doi.org/10.6084/m9.figshare.28625087.v1 The project contains the following underlying data: File name: Sepsis_PICU data (Raw excel sheet data) The data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0). Acknowledgements We thank all children and their families for participating in this study. We also thank the Medical Superintendent, Regional Advanced Pediatric Care Center, Mangalore, and Head of Department, Department of Pediatrics, KMC Mangalore. References 1. Souza DC, Jaramillo-Bustamante JC, Céspedes-Lesczinsky M, et al. : Challenges, and health-care priorities for reducing the burden of paediatric sepsis in Latin America: a call to action. Lancet Child Adolesc Health. 2022 Feb; 6 (2): 129–136. Epub 2021 Dec 11. PubMed Abstract | Publisher Full Text 2. Fleischmann-Struzek C, Goldfarb DM, Schlattmann P, et al. : The global burden of paediatric and neonatal sepsis: a systematic review. Lancet Respir. Med. 2018 Mar; 6 (3): 223–230. PubMed Abstract | Publisher Full Text 3. Tan B, Wong JJ, Sultana R, et al. : Global Case-Fatality Rates in Pediatric Severe Sepsis and Septic Shock: A Systematic Review and Meta-analysis. JAMA Pediatr. 2019 Apr 1; 173 (4): 352–362. 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Epub 2023 Mar 10. PubMed Abstract | Publisher Full Text 16. Ceran B, Alyamaç Dizdar E, Beşer E, et al. : Diagnostic Role of Systemic Inflammatory Indices in Infants with Moderate-to-Severe Hypoxic Ischemic Encephalopathy. Am. J. Perinatol. 2024 Feb; 41 (3): 248–254. Epub2021 Oct 19. PubMed Abstract | Publisher Full Text 17. Kawalec A: The Systemic Immune-Inflammation Index (SII) and Neutrophil-Lymphocyte Ratio (NLR) are related to hospitalisation time in paediatric burn patients. Family Medicine & Primary Care Review. 2024 Jan 1; 26 (1): 51–55. Publisher Full Text 18. Mathews S, Rajan A, Soans ST: Prognostic value of rise in neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR) in predicting the mortality in paediatric intensive care. Int. J. Contemp. Pediatr. 2019 May; 6 (3): 1052–1058. Publisher Full Text 19. Pasaribu FM, Setyaningtyas A, Andarsini MR: Neutrophil to lymphocyte ratio, monocyte to lymphocyte ratio, platelet to lymphocyte ratio, mean platelet volume as a predictor of sepsis mortality in children at Dr. Soetomo General Hospital. Crit. Care Shock. 2021 Mar 1; 24 (2). 20. Srikanth S: Sepsis_PICU. figshare. 2025 [cited 2025Nov25]. Reference Source Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 03 Feb 2026 ADD YOUR COMMENT Comment Author details Author details 1 Kasturba Medical College Mangalore, Mangaluru, Karnataka, 575001, India 2 Department of Pediatrics, Kasturba Medical College Mangalore, Mangaluru, Karnataka, India 3 Department of Surgery, Kasturba Medical College Mangalore, Mangaluru, Karnataka, India Sahajanya Srikanth Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Resources, Writing – Original Draft Preparation Gayathri Renganathan Roles: Conceptualization, Formal Analysis, Supervision, Validation, Writing – Original Draft Preparation Laxmi Kamath Roles: Supervision, Validation, Writing – Original Draft Preparation, Writing – Review & Editing Nishank Gowda Roles: Formal Analysis, Investigation, Writing – Original Draft Preparation, Writing – Review & Editing Sowmini P Kamath Roles: Supervision, Writing – Review & Editing Jayashree K Roles: Supervision, Writing – Review & Editing Smitha Sharlette D’Sa Roles: Supervision, Writing – Review & Editing Venkat Tarun Dungigalla Roles: Supervision, Writing – Review & Editing Competing interests No competing interests were disclosed. Grant information The author(s) declared that no grants were involved in supporting this work. Article Versions (1) version 1 Published: 03 Feb 2026, 15:179 https://doi.org/10.12688/f1000research.173741.1 Copyright © 2026 Srikanth S et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics Views Downloads F1000Research - - PubMed Central info_outline Data from PMC are received and updated monthly. - - Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article Srikanth S, Renganathan G, Kamath L et al. ROLE OF SYSTEMIC INFLAMMATORY INDICES IN IDENTIFYING SEPSIS IN PICU PATIENTS IN A TERTIARY HEALTHCARE CENTRE OF INDIA [version 1; peer review: 1 not approved] . F1000Research 2026, 15 :179 ( https://doi.org/10.12688/f1000research.173741.