Sepsis in children

Last reviewed: 22 Feb 2023
Last updated: 25 Jan 2023
25 Jan 2023

High rates of group A streptococcus infection in England

In a UK Health Security Agency (UKHSA) report, notifications of scarlet fever and invasive group A streptococcus (iGAS) disease in England are higher than expected for this time of year.

Prompt treatment of children with scarlet fever with antibiotics is recommended to reduce risk of possible complications and limit onward transmission. If there is uncertainty about the diagnosis, obtain a throat swab prior to commencing antibiotics. Children with scarlet fever should stay at home until 24 hours of antibiotic treatment has been received.

The Centers for Disease Control and Prevention (CDC) is looking into an increase in iGAS infections among children in the US.

Scarlet fever:

  • Around 90% of cases occur in children under 10 years

  • Usually a mild illness, but is highly infectious

  • Presents with a generalized, erythematous rash, which feels like sandpaper

  • Often preceded by sore throat (pharyngitis, tonsillitis)

  • Pharyngeal erythema with exudates, palatal petechiae, and a red, swollen (strawberry) tongue are suggestive features.

Invasive group A streptococcal infection:

  • The relatively higher rates of iGAS in children this season may reflect increased rates of a preceding viral infection (including respiratory viruses and chickenpox)

  • Clinicians are advised to maintain a high index of suspicion, as early recognition and prompt initiation of specific and supportive therapy for patients with iGAS infection can be life-saving.

Further information from CDC:

See Etiology

Original source of update



History and exam

Key diagnostic factors

  • fever or low body temperature
  • tachypnea
  • tachycardia
  • bradycardia (neonates and infants)
  • altered mental state or behavior
  • decreased peripheral perfusion
  • change in usual pattern of activity or feeding in a neonate
  • dry diapers/decreased urine output
  • mottling of the skin, ashen appearance, cyanosis
  • low oxygen saturation
  • vasoplegia
  • nonblanching purpuric rash
More key diagnostic factors

Other diagnostic factors

  • hypotension
  • specific focal signs and symptoms reflecting underlying pathology
Other diagnostic factors

Risk factors

  • immunodeficiency
  • comorbidities
  • male sex
  • younger age (especially neonates)
  • perinatal risk factors for infection (neonates)
  • healthcare-associated factors (neonates)
  • recent surgery or other invasive procedures
  • breached skin integrity
More risk factors

Diagnostic investigations

1st investigations to order

  • CBC with differential
  • serum glucose
  • blood culture
  • urinalysis
  • urine culture
  • blood gases
  • serum lactate
  • serum electrolytes
  • serum creatinine
  • LFTs
  • coagulation studies
  • C-reactive protein (CRP)
  • chest x-ray
More 1st investigations to order

Investigations to consider

  • lumbar puncture
  • meningococcal polymerase chain reaction analysis
  • bronchoalveolar lavage culture
  • herpes simplex virus (HSV) polymerase chain reaction (blood and cerebrospinal fluid)
More investigations to consider

Emerging tests

  • serum procalcitonin
  • emerging biomarkers
  • PhenoTest™ BC Kit

Treatment algorithm


presumed or confirmed sepsis



Akash Deep, MD, FRCPCH

Director and Professor of Paediatric Critical Care

Paediatric Intensive Care Unit

King’s College Hospital




AD declares that he has no competing interests.

Chris Duncan, BMBS, BMedSci, MRCP, FFICM, FEWM, PGCert

Professorial Fellow

Intensive Care Medicine

Nepean Hospital




CD declares that he has no competing interests.


Dr Akash Deep and Dr Chris Duncan would like to gratefully acknowledge Dr Jeremy Tong and Dr Adrian Plunkett, previous contributors to this topic.


JT and AP are authors involved in the Pediatric Sepsis Six initiative, cited in this topic.

Peer reviewers

Saul N. Faust, MA, MBBS, FRCPCH, PhD, FHEA

Professor of Paediatric Immunology & Infectious Diseases

Director, NIHR Wellcome Trust Clinical Research Facility

University of Southampton




SNF declares that he has no competing interests.

Mohan Pammi, MBBS, MD, MRCPCH

Assistant Professor

Texas Children's Hospital and Baylor College of Medicine




MP declares that he has no competing interests.

Jerry J. Zimmerman, MD, PhD

Faculty, Pediatric Critical Care Medicine

Seattle Children's Hospital

University of Washington School of Medicine




JJZ receives research grant support from NIH/NICHD and ImmuneXpress; travel reimbursement from the Society of Critical Care Medicine to attend board meetings; and royalties from Elsevier for action as a co-editor for the textbook Pediatric Critical Care.

  • Sepsis in children images
  • Differentials

    • Coronavirus disease 2019 (COVID-19)
    • Pediatric inflammatory multisystem syndrome
    • Congenital heart disease
    More Differentials
  • Guidelines

    • Surviving sepsis campaign: international guidelines for management of sepsis and septic shock: 2021
    • Neonatal infection: antibiotics for prevention and treatment
    More Guidelines
  • Patient leaflets

    Sepsis in children

    Pneumococcal vaccine in babies and children

    More Patient leaflets
  • padlock-lockedLog in or subscribe to access all of BMJ Best Practice

Use of this content is subject to our disclaimer