See also

Antibiotics
Febrile child
Febrile neutropenia
Emergency drug and fluid calculator

Invasive group A streptococcal infections: management of household contacts

Key points

1. Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection
2. It is important to diagnose sepsis quickly but also to not over-diagnose. Most children with fever (with or without a focus) do not have sepsis (see assessment section below)
3. Septic shock is sepsis with evidence of cardiovascular organ dysfunction; hypotension is a late sign
4. Rapid vascular access, early initiation of empiric antibiotics and carefully titrated fluid resuscitation is vital
5. Inotropes and vasopressors may be safely administered via peripheral cannula or intraosseous access (IO) in children during initial resuscitation

Background

• Sepsis is a major cause of morbidity and mortality in children
• Care delivered in the first hour following sepsis identification is crucial

High risk groups include:

• neonates
• immunocompromised children
• children with central venous access devices
• Aboriginal and Torres Strait Islanders

Major pathogens in infants <2 months of age:

• Escherichia coli
• Group B Streptococcus
• Listeria monocytogenes is uncommon
• HSV infection should be considered in differential diagnosis of sepsis

Major pathogens in older children:

• Neisseria meningitidis
• Streptococcus pneumoniae
• Staphylococcus aureus (MSSA or MRSA)
• Group A Streptococcus (GAS)

Assessment

Sepsis or septic shock should be considered in a patient with a suspected or proven bacterial infection and any of the following

• Altered conscious state (lethargy, irritability, floppiness, weak cry)
• Unwell appearance ± non-blanching rash
• Features of cardiovascular dysfunction:
  • reduced peripheral perfusion, pale, cool or mottled skin, prolonged central capillary refill time (CRT >2), tachycardia, decreased urine output (<1 mL/kg/hr) or narrow pulse pressure
  • cold shock: narrow pulse pressure, prolonged capillary refill (more common in neonates/infants)
  • warm shock: wide pulse pressure, bounding pulses, flushed skin with rapid capillary refill (more common in older children/adolescents and often under-recognised)
• Tachypnoea ± hypoxia ± grunting (not adequately explained by a respiratory illness)
• Unexplained pain
• Fever or hypothermia (temperature may be normal in neonates or the immunocompromised)

Toxin mediated sepsis: caused by superantigens from toxin-producing strains of S. aureus or GAS

• Clinical features may include fever, vomiting, diarrhoea, myalgia, conjunctival injection, confusion, collapse and a widespread erythematous rash

Red flag features

• High level of parental concern
• Representation within 48 hours
• Clinical deterioration despite treatment
• Recent surgery or burns

Management

Key principles in managing severe sepsis or septic shock

1. Early recognition/seeking senior help
2. Assess airway and breathing and administer oxygen if required
3. Rapid vascular access
4. Empiric antibiotic therapy
5. Carefully titrated fluid resuscitation
6. Early initiation of inotropes
7. Early involvement of critical care services
8. Source control
9. Frequent reassessment
   

Approach to Management

Consider consultation with local paediatric team 

Any child with suspected sepsis

Consider transfer to intensive care unit when

• Child requiring escalation of care beyond local centre
  • Signs of shock persisting despite 40 mL/kg fluid
  • Inotrope requirement
  • Persistent venous serum lactate >3 mmol/L
  • Neutropenia (<1000/mm³) unrelated to chemotherapy
  • Large pleural effusion (near white out of the hemithorax)
  • Coagulopathy (INR >1.6, APTT >60, Fib <1)

Secondary resuscitation measures (second line inotrope/vasopressor, steroids, haemofiltration, ECMO) should be discussed with Retrieval Services or PICU

For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services.

Parent information sheet

Sepsis (Health Direct)

Last Updated March 2020