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Version 1 VERSION 1 PUBLISHED 03 Feb 2026 Views 0 Cite How to cite this report: Magiorkinis E. Reviewer Report For: ROLE OF SYSTEMIC INFLAMMATORY INDICES IN IDENTIFYING SEPSIS IN PICU PATIENTS IN A TERTIARY HEALTHCARE CENTRE OF INDIA [version 1; peer review: 1 not approved] . F1000Research 2026, 15 :179 ( https://doi.org/10.5256/f1000research.191581.r462024 ) The direct URL for this report is: https://f1000research.com/articles/15-179/v1#referee-response-462024 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 26 Feb 2026 Emmanouil Magiorkinis , Department of Laboratory Haematology, Metaxa Cancer Hospital of Piraeus Oncology-Pathology (Ringgold ID: 546398), Pireas, Attica, Greece Not Approved VIEWS 0 https://doi.org/10.5256/f1000research.191581.r462024 This manuscript reports a prospective observational study conducted in a tertiary pediatric intensive care unit in India evaluating the diagnostic performance of systemic inflammatory indices including neutrophil to lymphocyte ratio, platelet to lymphocyte ratio, monocyte to lymphocyte ratio, systemic immune ... Continue reading READ ALL This manuscript reports a prospective observational study conducted in a tertiary pediatric intensive care unit in India evaluating the diagnostic performance of systemic inflammatory indices including neutrophil to lymphocyte ratio, platelet to lymphocyte ratio, monocyte to lymphocyte ratio, systemic immune inflammatory index, systemic inflammation response index, and pan immune inflammation value for the early identification of sepsis in critically ill children. Using data from 138 PICU patients equally divided between sepsis and non sepsis groups, the authors demonstrate significantly elevated inflammatory indices in septic patients and report very high discriminatory performance, particularly for neutrophil to lymphocyte ratio. The study addresses an important clinical problem, as timely recognition of pediatric sepsis remains challenging and resource intensive in many settings. Readily available bedside biomarkers derived from routine complete blood counts could, if validated rigorously, provide cost effective and rapid adjunctive tools to support early diagnosis and triage in resource constrained environments. However the paper has several problems to be addressed by the authors: 1. The study addresses a clinically relevant question, namely the early identification of sepsis in critically ill children using readily available laboratory parameters. The topic is important for low and middle income settings where rapid diagnostics are limited. However, the manuscript substantially overstates its findings, particularly the claim of perfect discrimination with an AUC of 1.000 for NLR. Such a result in a small single center observational study strongly suggests overfitting, spectrum bias, or methodological flaws. The authors acknowledge rarity but do not critically interrogate the plausibility of this finding. 2. The study design is described as prospective and observational, yet the sampling strategy raises concerns. The sepsis group appears to be defined by consensus criteria, but the definition and selection of the non sepsis group are insufficiently described. It is unclear whether non sepsis patients had suspected infection ruled out, or whether they were admitted for entirely unrelated conditions. Without careful matching or adjustment for confounders such as age and underlying diagnosis, the comparison is vulnerable to bias. 3. There is a significant age imbalance between groups. The median age in the sepsis group is 8 years, compared to 2 years in the non sepsis group as shown in Table 1 on page 6. Age is strongly associated with leukocyte distributions and immune response. The absence of adjustment for age in statistical modeling undermines the validity of the reported associations. A simple independent sample t test is insufficient in this context. 4. The statistical reporting contains inconsistencies. The methods section states that descriptive statistics were presented as medians and standard deviations, which is conceptually inconsistent because medians should be paired with interquartile ranges. Tables 2 and 3 correctly use medians and IQRs, suggesting an error in the methods description. This raises concerns about statistical rigor. 5. The use of independent sample t tests for variables reported as medians and IQRs suggests that assumptions of normality were not evaluated. For skewed hematological indices such as SII and PIV, non parametric tests would be more appropriate. The manuscript does not describe any assessment of distributional assumptions. 6. The ROC analysis lacks internal validation. There is no cross validation, bootstrapping, or split sample approach. Reporting an AUC of 1.000 with 100 percent sensitivity and specificity at a cut off of 1.957 for NLR strongly implies that the chosen threshold may perfectly separate the specific sample but may not generalize. Without confidence intervals that meaningfully vary, as shown in Table 4 where the 95 percent confidence interval for NLR is 1.000 to 1.000 on page 7, the result appears statistically implausible. 7. The manuscript repeatedly uses exaggerated language in the results, critical reflection, and discussion sections. Phrases such as unprecedented predictive value, strikingly high AUC, and markedly improved outcomes are not justified by the data. Observational diagnostic accuracy studies cannot demonstrate improved survival or reduced morbidity without interventional follow up. 8. The limitation section is inadequate and contains serious typographical errors. The repetition of the term spopulation multiple times on page 9 indicates poor proofreading. More importantly, key limitations such as lack of multivariable adjustment, absence of external validation, and potential incorporation bias are not thoroughly discussed. 