What are the initial antibiotics for pediatric sepsis?

Initial Antibiotics for Pediatric Sepsis

For pediatric sepsis, empiric broad-spectrum antibiotic therapy should be initiated immediately, with first-line treatment consisting of ampicillin plus gentamicin or amoxicillin plus gentamicin, administered within 1 hour of recognition for septic shock and within 3 hours for sepsis without shock. 1

Timing of Antibiotic Administration

The timing of antibiotic administration is critical for patient outcomes:

• For septic shock: Start antibiotics within 1 hour of recognition (strong recommendation) 1
• For sepsis without shock: Start antibiotics within 3 hours of recognition (weak recommendation) 1

First-Line Empiric Antibiotic Regimens

Recommended combinations:

• Ampicillin + gentamicin 1, 2
• Amoxicillin + gentamicin 1
• Benzylpenicillin + gentamicin 1

These combinations provide coverage against the most common pathogens in pediatric sepsis while minimizing the risk of developing antimicrobial resistance.

Second-Line Empiric Antibiotic Regimens

When first-line therapy is inappropriate due to patient factors or local resistance patterns:

• Amikacin + cloxacillin 1
• Cefotaxime (Watch category antibiotic) 1
• Ceftriaxone (Watch category antibiotic) 1

Special Considerations

Immunocompromised Patients

• For children with immune compromise or at high risk for multidrug-resistant pathogens, use empiric multi-drug therapy when septic shock or sepsis-associated organ dysfunction is present (weak recommendation) 1

Group B Streptococcal Sepsis

• In confirmed or strongly suspected group B streptococcal sepsis, consider using empiric multiple antimicrobials directed against the same pathogen for synergistic effect 1

Neonatal Sepsis

• For early-onset neonatal sepsis (first 72 hours of life): Benzylpenicillin + gentamicin or ampicillin + gentamicin 1
• For late-onset neonatal sepsis (>72 hours to 1 month): Consider coverage for coagulase-negative staphylococci, GBS, and gram-negative bacteria 1

Blood Culture Collection

• Obtain blood cultures before initiating antimicrobial therapy when this does not substantially delay antibiotic administration 1
• Do not delay antibiotics more than 1 hour for septic shock or 3 hours for sepsis without shock to obtain cultures 1

Antibiotic Management Protocol

1. Initial assessment: Rapidly identify sepsis or septic shock
2. Obtain cultures: Draw blood cultures before antibiotics if this doesn't cause substantial delay
3. Administer antibiotics: Start first-line empiric therapy within the recommended timeframe
4. Daily reassessment: Evaluate clinical response and culture results daily
5. De-escalation: Narrow antibiotic coverage once pathogen(s) and sensitivities are available
6. Duration: Typically 7-10 days, adjusted based on clinical response and source control

Common Pitfalls to Avoid

1. Delaying antibiotics: Never delay antibiotic administration beyond the recommended timeframes while waiting for cultures
2. Inappropriate narrowing: Don't narrow coverage prematurely before culture results are available
3. Failing to de-escalate: Always reassess and narrow therapy once pathogens are identified
4. Prolonged broad-spectrum therapy: Extended use of broad-spectrum antibiotics promotes resistance
5. Ignoring local resistance patterns: Consider local antibiograms when selecting empiric therapy

Source Control

• Implement emergent source control intervention as soon as possible after diagnosis of an infection amenable to source control 1
• Remove intravascular access devices confirmed as the source of sepsis after establishing alternative access 1

By following these evidence-based recommendations for antibiotic selection and administration timing, clinicians can optimize outcomes for children with sepsis while minimizing the development of antimicrobial resistance.