Pediatric sepsis

Pediatric sepsis is an acute, life-threatening condition in which infection leads to organ dysfunction. Without prompt intervention, affected children frequently progress to septic shock and multiple organ failure. The precipitating infection is most commonly bacterial. Clinical features are often nonspecific and include fever, tachycardia, signs of organ dysfunction (e.g., reduced GCS, jaundice), and signs of shock. Diagnosis occurs alongside management and involves blood cultures, lactate, assessment for markers of infection and end-organ dysfunction, and investigation of the underlying etiology. Initial management focuses on the delivery of the hour-1 bundle for children, which combines definitive treatment (empiric antibiotic therapy) and resuscitation (intravenous fluids, vasoactive medications). Ongoing management includes nutritional support, tailored antibiotic therapy, and regular reassessment. Prevention of sepsis involves infection control measures and early recognition and management of severe infections. Screening for sepsis is recommended in all acutely unwell children.

For neonates, see "Neonatal bacterial infections."

• Sepsis in children: suspected infection and signs of organ dysfunction (e.g., renal impairment, hypoxia, altered mental state) ^[1][2]
• Septic shock in children: sepsis with evidence of cardiovascular dysfunction (e.g., hypotension, need for vasoactive medications, significantly elevated lactate) ^[1][2]

• Worldwide, half of sepsis cases occur in children ≤ 18 years of age.
  • ∼ 25 million cases (> 80% in children < 5 years of age)
  • ∼ 3 million deaths
• Estimated prevalence in the US ^[3]
  • 2.25 per 1000 in those aged 1–12 months
  • 0.23–0.52 per 1000 in those aged between 1 and 19 years of age

Epidemiological data refers to the US, unless otherwise specified.

Common sources of sepsis in children ^[4][5]

• Pneumonia in children
• Urinary tract infections in children
• Meningitis in children
• Device-related infections including IV catheter-related infections
• Infectious gastroenteritis in children
• Osteomyelitis in children
• Infective endocarditis in children
• Intra-abdominal infections
• Skin and soft tissue infections

Common pathogens ^[4]

• Staphylococcus aureus or MRSA
• Clostridium difficile
• Pseudomonas aeruginosa
• Streptococcus spp.
• Escherichia coli
• Klebsiella pneumoniae
• Haemophilus influenzae
• Fungal infections (e.g., Candida spp.)
• Viral (e.g., influenza, COVID-19)

Risk factors for sepsis in children ^[6]

• Age < 12 months ^[3]
• Immunosuppression
• Indwelling devices (e.g., central venous catheter)
• Serious comorbidities (e.g., congenital heart disease, neurological disease)

In addition to features of the underlying primary infection (e.g., clinical features of pneumonia in children), the following nonspecific symptoms may be present. ^[1][7]

• Fever or below normal temperature
• Tachycardia
• Tachypnea
• Clinical features of organ dysfunction, e.g.: ^[1]
  • Reduced GCS
  • Hypoxia
  • Jaundice
• Features of septic shock, e.g.: ^[2][8]
  • Hypotension, low MAP
  • Signs of poor peripheral perfusion
  • Decreased urine output
• Additional features in infants ^[1][7]
  • Poor tone
  • Irritability
  • Poor feeding

Approach ^[9]

• Begin diagnostics alongside initial management, including the hour-1 bundle for children.
• Perform initial studies to confirm the diagnosis and assess for end-organ dysfunction.
• Obtain further studies based on clinical features to determine the underlying cause.
• Consider tools (e.g., Phoenix score) to help diagnose sepsis and septic shock.