9. The operational definition of sepsis relies on the Third International Consensus Definitions from 2016, which were developed primarily for adults. The manuscript does not clarify how pediatric specific considerations were handled. The use of SOFA and MAP thresholds may not be fully applicable to all pediatric age groups. 10. The control of confounding variables is absent. No multivariable logistic regression was performed to assess whether NLR or SII independently predict sepsis after adjusting for total leukocyte count, age, sex, or clinical severity. Given that NLR is mathematically derived from neutrophil and lymphocyte counts, its association with sepsis is expected when these counts differ significantly between groups, as shown in Table 2. 11. The interpretation of platelet findings is inconsistent. Platelet count was not significantly different between groups, yet platelet derived indices such as SII and PLR were highly significant. This is mathematically possible but warrants deeper analysis. The discussion does not sufficiently explore this paradox. 12. The study population is relatively small with 69 patients per group. While the sample size calculation is described, it is based on PLR differences from a prior study. It is unclear whether this calculation is appropriate for ROC analysis across multiple biomarkers. No correction for multiple comparisons was applied despite testing six indices 13. The manuscript structure includes a section labeled Critical reflection within the results narrative. This section reads as speculative and promotional rather than analytical. It would be more appropriate to incorporate critical interpretation within the discussion and to temper claims regarding clinical implementation. 14. There are multiple language and formatting issues throughout the manuscript. These include inconsistent capitalization, grammatical errors, typographical mistakes, and formula rendering problems in the methods section where multiplication symbols appear corrupted. These errors detract from scientific credibility. 15. The conclusion overreaches by suggesting that these indices could serve as primary diagnostic tools and markedly improve survival. The study demonstrates association and discrimination within a specific cohort but does not demonstrate clinical impact, cost effectiveness, or superiority over existing sepsis screening tools. In summary, while the research question is clinically relevant and the use of routine hematological indices is appealing, the manuscript suffers from major methodological limitations, statistical concerns, exaggerated interpretation, and editorial issues. Substantial revision is required. Specifically, the authors should reanalyze the data using appropriate non parametric methods, perform multivariable logistic regression with adjustment for age and other confounders, apply internal validation for ROC analysis, correct reporting inconsistencies, moderate their claims, and thoroughly revise the language and limitations section before the work can be considered reliable or generalizable. Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Partly Are sufficient details of methods and analysis provided to allow replication by others? Partly If applicable, is the statistical analysis and its interpretation appropriate? Partly Are all the source data underlying the results available to ensure full reproducibility? Partly Are the conclusions drawn adequately supported by the results? Partly Competing Interests: No competing interests were disclosed. Reviewer Expertise: Laboratory Haematology, Virology, Microbiology, Infectious Diseases I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Magiorkinis E. Reviewer Report For: ROLE OF SYSTEMIC INFLAMMATORY INDICES IN IDENTIFYING SEPSIS IN PICU PATIENTS IN A TERTIARY HEALTHCARE CENTRE OF INDIA [version 1; peer review: 1 not approved] . F1000Research 2026, 15 :179 ( https://doi.org/10.5256/f1000research.191581.r462024 ) The direct URL for this report is: https://f1000research.com/articles/15-179/v1#referee-response-462024 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 03 Feb 2026 ADD YOUR COMMENT Comment keyboard_arrow_left keyboard_arrow_right Open Peer Review Reviewer Status info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Reviewer Reports Invited Reviewers 1 Version 1 03 Feb 26 read Emmanouil Magiorkinis , Metaxa Cancer Hospital of Piraeus Oncology-Pathology (Ringgold ID: 546398), Pireas, Greece Comments on this article All Comments (0) Add a comment Sign up for content alerts Sign Up You are now signed up to receive this alert Browse by related subjects keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2026 Magiorkinis E. