Recognition of Pediatric

Sepsis
Paria M Wilson, MD
Pediatric Resident, PL3

Objectives
Review of SIRS criteria and
recognition of early sepsis
Discuss the initial management of
sepsis
Touch on the antibiotic selection for
sepsis
Discuss burden of sepsis globally

Systemic Inflammatory Response

Syndrome (SIRS)
Core temperature of >38.5 or <36
OR
WBC count above or below age
specific cutoffs
AND presence of at least 1 of the
following:
HR> 2 SD above normal for age,
bradycardia for children < 1 yr
RR > 2 SD above normal for age
Goldstein, B., B. Giroir, and A. Randolph, International pediatric sepsis consensus
conference: definitions for sepsis and organ dysfunction in pediatrics, in Pediatr Crit Care

Leukocyte Count
Age Group

WBC

Newborn (0-1wk)

>34

Neonate (1wk-1mo)

>19.5 or <5

Infant (1mo-1yr)

>17.5 or <5

Toddler (2yr-5yr)

>15.5 or <6

School Aged (6yr-12yr)

>13.5 or <4.5

Adolescent (13yr-18yr)

>11 or <4.5

Goldstein, B., B. Giroir, and A. Randolph, International pediatric sepsis consensus

conference: definitions for sepsis and organ dysfunction in pediatrics, in Pediatr Crit Care

Heart Rate
Age Group

Tachycardia/Bradycardia

Newborn (0-1wk)

>180, <100

Neonate (1wk-1mo)

>180, <100

Infant (1mo-1yr)

>180, <90

Toddler (2yr-5yr)

>140

School Aged (6yr-12yr)

>130

Adolescent (13yr-18yr)

>110

THE PRESENCE OF
TACHYCARDIA ALONE CAN BE
INDICATIVE OF SEPSIS
Goldstein, B., B. Giroir, and A. Randolph, International pediatric sepsis consensus
conference: definitions for sepsis and organ dysfunction in pediatrics, in Pediatr Crit Care

Respiratory Rate
Age Group

Tachypnea

Newborn (0-1wk)

>50

Neonate (1wk-1mo)

>40

Infant (1mo-1yr)

>34

Toddler (2yr-5yr)

>22

School Aged (6yr-12yr)

>18

Adolescent (13yr-18yr)

>14

Goldstein, B., B. Giroir, and A. Randolph, International pediatric sepsis consensus

conference: definitions for sepsis and organ dysfunction in pediatrics, in Pediatr Crit Care

Systolic Blood Pressure

Age Group

Hypotension

Newborn (0-1wk)

<65

Neonate (1wk-1mo)

<75

Infant (1mo-1yr)

<100

Toddler (2yr-5yr)

<94

School Aged (6yr-12yr)

<105

Adolescent (13yr-18yr)

<117

Goldstein, B., B. Giroir, and A. Randolph, International pediatric sepsis consensus

conference: definitions for sepsis and organ dysfunction in pediatrics, in Pediatr Crit Care

Tachycardia with signs of decreased

perfusion
Peripheral pulses < Central pulses
Altered alertness/mental status
Flash cap refill or prolonged cap refill
>2sec
Mottled or cool extremities
Decreased urine output

Goldstein, B., B. Giroir, and A. Randolph, International pediatric sepsis consensus

conference: definitions for sepsis and organ dysfunction in pediatrics, in Pediatr Crit Care

Signs of Decreased
Perfusion
Number of wet diapers
in the first 5 days of life
is equivalent to age in
days
In the neonate/infant,
ask parents how many
wet diapers a day, if
urinating less than
that amount, concern
for dehydration
In older kids, ask about
color of urine

How to save a life

ABCswith a giant focus
on the C
Isotonic Fluids

Access: IV/IO
20ml/kg bolus over 5
minutes
Continue fluids in 20ml/kg
boluses until tachycardia
resolves, UOP improves,
or rales develop

Brierley, J., et al., Clinical practice parameters for hemodynamic support of pediatric and
neonatal septic shock: 2007 update from the American College of Critical Care Medicine,
in Crit Care Med2009: United States. p. 666-88

Rehydration: Is IV the only route?

Numerous studies have shown that outpatient ORT
is safe and equally effective as IV therapy for even
moderate-severe dehydration
Randomized study done in UCLA for gastroenteritis
patients with mild-moderate dehydration
No statistically significant difference noted between the
two modalities but cost savings is a significant factor

Sharifi et al: randomized prospective trial in Iran

for 470 hospitalized children with mod-severe
dehydration NG ORT equally effective as IV

Nager, A.L. and V.J. Wang, Comparison of nasogastric and intravenous methods of
rehydration in pediatric patients with acute dehydration. Pediatrics, 2002. 109(4): p. 566-

Fluid Resuscitation
Study has been done on burn shock
in low resource settings which
showed that compared to lactated
ringers, intestinal absorption rates
were sufficient with ORS for
resuscitation of up to 40% body
surface area burn
BUT, enteral fluid loading has not yet
been studied as a strategy for sepsis
management
Michell,
M.W., et al., Enteral resuscitation of burn shock using World Health Organization
oral rehydration solution: a potential solution for mass casualty care, in J Burn Care

So youve given 60ml/kg

Fluid refractory shock
Consider inotropes/vasopressors

Brierley, J., et al., Clinical practice parameters for hemodynamic support of pediatric and
neonatal septic shock: 2007 update from the American College of Critical Care Medicine,
in Crit Care Med2009: United States. p. 666-88

