Pediatric Sepsis Management

Introduction to Pediatric Sepsis

• Pediatric sepsis is a life-threatening condition that requires prompt recognition and treatment, with a focus on early administration of antibiotics and fluid resuscitation, as recommended by the Critical Care Medicine society 1

Antibiotic Therapy

• The combination of ampicillin and gentamicin is the recommended empiric antibiotic therapy for pediatric sepsis, administered intravenously within the first hour of sepsis identification, as recommended by the American Academy of Pediatrics and the Critical Care Medicine society 2, 1, 3
• Alternative therapy is flucloxacillin + gentamicin if staphylococcal infection is suspected, as recommended by the British Society for Antimicrobial Chemotherapy 4
• Cefotaxime should be added when there is evidence of gram-negative bacterial sepsis, confirmed meningitis, or documented aminoglycoside resistance 2
• Third-generation cephalosporins should be reserved for confirmed gram-negative resistance to first-line agents, evidence of meningitis, or documented aminoglycoside resistance, as recommended by the Centers for Disease Control and Prevention 2, 5

Special Considerations in Hipoalbuminemia

• Hipoalbuminemia alters the pharmacokinetics of antibiotics with high protein binding, increasing the free fraction of the drug and reducing the total plasma concentration, as stated by 2
• Hipoalbuminemia is a marker of poor prognosis in pediatric sepsis, with albumin levels inversely correlated with mortality, as stated by the Critical Care Medicine society 1

Dosage Adjustments

• For time-dependent antibiotics, such as beta-lactams, consider prolonged or continuous infusions and monitor serum levels when possible, as recommended by 2
• For antibiotics with high protein binding, consider more frequent or higher doses to maintain therapeutic levels, as recommended by 2

Duration of Treatment

• The recommended duration of antibiotic treatment is:

  Condition	Duration
  Culture-negative sepsis	7-10 days
  Culture-positive sepsis	10-14 days
  Bacterial meningitis	14-21 days
  Urinary tract infection	10-14 days

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• The minimum duration of antibiotic therapy should be at least 48-72 hours after the patient defervesces, as recommended by 2

Monitoring and Adjustments

• Evaluate clinical response at 48-72 hours and adjust antibiotics based on culture and susceptibility results, as recommended by 2
• Consider therapeutic drug monitoring in cases of severe hipoalbuminemia, as recommended by 2
• Daily reassessment should be performed to consider de-escalation or discontinuation of antibiotics after 48 hours if blood cultures remain negative, clinical signs of infection resolve, or an alternative diagnosis is established, as recommended by the American Academy of Pediatrics and 7
• Local resistance patterns should be considered when selecting empiric therapy to minimize the risk of antimicrobial resistance, as recommended by the Centers for Disease Control and Prevention and 2, 5

Initial Management and Prevention

• Initial fluid resuscitation should include infusion of isotonic crystalloids with boluses of up to 20 mL/kg over 5-10 minutes, as recommended by the Critical Care Medicine guidelines 1
• Dedicated cleaning interventions to reduce contaminated surfaces can help prevent the spread of infection, as stated by the Centers for Disease Control and Prevention 5
• Schedule follow-up within 24 hours after discharge, provide clear instructions to parents about concerning symptoms requiring immediate return, ensure access to emergency care if clinical status changes, and document telephone contact at appropriate intervals after discharge, as recommended by the American Academy of Pediatrics 6

Newborn-Specific Guidelines

• For all newborns with signs of sepsis, perform a full diagnostic evaluation including blood culture, complete blood count (CBC) with differential, and lumbar puncture, and initiate empirical antimicrobial therapy immediately with ampicillin and gentamicin, as recommended by the American Academy of Pediatrics 3
• For newborns born to mothers with chorioamnionitis, even if well-appearing, perform a limited evaluation (blood culture and CBC with differential) and start empirical antimicrobial therapy with ampicillin and gentamicin, as recommended by the American Academy of Pediatrics 3
• For well-appearing term newborns whose mothers received adequate intrapartum antibiotic prophylaxis (IAP), routine care and observation for 48 hours is recommended, with possible discharge as early as 24 hours if other discharge criteria are met, with follow-up within 48-72 hours, as recommended by the American Academy of Pediatrics 3
• For well-appearing term newborns whose mothers received no/inadequate IAP with rupture of membranes <18 hours, observation for 48 hours without antibiotics is recommended, as recommended by the American Academy of Pediatrics 3
• For well-appearing term newborns whose mothers received no/inadequate IAP with rupture of membranes ≥18 hours, limited evaluation (blood culture and CBC with differential) and observation for at least 48 hours is recommended, as recommended by the American Academy of Pediatrics 3
• For all preterm infants (<37 weeks) born to women with no/inadequate IAP, limited evaluation and observation for at least 48 hours is recommended, as recommended by the American Academy of Pediatrics 3