Pediatric Sepsis Management

Immediate Recognition and Antibiotic Administration

The American Academy of Pediatrics and other medical societies recommend starting broad-spectrum empiric antibiotics within 1 hour of recognition for pediatric patients with suspected septic shock, and within 3 hours for sepsis-associated organ dysfunction without shock 1
The Society of Critical Care Medicine suggests obtaining blood cultures before administering antibiotics whenever possible, but never delaying antibiotic administration to obtain cultures 2, 1
The Infectious Diseases Society of America recommends that empiric therapy must cover all likely pathogens based on age, immune status, and local resistance patterns 2, 1
For infants 0-3 months, the American Academy of Pediatrics recommends ampicillin (or penicillin) plus gentamicin or cefotaxime to cover Group B Streptococcus, E. coli, and Listeria 3
For older children, the Pediatric Infectious Diseases Society recommends vancomycin plus ceftriaxone or cefotaxime to cover MRSA and resistant gram-negatives 4
The Society of Critical Care Medicine suggests adding clindamycin for suspected toxic shock syndrome with refractory hypotension 2

The American College of Critical Care Medicine recommends administering isotonic crystalloids or albumin in 20 mL/kg boluses over 5-10 minutes, titrated to reverse hypotension and restore perfusion markers 2
The Society of Critical Care Medicine suggests continuing boluses up to 40-60 mL/kg or more during the first hour if needed 2, 5
The American Academy of Pediatrics recommends stopping fluid boluses immediately if hepatomegaly or rales develop, indicating fluid overload requiring inotropic support instead 2
The Society of Critical Care Medicine suggests monitoring for signs of adequate perfusion, including normalized heart rate, capillary refill <2 seconds, warm extremities, adequate urine output (>1 mL/kg/hr), and improved mental status 2

The Society of Critical Care Medicine recommends beginning peripheral inotropic support immediately if the patient remains hypotensive or has poor perfusion after initial fluid resuscitation, while establishing central venous access 2
The American College of Critical Care Medicine suggests using epinephrine or adding vasodilators (milrinone, nitroprusside) to inotropes if blood pressure is normal 2, 5

The Society of Critical Care Medicine recommends administering hydrocortisone 50 mg/m²/24 hours as continuous infusion for suspected absolute adrenal insufficiency (present in ~25% of pediatric septic shock) 2, 5
The American College of Critical Care Medicine suggests considering ECMO for refractory septic shock unresponsive to all medical therapies 2, 5
The Pediatric Infectious Diseases Society reports survival rates of 73% for newborns and 39% for older children 5

The Infectious Diseases Society of America recommends identifying and controlling the infection source as early and aggressively as possible 2
The Society of Critical Care Medicine suggests removing infected indwelling devices after establishing alternative access 3
The American College of Surgeons recommends draining abscesses or infected fluid collections emergently 4
The Infectious Diseases Society of America suggests performing surgical debridement for necrotizing infections 2

The American College of Critical Care Medicine recommends reviewing all culture results and clinical response to guide narrowing or stopping antibiotics at 48-72 hours 1, 3
The Infectious Diseases Society of America suggests discontinuing antibiotics if cultures are negative and clinical probability of sepsis is low with clinical improvement 3
The American College of Critical Care Medicine recommends narrowing to targeted therapy based on sensitivities if a pathogen is identified 1
The Infectious Diseases Society of America suggests narrowing empiric coverage in consultation with infectious disease if no pathogen but clear infection source with good clinical response 1

The Society of Critical Care Medicine recommends targeting hemoglobin 10 g/dL during resuscitation when ScvO₂ <70% 2, 5
The American College of Critical Care Medicine suggests targeting hemoglobin >7 g/dL after stabilization 2

The Society of Critical Care Medicine recommends targeting glucose <180 mg/dL 2
The American College of Critical Care Medicine suggests always providing glucose infusion with insulin therapy in newborns and children, as some are insulin-deficient while others are insulin-resistant 2

The American Thoracic Society recommends using lung-protective strategies with low tidal volumes (6-8 mL/kg ideal body weight) 2
The Society of Critical Care Medicine suggests implementing sedation protocols with defined sedation goals 2

The American College of Critical Care Medicine recommends using diuretics to reverse fluid accumulation once shock resolves 2, 5
The Society of Critical Care Medicine suggests initiating CVVH or intermittent dialysis to prevent >10% total body weight fluid overload if diuretics fail 2, 5

The Society of Critical Care Medicine recommends monitoring drug levels closely as drug metabolism is significantly reduced during severe sepsis, increasing adverse event risk 2, 5

The American Academy of Pediatrics recommends implementing institutional protocols/guidelines for systematic screening and management of pediatric sepsis 1
The Society of Critical Care Medicine suggests that systematic screening must be tailored to patient population, resources, and institutional procedures 1
The American College of Critical Care Medicine recommends protocol-driven therapy targeting ScvO₂ ≥70% to improve outcomes 5