Sepsis in children

Sepsis in children may present initially with nonspecific, nonlocalized symptoms (especially in younger age groups) therefore it is important to have a low threshold for suspecting sepsis.

Given the time-critical nature of sepsis and septic shock, when sepsis is suspected on clinical grounds it is usually best to initiate sepsis investigations and treatment together, including administering antibiotics and fluid resuscitation. These should continue until sepsis has been excluded.

Progression to organ failure and shock is often very rapid, so early recognition and treatment is crucial.

Empiric broad-spectrum antibiotic therapy (based on the most probable pathogens) should be administered as soon as possible, and always within the first hour following recognition of sepsis.

Other treatments are primarily supportive, and should be delivered according to internationally recognized consensus-based guidelines.

Sepsis is a clinical syndrome resulting from a dysregulated immune response to infection.[1]Bone RC. The sepsis syndrome: definition and general approach to management. Clin Chest Med. 1996 Jun;17(2):175-81. http://www.ncbi.nlm.nih.gov/pubmed/8792059?tool=bestpractice.com It is characterized by derangements in multiple pathobiologic processes, which may lead to widespread tissue injury.[2]Angus DC, van der Poll T. Severe sepsis and septic shock. N Engl J Med. 2013 Aug 29;369(9):840-51. http://www.nejm.org/doi/full/10.1056/NEJMra1208623 http://www.ncbi.nlm.nih.gov/pubmed/23984731?tool=bestpractice.com It encompasses a clinical spectrum of severity including severe sepsis, septic shock, and multiorgan failure.[3]Goldstein B, Giroir B, Randolph A; International Consensus Conference on Pediatric Sepsis. International pediatric sepsis consensus conference: definitions for sepsis and organ dysfunction in pediatrics. Pediatr Crit Care Med. 2005 Jan;6(1):2-8. http://www.ncbi.nlm.nih.gov/pubmed/15636651?tool=bestpractice.com Sepsis is a leading cause of morbidity and mortality in children worldwide.[4]World Health Organization Global Health Observatory. Causes of child mortality. 2017 [internet publication]. https://www.who.int/data/gho/data/themes/topics/topic-details/GHO/child-mortality-and-causes-of-death

Traditionally, sepsis has been defined based on the presence or absence of the systemic inflammatory response syndrome (SIRS). In adults, the definitions of sepsis were updated in 2016, moving away from the SIRS definition and removing the term "severe sepsis."[3]Goldstein B, Giroir B, Randolph A; International Consensus Conference on Pediatric Sepsis. International pediatric sepsis consensus conference: definitions for sepsis and organ dysfunction in pediatrics. Pediatr Crit Care Med. 2005 Jan;6(1):2-8. http://www.ncbi.nlm.nih.gov/pubmed/15636651?tool=bestpractice.com ​ Similarly, in children it is now recommended that because any life-threatening condition is severe, the term “severe sepsis” is redundant.[5]Schlapbach LJ, Watson RS, Sorce LR, et al. International consensus criteria for pediatric sepsis and septic shock. JAMA. 2024 Feb 27;331(8):665-74. http://www.ncbi.nlm.nih.gov/pubmed/38245889?tool=bestpractice.com

In 2020 the Surviving Sepsis Campaign proposed a definition for septic shock in children: "severe infection leading to cardiovascular dysfunction (including hypotension, need for treatment with a vasoactive medication, or impaired perfusion)."[6]Weiss SL, Peters MJ, Alhazzani W, et al. Surviving Sepsis Campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children. Pediatr Crit Care Med. 2020 Feb;21(2):e52-e106. https://www.doi.org/10.1097/PCC.0000000000002198 http://www.ncbi.nlm.nih.gov/pubmed/32032273?tool=bestpractice.com ​ Subsequently, the novel Phoenix sepsis criteria for sepsis and septic shock in children has been validated by the Society of Critical Care Medicine Pediatric Sepsis Definition Task Force in 2024. The Phoenix sepsis criteria are intended to identify life-threatening organ dysfunction due to infection; however, it is not a screening tool for sepsis.[5]Schlapbach LJ, Watson RS, Sorce LR, et al. International consensus criteria for pediatric sepsis and septic shock. JAMA. 2024 Feb 27;331(8):665-74. http://www.ncbi.nlm.nih.gov/pubmed/38245889?tool=bestpractice.com [7]Sanchez-Pinto LN, Bennett TD, DeWitt PE, et al. Development and validation of the Phoenix criteria for pediatric sepsis and septic shock. JAMA. 2024 Feb 27;331(8):675-86. http://www.ncbi.nlm.nih.gov/pubmed/38245897?tool=bestpractice.com