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 26 Feb 2026 | for Version 1 Emmanouil Magiorkinis , Department of Laboratory Haematology, Metaxa Cancer Hospital of Piraeus Oncology-Pathology (Ringgold ID: 546398), Pireas, Attica, Greece 0 Views copyright © 2026 Magiorkinis E. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Not Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions This manuscript reports a prospective observational study conducted in a tertiary pediatric intensive care unit in India evaluating the diagnostic performance of systemic inflammatory indices including neutrophil to lymphocyte ratio, platelet to lymphocyte ratio, monocyte to lymphocyte ratio, systemic immune inflammatory index, systemic inflammation response index, and pan immune inflammation value for the early identification of sepsis in critically ill children. Using data from 138 PICU patients equally divided between sepsis and non sepsis groups, the authors demonstrate significantly elevated inflammatory indices in septic patients and report very high discriminatory performance, particularly for neutrophil to lymphocyte ratio. The study addresses an important clinical problem, as timely recognition of pediatric sepsis remains challenging and resource intensive in many settings. Readily available bedside biomarkers derived from routine complete blood counts could, if validated rigorously, provide cost effective and rapid adjunctive tools to support early diagnosis and triage in resource constrained environments. However the paper has several problems to be addressed by the authors: 1. The study addresses a clinically relevant question, namely the early identification of sepsis in critically ill children using readily available laboratory parameters. The topic is important for low and middle income settings where rapid diagnostics are limited. However, the manuscript substantially overstates its findings, particularly the claim of perfect discrimination with an AUC of 1.000 for NLR. Such a result in a small single center observational study strongly suggests overfitting, spectrum bias, or methodological flaws. The authors acknowledge rarity but do not critically interrogate the plausibility of this finding. 2. The study design is described as prospective and observational, yet the sampling strategy raises concerns. The sepsis group appears to be defined by consensus criteria, but the definition and selection of the non sepsis group are insufficiently described. It is unclear whether non sepsis patients had suspected infection ruled out, or whether they were admitted for entirely unrelated conditions. Without careful matching or adjustment for confounders such as age and underlying diagnosis, the comparison is vulnerable to bias. 3. There is a significant age imbalance between groups. The median age in the sepsis group is 8 years, compared to 2 years in the non sepsis group as shown in Table 1 on page 6. Age is strongly associated with leukocyte distributions and immune response. The absence of adjustment for age in statistical modeling undermines the validity of the reported associations. A simple independent sample t test is insufficient in this context. 4. The statistical reporting contains inconsistencies. The methods section states that descriptive statistics were presented as medians and standard deviations, which is conceptually inconsistent because medians should be paired with interquartile ranges. Tables 2 and 3 correctly use medians and IQRs, suggesting an error in the methods description. This raises concerns about statistical rigor. 5. The use of independent sample t tests for variables reported as medians and IQRs suggests that assumptions of normality were not evaluated. For skewed hematological indices such as SII and PIV, non parametric tests would be more appropriate. The manuscript does not describe any assessment of distributional assumptions. 6. The ROC analysis lacks internal validation. There is no cross validation, bootstrapping, or split sample approach. Reporting an AUC of 1.000 with 100 percent sensitivity and specificity at a cut off of 1.957 for NLR strongly implies that the chosen threshold may perfectly separate the specific sample but may not generalize. Without confidence intervals that meaningfully vary, as shown in Table 4 where the 95 percent confidence interval for NLR is 1.000 to 1.000 on page 7, the result appears statistically implausible. 7. The manuscript repeatedly uses exaggerated language in the results, critical reflection, and discussion sections. Phrases such as unprecedented predictive value, strikingly high AUC, and markedly improved outcomes are not justified by the data. Observational diagnostic accuracy studies cannot demonstrate improved survival or reduced morbidity without interventional follow up. 8. The limitation section is inadequate and contains serious typographical errors. The repetition of the term spopulation multiple times on page 9 indicates poor proofreading. More importantly, key limitations such as lack of multivariable adjustment, absence of external validation, and potential incorporation bias are not thoroughly discussed. 