Initial Management of Pediatric Sepsis with Bandemia
For pediatric sepsis with bandemia, immediate initiation of empiric broad-spectrum antibiotics within 1 hour of recognition for septic shock and within 3 hours for sepsis without shock is essential, along with fluid resuscitation using isotonic crystalloids in boluses of up to 20 mL/kg over 5-10 minutes. 1
Initial Assessment and Stabilization
Immediate Actions
- Obtain blood cultures before initiating antimicrobial therapy when this does not substantially delay administration 1
- 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
Fluid Resuscitation
- Begin with infusion of isotonic crystalloids with boluses of up to 20 mL/kg over 5-10 minutes 1
- Titrate to reverse hypotension, increase urine output, and attain normal capillary refill, peripheral pulses, and level of consciousness
- Stop fluid administration if hepatomegaly or rales develop 1
- Large fluid deficits may require 40-60 mL/kg or more in the absence of signs of fluid overload 1
Antimicrobial Therapy
Empiric Antibiotic Selection
- Use empiric broad-spectrum therapy with one or more antimicrobials to cover all likely pathogens 1
- Common empiric regimens include:
Dosing Considerations
- Use antimicrobial dosing strategies optimized based on pharmacokinetic/pharmacodynamic principles 1
- For neonates: Ampicillin (50 mg/kg IV every 6 hours) PLUS cefotaxime (50 mg/kg IV every 6-8 hours) 2
- Monitor gentamicin levels (peak and trough) after the third dose if using aminoglycosides 2
Hemodynamic Support
Inotropic/Vasopressor Support
- Begin peripheral inotropic support until central venous access can be attained in children not responsive to fluid resuscitation 1
- Choose vasopressor or inotrope therapy according to the hemodynamic state 1:
- Low cardiac output with high systemic vascular resistance
- High cardiac output with low systemic vascular resistance
- Low cardiac output with low systemic vascular resistance
Refractory Shock
- For dopamine-refractory shock, consider epinephrine or norepinephrine infusion 1
- For patients with low cardiac output and elevated systemic vascular resistance with normal blood pressure, consider vasodilator therapies in addition to inotropes 1
- Consider ECMO in children with refractory septic shock or refractory respiratory failure associated with sepsis 1
Ongoing Management
Daily Assessment and De-escalation
- Perform daily assessment for de-escalation of antimicrobial therapy 1
- Review ongoing indication for empiric antimicrobial therapy after the first 48 hours 1
- Narrow empiric antimicrobial coverage once pathogen(s) and sensitivities are available 1
- If no pathogen is identified, narrow or stop empiric antimicrobial therapy according to clinical presentation, site of infection, host risk factors, and adequacy of clinical improvement 1
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 if confirmed as the source of sepsis after establishing alternative access 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 1, 2
- In confirmed or strongly suspected group B streptococcal sepsis, consider using empiric multiple antimicrobials directed against the same pathogen for synergistic effect 2
Duration of Treatment
- Determine duration of antimicrobial therapy according to the site of infection, microbial etiology, response to treatment, and ability to achieve source control 1
- Recommended durations 2:
- Culture-negative sepsis: 7-10 days
- Culture-positive sepsis: 10-14 days
- Bacterial meningitis: 14-21 days
- Urinary tract infection: 10-14 days
Common Pitfalls and Caveats
- Delay in antimicrobial administration is associated with increased mortality risk 3
- Blood pressure alone is not a reliable endpoint for assessing the adequacy of resuscitation in children 1
- Avoid excessive fluid administration; monitor for signs of fluid overload (hepatomegaly, rales) 1
- Delay in inotropic therapies is associated with major increases in mortality risk 1
- In resource-limited settings, consider local antimicrobial resistance patterns when selecting empiric therapy 1
By following this algorithmic approach to the management of pediatric sepsis with bandemia, clinicians can optimize outcomes by ensuring timely recognition and appropriate intervention with fluids, antibiotics, and hemodynamic support.