What is the recommended treatment for a pediatric patient with suspected sepsis?

Pediatric Sepsis Management

Immediate Recognition and Antibiotic Administration

For pediatric patients with suspected septic shock, start broad-spectrum empiric antibiotics within 1 hour of recognition; for sepsis-associated organ dysfunction without shock, initiate antibiotics within 3 hours of recognition. 1

• Obtain blood cultures before administering antibiotics whenever possible, but never delay antibiotic administration to obtain cultures 1
• Empiric therapy must cover all likely pathogens based on age, immune status, and local resistance patterns 1
• For infants 0-3 months: ampicillin (or penicillin) plus gentamicin or cefotaxime to cover Group B Streptococcus, E. coli, and Listeria 2
• For older children: vancomycin plus ceftriaxone or cefotaxime to cover MRSA and resistant gram-negatives 3
• Add clindamycin for suspected toxic shock syndrome with refractory hypotension 1

Fluid Resuscitation Protocol

Administer isotonic crystalloids or albumin in 20 mL/kg boluses over 5-10 minutes, titrated to reverse hypotension and restore perfusion markers (capillary refill, peripheral pulses, mental status, urine output) 1

• Continue boluses up to 40-60 mL/kg or more during the first hour if needed 1, 4
• Stop fluid boluses immediately if hepatomegaly or rales develop—this indicates fluid overload requiring inotropic support instead 1
• Monitor for signs of adequate perfusion: normalized heart rate, capillary refill <2 seconds, warm extremities, adequate urine output (>1 mL/kg/hr), improved mental status 1

Critical Pitfall

In resource-limited settings without access to mechanical ventilation and inotropes, be cautious with aggressive fluid administration due to fluid overload risks 5

Vasoactive Support for Fluid-Refractory Shock

Begin peripheral inotropic support immediately if the patient remains hypotensive or has poor perfusion after initial fluid resuscitation, while establishing central venous access 1

Hemodynamic Phenotype-Directed Therapy

• Cold shock (low cardiac output, high SVR): Use epinephrine or add vasodilators (milrinone, nitroprusside) to inotropes if blood pressure is normal 1, 4
• Warm shock (high cardiac output, low SVR): Use norepinephrine 5
• Dopamine is an alternative first-line agent, though epinephrine or norepinephrine are preferred 5

Refractory Shock Management

For shock persisting despite 40-60 mL/kg fluid and high-dose catecholamines with ≥2 vasopressors:

• Administer hydrocortisone 50 mg/m²/24 hours as continuous infusion for suspected absolute adrenal insufficiency (present in ~25% of pediatric septic shock) 1, 4
• Consider ECMO for refractory septic shock unresponsive to all medical therapies 1, 4
• Survival rates: 73% for newborns, 39% for older children 4

Source Control

Identify and control the infection source as early and aggressively as possible 1

• Remove infected indwelling devices after establishing alternative access 2
• Drain abscesses or infected fluid collections emergently 3
• Perform surgical debridement for necrotizing infections 1

Antimicrobial De-escalation Protocol

At 48-72 hours, review all culture results and clinical response to guide narrowing or stopping antibiotics 1, 2

• If cultures are negative and clinical probability of sepsis is low with clinical improvement, discontinue antibiotics 2
• If pathogen identified, narrow to targeted therapy based on sensitivities 1
• If no pathogen but clear infection source with good clinical response, narrow empiric coverage in consultation with infectious disease 1

Supportive Care Targets

Hemoglobin Management

• Target hemoglobin 10 g/dL during resuscitation when ScvO₂ <70% 1, 4
• After stabilization, target hemoglobin >7 g/dL 1

Glycemic Control

• Target glucose <180 mg/dL 1
• Always provide glucose infusion with insulin therapy in newborns and children, as some are insulin-deficient while others are insulin-resistant 1

Mechanical Ventilation

• Use lung-protective strategies with low tidal volumes (6-8 mL/kg ideal body weight) 1
• Implement sedation protocols with defined sedation goals 1

Fluid Overload Prevention

• Once shock resolves, use diuretics to reverse fluid accumulation 1, 4
• If diuretics fail, initiate CVVH or intermittent dialysis to prevent >10% total body weight fluid overload 1, 4

Drug Toxicity Monitoring

• Monitor drug levels closely as drug metabolism is significantly reduced during severe sepsis, increasing adverse event risk 1, 4

Implementation Strategy

Implement institutional protocols/guidelines for systematic screening and management of pediatric sepsis 1

• Systematic screening must be tailored to patient population, resources, and institutional procedures 1
• Protocol-driven therapy targeting ScvO₂ ≥70% improves outcomes 4
• Bundle implementation and advanced technologies have demonstrated mortality reduction 6, 5