Summary
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 stabilization 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.
For neonates, see "Neonatal bacterial infections."
Definitions
- 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]
Epidemiology
- Worldwide, half of sepsis cases occur in children ≤ 18 years of age. [3]
- ∼ 25 million cases (> 80% in children < 5 years of age)
- ∼ 3 million deaths
- Estimated prevalence in the US [4]
- 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.
Etiology
Common sources of sepsis in children [5][6]
- 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 [5]
- 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 [7]
- Age < 12 months [4]
- Immunosuppression
- Indwelling devices (e.g., central venous catheter)
- Serious comorbidities (e.g., congenital heart disease, neurological disease)
Clinical features
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][8]
- Fever or below normal temperature
- Tachycardia
- Tachypnea
- Clinical features of organ dysfunction, e.g.: [1]
- Features of septic shock, e.g.: [2][9]
- Hypotension, low MAP
- Signs of poor peripheral perfusion
- Decreased urine output
- Additional features in infants [1][8]
- Poor tone
- Irritability
- Poor feeding
Management
Approach [1][10]
- 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).
- Provide initial stabilization with:
- Perform additional diagnostic studies to:
- Confirm the diagnosis.
- Assess for end-organ dysfunction.
- Determine the underlying cause.
- Regularly reassess patients for deterioration and provide further management as needed.
Initial stabilization
Hour-1 bundle for children with sepsis [1][11]
- 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. [10]
Antibiotics and infection management [10]
- 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.:
- Antiviral or antifungal therapy may be required (e.g., in patients with immunocompromise or atypical features).
- Source control for sepsis (e.g., removal of infected intravascular device) may also be required. [10]
| Empiric antibiotics for sepsis in children (unknown source) [12][13] | |
|---|---|
| Patient characteristics | Commonly used regimens |
| Community-acquired sepsis in previously healthy children |
|
| Immunocompromised or hospital-acquired sepsis |
|
Fluid resuscitation for children with sepsis [10]
- Assess for signs of significant dehydration, shock, and organ dysfunction (see "Phoenix sepsis score").
- If sepsis-related organ dysfunction or shock is present:
- Give isotonic crystalloid 10–20 mL/kg over 5–20 minutes; if ICU care is unavailable, administer only if hypotensive. [1][10][14]
- Reassess hemodynamic status (repeat after any subsequent fluid boluses). [1][10]
- 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).
- Consider advanced monitoring. [10]
- If hypotensive and fluid responsive, repeat boluses as needed. [10]
Discontinue IV fluids if signs and/or symptoms of fluid overload develop. [1]
Management of pediatric septic shock [1][10]
- Vasopressors can be given before or after the initial fluid bolus. [10]
- First-line: epinephrine or norepinephrine via peripheral or central line
- The optimum MAP is unclear. [10]
- If central venous access is available, aim for central venous oxygen saturation ≥ 70%. [10]
-
Refractory shock [10]
- Add adjuvant vasopressin.
- Consider intubation and mechanical ventilation in children. [10]
- If still unresponsive, consider extracorporeal membrane oxygenation (ECMO). [10]
While hydrocortisone is not recommended for routine management of septic shock, it is indicated for suspected adrenal insufficiency. [10]
Respiratory support [10]
- Start respiratory support (e.g., oxygen therapy for children) to maintain saturations between 92 and 98% (88–92% for children who are intubated). [1][10]
- If acute respiratory distress syndrome (ARDS) is suspected, consider in consultation with a specialist: [15]
- Invasive mechanical ventilation in children may be required; for refractory hypoxia, consider ECMO.
Diagnostics for sepsis
Initial studies for sepsis in children [1][10]
- As part of the hour-1 bundle for children, obtain:
- Assess for markers of infection.
- CBC with differential: may show leukopenia, 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 [9]
- Blood gas analysis: may show metabolic acidosis or hypoxia
Obtain blood cultures before administering antibiotics, unless doing so delays treatment. [10]
Further diagnostics to identify the source of infection [8]
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
Phoenix sepsis score
- 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]
| Phoenix sepsis score for pediatric sepsis [2] | |
|---|---|
| Criteria | Points |
| Respiratory (0–3 points) |
|
| Cardiovascular (0–6 points) |
|
| Coagulation (0–2 points) |
|
| Neurological (0–2 points) |
|
| |
The criteria for SIRS and severe sepsis are not used in children. [9]
Further management
- Regularly reassess patients for signs of deterioration.
- Provide electrolyte repletion as needed. [10]
- Consider in consultation with a specialist: [10]
- Blood transfusion for severe anemia
- Renal replacement therapy for children with refractory fluid overload
- Immune stimulants in select cases (e.g., children with concurrent cancer)
- Consider supportive care for pediatric fever if the child is uncomfortable. [10]
- If blood cultures are positive for a pathogen: [10]
- Discuss with infectious disease or medical microbiology.
- Tailor antibiotics to sensitivities.
- Start an early rehabilitation bundle. [10]
- Following resolution of sepsis [10]
- Educate patients and caregivers on potential long-term complications of pediatric sepsis.
- Assess for complications of pediatric sepsis both before and at regular intervals after discharge.
Nutritional supplements (e.g., thiamine, ascorbic acid, vitamin D) are not recommended in children with sepsis unless treating deficiency. [10]
Differential diagnoses
- See "Differential diagnoses of sepsis" and "Causes of pediatric fever."
- In shock, consider: [8]
- In multiorgan involvement, consider:
- In neonates, consider: [8]
The differential diagnoses listed here are not exhaustive.
Complications
- Severe complicatiosn of sepsis include: [1][10]
- Sequelae are seen in up to a third of survivors, including: [1][10]
- Impaired baseline functional ability (e.g., sustained disability)
- Recurrent severe infections
We list the most important complications. The selection is not exhaustive.
Prevention
Primary prevention
- Prevention of infection, e.g.: [18]
- 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) [19]
- Once infections develop, early identification and treatment can prevent sepsis. [20]
Screening for sepsis in children
- The role of screening for sepsis in acutely unwell children is unclear. [10]
- If performed, no specific screening tool is recommended; follow local protocols. [10][21]
Related One-Minute Telegram
- One-Minute Telegram 148-2026-3/3: A wash: balanced crystalloids vs. normal saline in pediatric septic shock
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