What is the treatment for sepsis (systemic inflammatory response syndrome) in an 8-month-old infant?

Treatment of Sepsis in an 8-Month-Old Infant

Immediate administration of empiric antibiotics within 1 hour of sepsis recognition, along with aggressive fluid resuscitation using isotonic crystalloids (up to 20 mL/kg boluses), is the cornerstone of treatment for septic shock in an 8-month-old infant. 1

Initial Recognition and Assessment

• Look for clinical signs of sepsis in the infant:

  • Hypothermia or hyperthermia
  • Altered mental status
  • Abnormal peripheral perfusion (capillary refill >2 seconds)
  • Tachycardia or bradycardia
  • Respiratory distress (most common presenting symptom)

• Critical vital sign thresholds associated with increased mortality:

  • Heart rate <90 or >160 beats per minute
  • Hypotension (late sign in pediatric sepsis)

Treatment Algorithm

First 5 Minutes

1. Establish vascular access (IV or intraosseous)
2. Obtain blood cultures before antibiotics if this doesn't delay administration 1
3. Begin empiric antibiotics immediately within 1 hour of sepsis recognition 1
   • Broad-spectrum coverage based on likely pathogens
   • Common regimens include:
     • Gentamicin (for gram-negative coverage) 2
     • Cefotaxime (for meningitis coverage) 3
   • Adjust based on local resistance patterns

First 15 Minutes

1. Fluid resuscitation 1

   • Administer isotonic crystalloids or albumin
   • Boluses of 20 mL/kg over 5-10 minutes
   • Titrate to:
     • Improved blood pressure
     • Increased urine output
     • Normal capillary refill
     • Improved peripheral pulses and level of consciousness
   • Continue boluses up to 40-60 mL/kg in the first hour unless signs of fluid overload develop (hepatomegaly or rales)

2. Correct metabolic abnormalities

   • Treat hypoglycemia
   • Correct hypocalcemia

If Shock Persists After Initial Fluid Boluses (Fluid-Refractory Shock)

1. Begin inotropic support 1
   • Start peripheral inotropes until central access is established
   • For cold shock (poor perfusion with normal BP): start with dopamine or epinephrine
   • For warm shock (vasodilated): start with norepinephrine

By 60 Minutes (Catecholamine-Resistant Shock)

1. Consider hydrocortisone for suspected adrenal insufficiency 1, 4

   • Approximately 25% of children with septic shock have absolute adrenal insufficiency
   • Dose: 50 mg/m²/24 hours (may require up to 50 mg/kg/day in short term)

2. Optimize hemodynamics based on shock type:

   • Cold shock with normal BP: Add vasodilators (nitrosovasodilators, milrinone)
   • Cold shock with low BP: Titrate epinephrine, consider norepinephrine
   • Warm shock with low BP: Titrate norepinephrine, consider vasopressin

3. Target hemoglobin levels of 10 g/dL during resuscitation 1

For Persistent Shock

1. Rule out and correct pericardial effusion, pneumothorax, or increased intra-abdominal pressure 1

2. Consider ECMO for refractory septic shock and respiratory failure 1

Source Control

• Identify and control infection source aggressively and early 1
• Remove infected devices (e.g., central lines) if identified as source 1
• Surgical intervention may be needed for abscesses, necrotizing infections, or perforated viscus

Supportive Care

1. Mechanical ventilation with lung-protective strategies if needed 1
2. Glycemic control targeting <180 mg/dL 1
3. Monitor for drug toxicity as metabolism is reduced during severe sepsis 1
4. Nutrition support - enteral if tolerated, parenteral if not 1

Common Pitfalls to Avoid

• Delaying antibiotics while waiting for cultures - this increases mortality
• Inadequate fluid resuscitation - infants need aggressive volume replacement
• Missing signs of fluid overload (hepatomegaly, rales) - switch to inotropes if these develop
• Focusing only on blood pressure - normal BP with poor perfusion still indicates shock
• Overlooking adrenal insufficiency - consider early hydrocortisone in refractory shock

Remember that early recognition and intervention within the first hour significantly improves outcomes in pediatric septic shock 5, 6. The mortality rate for septic shock in children remains high, making prompt, aggressive treatment essential for survival.