9. The operational definition of sepsis relies on the Third International Consensus Definitions from 2016, which were developed primarily for adults. The manuscript does not clarify how pediatric specific considerations were handled. The use of SOFA and MAP thresholds may not be fully applicable to all pediatric age groups. 10. The control of confounding variables is absent. No multivariable logistic regression was performed to assess whether NLR or SII independently predict sepsis after adjusting for total leukocyte count, age, sex, or clinical severity. Given that NLR is mathematically derived from neutrophil and lymphocyte counts, its association with sepsis is expected when these counts differ significantly between groups, as shown in Table 2. 11. The interpretation of platelet findings is inconsistent. Platelet count was not significantly different between groups, yet platelet derived indices such as SII and PLR were highly significant. This is mathematically possible but warrants deeper analysis. The discussion does not sufficiently explore this paradox. 12. The study population is relatively small with 69 patients per group. While the sample size calculation is described, it is based on PLR differences from a prior study. It is unclear whether this calculation is appropriate for ROC analysis across multiple biomarkers. No correction for multiple comparisons was applied despite testing six indices 13. The manuscript structure includes a section labeled Critical reflection within the results narrative. This section reads as speculative and promotional rather than analytical. It would be more appropriate to incorporate critical interpretation within the discussion and to temper claims regarding clinical implementation. 14. There are multiple language and formatting issues throughout the manuscript. These include inconsistent capitalization, grammatical errors, typographical mistakes, and formula rendering problems in the methods section where multiplication symbols appear corrupted. These errors detract from scientific credibility. 15. The conclusion overreaches by suggesting that these indices could serve as primary diagnostic tools and markedly improve survival. The study demonstrates association and discrimination within a specific cohort but does not demonstrate clinical impact, cost effectiveness, or superiority over existing sepsis screening tools. In summary, while the research question is clinically relevant and the use of routine hematological indices is appealing, the manuscript suffers from major methodological limitations, statistical concerns, exaggerated interpretation, and editorial issues. Substantial revision is required. Specifically, the authors should reanalyze the data using appropriate non parametric methods, perform multivariable logistic regression with adjustment for age and other confounders, apply internal validation for ROC analysis, correct reporting inconsistencies, moderate their claims, and thoroughly revise the language and limitations section before the work can be considered reliable or generalizable. Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Partly Are sufficient details of methods and analysis provided to allow replication by others? Partly If applicable, is the statistical analysis and its interpretation appropriate? Partly Are all the source data underlying the results available to ensure full reproducibility? Partly Are the conclusions drawn adequately supported by the results? Partly Competing Interests No competing interests were disclosed. Reviewer Expertise Laboratory Haematology, Virology, Microbiology, Infectious Diseases I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above. reply Respond to this report Responses (0) Magiorkinis E. Peer Review Report For: ROLE OF SYSTEMIC INFLAMMATORY INDICES IN IDENTIFYING SEPSIS IN PICU PATIENTS IN A TERTIARY HEALTHCARE CENTRE OF INDIA [version 1; peer review: 1 not approved] . F1000Research 2026, 15 :179 ( https://doi.org/10.5256/f1000research.191581.r462024) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/15-179/v1#referee-response-462024 Alongside their report, reviewers assign a status to the article: Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions Adjust parameters to alter display View on desktop for interactive features Includes Interactive Elements View on desktop for interactive features Competing Interests Policy Provide sufficient details of any financial or non-financial competing interests to enable users to assess whether your comments might lead a reasonable person to question your impartiality. 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