Initial studies for sepsis in children ^[1]

• As part of the hour-1 bundle for children, obtain:
  • Blood cultures
  • Lactate: Significant elevations suggest septic shock in children. ^[1][9]
• Assess for markers of infection.
  • CBC with differential: may show leukocytosis, thrombocytopenia
  • Inflammatory markers (e.g., CRP, procalcitonin): typically raised
• Assess for markers of end-organ dysfunction.
  • Comprehensive metabolic panel: may show renal or hepatic dysfunction (e.g., raised creatinine, deranged liver studies)
  • Coagulation panel: may show increased PT, PTT, and INR ^[8]
  • Blood gas analysis: may show metabolic acidosis or hypoxia

Obtain blood cultures before administering antibiotics, unless doing so delays treatment. ^[9]

Further diagnostics to identify the source of infection ^[7]

Obtain additional studies (e.g., microbiology, imaging) based on the suspected source of sepsis in children, e.g.:

• Chest x-ray as part of diagnostics for pediatric CAP
• Urine dipstick and culture as part of diagnostics for UTI in children
• CSF analysis as part of diagnostics for meningitis in children

• The Phoenix sepsis score is a pediatric organ dysfunction scoring system developed in 2024 by the Society of Critical Care Medicine. ^[2]
• Points are based on dysfunction of the respiratory, cardiovascular, coagulation, and neurological systems. ^[2]

The criteria for SIRS and severe sepsis are not used in children. ^[8]

Approach ^[1][9]

• Begin management in conjunction with diagnostic studies; do not delay treatment while waiting for results.
• Consult urgently with specialists (e.g., infectious disease, critical care); PICU admission may be required.
• Start continuous monitoring (e.g., cardiac monitoring, pulse oximetry, urine output).
• Initiate initial management with:
  • The hour-1 bundle for sepsis in children, which includes:
    • Antibiotics
    • Fluid resuscitation
    • Vasopressors in refractory hypotension
  • Supportive care to stabilize the patient (e.g., respiratory support, electrolyte repletion)
• Regularly reassess patients for deterioration and provide ongoing management (e.g., nutritional support) as needed.

Hour-1 bundle for children with sepsis ^[1][9][10]

• As part of initial studies for sepsis in children:
  • Obtain serum lactate.
  • Draw blood cultures (ideally prior to antibiotic administration).
• Begin empiric broad-spectrum antibiotics.
• Begin fluid resuscitation in children with sepsis.
• Septic shock and/or persistent hypotension: Start vasopressors.

Administer antibiotics as soon as possible: within 1 hour in children with septic shock and within 3 hours in children without septic shock. ^[9]

Antibiotics and infection management

• Unclear source of infection: Give empiric antibiotic therapy; follow local hospital protocols when available.
• If a specific source is suspected, tailor antibiotic therapy, e.g.:
  • Empiric antibiotics for pediatric UTI
  • Empiric antibiotic therapy for pediatric CAP
• Consider further coverage as needed, e.g.: ^[9]
  • Respiratory illness in influenza season: antiviral therapy for influenza while awaiting results of respiratory viral panel
  • Potential fungal infection (e.g., immunocompromised individuals or preterm infants): Consult infectious disease for advice on antifungals.
• Consider if source control for sepsis is also required. ^[9]

Fluid resuscitation for children with sepsis ^[9]

• Assess for signs of significant dehydration, shock, and organ dysfunction (see "Phoenix sepsis score").
• If sepsis-relelated organ dysfunction or shock is present:
  • Give isotonic crystalloid 10–20 mL/kg bolus over 5–20 minutes. ^[1][9][12]
  • Reassess hemodynamic status (repeat after any subsequent fluid boluses). ^[1][9]
    • Assess for markers of cardiac output (e.g., heart rate, BP, capillary refill, urine output, serum lactate).
    • Assess for signs of fluid responsiveness (e.g., passive leg raise test).
    • Use advanced monitoring when possible. ^[9]
  • If hypotensive and fluid responsive, repeat boluses as needed.
    • ICU available: 40–60 mL/kg total in the first hour
    • No ICU available: 40 mL/kg total in the first hour ^[9]
  • If hypotension but nonresponsive to fluid or there are signs of fluid overload, start vasopressors.

