How should I manage a child with Pseudomonas sepsis, including initial fluid resuscitation, empiric anti‑pseudomonal antibiotic therapy, source control, and supportive care?

Management of Pseudomonas Sepsis in Children

Administer anti-pseudomonal antibiotics within 1 hour of recognizing septic shock, begin aggressive fluid resuscitation with 20 mL/kg isotonic crystalloid boluses up to 40-60 mL/kg in the first hour, and initiate vasopressor support early if shock persists despite adequate fluid administration. 1

Immediate Resuscitation (0-15 Minutes)

Airway and Breathing

• Provide high-flow oxygen via face mask, high-flow nasal cannula, or nasopharyngeal CPAP to maintain SpO₂ >90% 1
• Secure peripheral IV or intraosseous access immediately for fluid and medication administration 1
• Perform cardiovascular resuscitation before intubation if mechanical ventilation is needed, as this reduces hemodynamic instability during the procedure 1

Initial Fluid Resuscitation

• Administer 20 mL/kg boluses of isotonic crystalloid (normal saline or balanced solution) over 5-10 minutes, repeating up to 40-60 mL/kg total in the first hour 1
• Titrate fluid administration to clinical endpoints: capillary refill ≤2 seconds, normal blood pressure for age, warm extremities, urine output ≥1 mL/kg/hr, normal mental status, and no differential between peripheral and central pulses 1
• Stop fluid boluses immediately if hepatomegaly or rales develop—these indicate fluid overload and mandate inotropic support rather than additional fluids 1

Metabolic Correction

• Check and correct hypoglycemia and hypocalcemia immediately 1

Anti-Pseudomonal Antibiotic Therapy (Within 1 Hour)

Empiric Coverage

• Obtain blood cultures before antibiotics when possible, but never delay antibiotic administration beyond 1 hour to obtain cultures 1
• Administer broad-spectrum anti-pseudomonal beta-lactam antibiotics within 1 hour of septic shock recognition—each hour of delay increases mortality 2, 3
• Recommended empiric regimens for Pseudomonas coverage include:
  • Ceftazidime 50 mg/kg IV every 8 hours (max 2 g/dose), OR
  • Piperacillin-tazobactam 100 mg/kg IV every 6-8 hours (max 4.5 g/dose), OR
  • Meropenem 20-40 mg/kg IV every 8 hours (max 2 g/dose) 2
• Add aminoglycoside (gentamicin 7.5 mg/kg IV once daily or tobramycin 7.5 mg/kg IV once daily) for synergy in severe Pseudomonas septic shock 1
• Consider adding vancomycin 15 mg/kg IV every 6 hours if MRSA co-infection is suspected (recent ICU stay, indwelling devices) 2

Hemodynamic Support (15-60 Minutes)

Fluid-Refractory Shock

• Begin peripheral inotropic support if central venous access is not yet available in children who remain hypotensive after 40-60 mL/kg fluid resuscitation 1
• Obtain central venous access and secure airway as needed 1

Vasopressor/Inotrope Selection Based on Shock Phenotype

For "cold shock" (cold extremities, delayed capillary refill, normal or elevated blood pressure):

• Titrate central dopamine 5-10 mcg/kg/min, OR
• If dopamine-resistant, titrate central epinephrine 0.05-0.3 mcg/kg/min 1

For "warm shock" (warm extremities, bounding pulses, low blood pressure):

• Titrate central norepinephrine 0.05-0.3 mcg/kg/min 1

Catecholamine-Resistant Shock (After 60 Minutes)

• Administer hydrocortisone 2 mg/kg IV (max 100 mg) if at risk for absolute adrenal insufficiency and shock persists despite adequate fluid and catecholamines 1
• Monitor central venous pressure (CVP) and target normal MAP-CVP with ScvO₂ ≥70% 1
• Target hemoglobin ≥10 g/dL during active resuscitation if ScvO₂ <70% 1

For cold shock with normal blood pressure:

• Add vasodilator therapy (nitrosovasodilators or milrinone) with volume loading if ScvO₂ remains <70% 1

For cold shock with low blood pressure:

• Consider adding norepinephrine if ScvO₂ <70% despite epinephrine 1

For warm shock with low blood pressure:

• Consider vasopressin, terlipressin, or angiotensin if hypotension persists 1

Refractory Shock

• Evaluate for and reverse pneumothorax, pericardial tamponade, or endocrine emergencies 1
• Consider ECMO for refractory pediatric septic shock 1

Source Control

• Identify and control the infection source as soon as possible—inadequate source control synergistically increases mortality 1
• Perform emergent imaging (ultrasound, CT) to identify abscesses, empyema, necrotizing pneumonia, or other drainable foci 1
• Debride necrotizing fasciitis or gangrenous myonecrosis urgently 1
• Remove infected intravascular devices after establishing alternative access 1

Ongoing Monitoring and Supportive Care

Hemodynamic Targets

• Maintain MAP appropriate for age, capillary refill ≤2 seconds, urine output ≥1 mL/kg/hr, normal mental status, and cardiac index 3.3-6.0 L/min/m² 1
• Monitor serial lactate levels to guide resuscitation toward normalization 2, 4

Mechanical Ventilation (If Required)

• Use lung-protective strategies: tidal volume 6 mL/kg predicted body weight, plateau pressure ≤30 cm H₂O 1, 3
• Maintain head-of-bed elevation 30-45° 1

Glycemic Control

• Target glucose <180 mg/dL; provide glucose infusion with insulin therapy in neonates and children (some are insulin-deficient, others insulin-resistant) 1, 3

Fluid Overload Management

• Use diuretics to reverse fluid overload once shock has resolved; if unsuccessful, initiate continuous venovenous hemofiltration or intermittent dialysis to prevent >10% total body weight fluid overload 1, 3

Nutrition

• Begin enteral nutrition as soon as hemodynamically stable; provide parenteral nutrition if enteral feeding is not tolerated 1, 3

Sedation and Drug Monitoring

• Use sedation with a defined goal in mechanically ventilated patients 1
• Monitor drug toxicity levels closely because drug metabolism is reduced in severe sepsis, increasing the risk of adverse drug events 1, 3

Antimicrobial Stewardship

• Reassess antibiotic therapy daily once pathogen identification and susceptibilities are available, typically within 48-72 hours 2, 4, 3
• Narrow to the most appropriate single agent (e.g., ceftazidime or cefepime monotherapy) within 3-5 days based on culture results and clinical improvement 2, 4
• Plan a total antibiotic course of 7-10 days for most Pseudomonas infections; extend duration for slow clinical response, undrained foci, or immunodeficiency 2, 4

Common Pitfalls

• Do not delay antibiotics to obtain cultures—blood cultures should be drawn rapidly, but antibiotic administration must occur within 1 hour regardless 1
• Do not continue fluid boluses if hepatomegaly or rales develop—this indicates fluid overload and requires immediate transition to inotropic support 1
• Do not use dopamine as first-line therapy in warm shock—norepinephrine is the preferred vasopressor for distributive (warm) shock 1
• Do not assume all pediatric septic shock is "cold shock"—assess perfusion phenotype (cold vs. warm) to guide vasopressor/inotrope selection 1
• Do not overlook source control—failure to drain abscesses or remove infected devices is independently associated with increased mortality 1