Approach

Early recognition of sepsis is essential because early treatment - when sepsis is suspected but has not yet been confirmed - is associated with significant short- and long-term benefits in outcome.[38][45] However, detection can be challenging because the clinical presentation of sepsis can be subtle and non-specific. A low threshold for suspecting sepsis is therefore important. The aim is to identify those at risk of deterioration to possible sepsis before it develops. In general, sepsis should be considered in any child with a suspected infection with signs of a systemic response, which may be indicated by a change in observations or a change in a child’s normal behaviour.[14][38] Parental concern about a child’s behaviour or condition should always be taken into consideration as an important indicator.[38]

Sepsis may present initially with non-specific, non-localised symptoms, such as feeling very unwell with normal temperature. If a child presents with signs or symptoms that indicate possible infection, regardless of temperature, sepsis should be considered.[38] Initial assessment includes identifying the likely source of infection, identifying risk factors for sepsis (e.g., very young [<1 year]; recent trauma, surgery or invasive procedure; impaired immunity due to illness or medication; maternal infection during perinatal period [e.g., maternal carriage of group B streptococci]; indwelling line or catheter; or any breach of skin integrity [e.g., cuts, burns, blisters, or skin infections]), and identifying indicators of clinical concern, such as abnormalities of behaviour, circulation, or respiration.

While laboratory tests (e.g., blood cultures, biomarkers) are helpful in supporting the diagnosis, the diagnosis has to be made initially using clinical judgement. Diagnostic criteria from international consensus guidelines are primarily considered to be research criteria designed to facilitate meaningful research. Research criteria and clinical judgement do not always agree: up to one third of patients with clinical sepsis do not fulfil research diagnostic criteria.[46]

Therefore, given the time-critical nature of severe sepsis and septic shock, when sepsis is suspected on clinical grounds, it is usually best to initiate sepsis investigations and treatment and to continue until sepsis has been excluded.

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