Discontinue IV fluids if signs and/or symptoms of fluid overload develop. ^[1]

Management of septic shock ^[1][9]

• Vasopressors are indicated in shock if the following features are present: ^[1][9]
  • Minimal response to fluid resuscitation ^[9]
  • Signs of fluid overload
  • Myocardial dysfunction
• First-line: epinephrine or norepinephrine
• The optimum MAP is unclear; consider aiming for between the 5–50th percentile or > 50th percentile for age. ^[9]
• If shock remains refractory, consider:
  • Adjuvant IV hydrocortisone ^[9]
  • Intubation and mechanical ventilation in children ^[9]
• If still unresponsive, consider extracorporeal membrane oxygenation (ECMO). ^[9]

Additional supportive therapy ^[9]

• Start respiratory support with the goal of maintaining saturations between 92 and 98%. ^[1][9]
  • Provide oxygen therapy for children.
  • If acute respiratory distress syndrome (ARDS) is suspected, consider in consultation with a specialist: ^[9][13]
    • Noninvasive ventilation
    • Prone positioning
    • Inhaled nitric oxide ^[9]
  • Invasive mechanical ventilation in children may be required; for refractory hypoxia, consider ECMO.
• Offer supportive care for pediatric fever.
• Provide electrolyte repletion as needed. ^[9]
• Maintain normoglycemia. ^[9]
• Consider in consultation with a specialist: ^[9]
  • Blood transfusion for children with an Hb < 7g/dL
  • Renal replacement therapy for children with refractory fluid overload

• Regularly reassess patients for signs of deterioration and obtain daily laboratory studies. ^[9]
• Tailor antimicrobial therapy to sensitivities when available.
• Provide nutritional support.
  • Consider enteral feeding within 48 hours of admission. ^[9]
  • Consider parenteral nutrition after 7 days of PICU admission if enteral nutrition is < 80% of recommended intake. ^[9]
• Consider the need for prophlyatic therapies in select high-risk patients. ^[9]
  • Initiate stress ulcer prophylaxis for children with any of the following characteristics: ^[9]
    • Recieving mechanical ventilation > 48 hours
    • Persistent shock or multiple-organ dysfunction
    • Coagulopathies
    • Receiving treatment with NSAIDS and corticosteroids
  • Consider VTE prophylaxis only in patients with high-risk features (e.g., cancer, obesity). ^[9]

There is no evidence to support using nutritional supplements (e.g., selenium, zinc, glutamine, arginine, ascorbic acid, vitamin D) to improve outcomes in children with sepsis.^[9]

• See "Differential diagnoses of sepsis" and "Causes of pediatric fever."
• In shock, consider: ^[7]
  • Anaphylaxis
  • Myocarditis
  • Adrenal insufficiency
  • Hypovolemia
• In multiorgan involvement, consider:
  • Macrophage activation syndrome
  • Hemolytic uremic syndrome
  • Multisystem inflammatory syndrome in children ^[14]
• In neonates, consider: ^[7]
  • Congenital heart disease
  • Inborn errors of metabolism

The differential diagnoses listed here are not exhaustive.

• Severe complicatiosn of sepsis include: ^[1][9]
  • Shock
  • Pediatric ARDS
  • DIC
  • Death
• Sequelae are seen in up to a third of survivors, including: ^[1]
  • Impaired baseline functional ability (e.g., sustained disability)
  • Recurrent severe infections

We list the most important complications. The selection is not exhaustive.

Primary prevention

• Prevention of infection, e.g.: ^[15]
  • Routine immunizations
  • Antibiotic prophylaxis (e.g., in patients with asplenia)
  • Prevention of health care-associated infections (e.g., via hand hygiene, respiratory hygiene, aseptic technique)
  • Population-level interventions (e.g., safe drinking water, access to health care) ^[16]
• Once infections develop, early identification and treatment can prevent sepsis. ^[17]

Screening for sepsis in children

• Screening for sepsis is recommended in acutely unwell children. ^[9]
• No specific tool is endorsed by guidelines; follow local protocols. ^[9][18]