Antibiotic Selection

Start broad and narrow down, but focus on your

clinical suspicion as the cause of infection
CLINICAL SCENARIO

ANTIMICROBIAL

RATIONALE

Newborn <28 days

Amp & Gent or Amp and Cover Listeria, E.coli,

Cefotax
GBS

Meningitis/Pneumonia
GPC
on gram stain

Vanc + 3rd gen

cephalosporin

Cover for resistant S.

pneumo

Meningitis gram neg

diplococci

3rd gen cephalosporin

Likely N. meningitides

Neutropenia

Vanc + Zosyn

Pts are susceptible to

Pseudomonas & other
SPACE organisms

Toxic shock

Clinda + Vanc

Cover for MRSA/Strep

Indwelling central
venous catheters

Vanc + 3rd gen

cephalosporin

Vanc is needed for

Gram +
organisms, most
notably S.
epi.

Antibiotic Selection
Spectrum of bacterial pathogens
seen globally is diverse
Ex: In Thailand CAP most commonly
caused by S. aureus, in neighboring
Laos, its Salmonella enterica

In many developing countries,

antibiotics are not regulated and are
freely available
Major implications for antibiotic resistance
Cheng, A.C., et al., Strategies to reduce mortality from bacterial sepsis in adults in
developing countries, in PLoS Med2008: United States. p. e175

4 leading infectious causes of death

in kids

Pneumonia
Diarrhea
Malaria
Measles
The World Health report 1996--fighting disease, fostering development. World Health
Forum, 1997. 18(1): p. 1-8.

Measures that have reduced the

global burden of sepsis worldwide
Prevention:
Heterologous
immunizations
Specific immunizations
(specially flu vaccine)
Vitamin & mineral
supplementation
Antepartum GBS
prophylaxis in mothers
Washing your hands
Carcillo, J.A., Reducing the global burden of sepsis in infants and children: a clinical
practice research agenda, in Pediatr Crit Care Med2005: United States. p. S157-64.

Measures that have reduced the

global burden of sepsis worldwide
Early Recognition and Treatment:
Bang et al: rural initiative in India demonstrated
50% reduction in infant mortality
Ngo et al: RCT in children with Dengue shock in
Kenya demonstrated that aggressive IV fluid
resuscitation in the 1st hour achieved 100%
survival
Rapid IVF resuscitation before hypotension occurs
EVERY HOUR THAT PASSES WITHOUT AGGRESSIVE
IVF RESUSCITATION AND INOTROPIC SUPPORT
INCREASED MORTALITY BY 40%
Carcillo, J.A., Reducing the global burden of sepsis in infants and children: a clinical
practice research agenda, in Pediatr Crit Care Med2005: United States. p. S157-64.

Spread the Word

Education of health care providers about
sepsis is critical to enhance the early
identification of sick patients and may help
facilitate transfer to available health care
facilities
Implementation of strategies to promote
recognition of sepsis as a clinical syndrome
should be feasible even in the most resourcechallenged areas where supportive
radiographic imaging or laboratory
measurements are not available
Cheng, A.C., et al., Strategies to reduce mortality from bacterial sepsis in adults in
developing countries, in PLoS Med2008: United States. p. e175.

Questions?

References
1. Goldstein, B., B. Giroir, and A. Randolph, International pediatric sepsis consensus conference: definitions for sepsis and
organ dysfunction in pediatrics, in Pediatr Crit Care Med2005: United States. p. 2-8.
2. Watson, R.S. and J.A. Carcillo, Scope and epidemiology of pediatric sepsis, in Pediatr Crit Care Med2005: United States. p.
S3-5.
3. Duggan, C., M. Santosham, and R.I. Glass, The management of acute diarrhea in children: oral rehydration, maintenance,
and nutritional therapy. Centers for Disease Control and Prevention. MMWR Recomm Rep, 1992. 41(RR-16): p. 1-20.
4. Brierley, J., et al., Clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock: 2007
update from the American College of Critical Care Medicine, in Crit Care Med2009: United States. p. 666-88.
5. Michell, M.W., et al., Enteral resuscitation of burn shock using World Health Organization oral rehydration solution: a
potential solution for mass casualty care, in J Burn Care Res2006: United States. p. 819-25.
6. Nager, A.L. and V.J. Wang, Comparison of nasogastric and intravenous methods of rehydration in pediatric patients with
acute dehydration. Pediatrics, 2002. 109(4): p. 566-72.
7. Sharifi, J., et al., Oral versus intravenous rehydration therapy in severe gastroenteritis. Arch Dis Child, 1985. 60(9): p.
856-60.
8. Cheng, A.C., et al., Strategies to reduce mortality from bacterial sepsis in adults in developing countries, in PLoS
Med2008: United States. p. e175.
9. The World Health report 1996--fighting disease, fostering development. World Health Forum, 1997. 18(1): p. 1-8.
10. Carcillo, J.A., Reducing the global burden of sepsis in infants and children: a clinical practice research agenda, in Pediatr
Crit Care Med2005: United States. p. S157-64.
11. Bang, A.T., et al., Effect of home-based neonatal care and management of sepsis on neonatal mortality: field trial in rural
India, in Lancet1999: England. p. 1955-61.
12. Ngo, N.T., et al., Acute management of dengue shock syndrome: a randomized double-blind comparison of 4 intravenous
fluid regimens in the first hour, in Clin Infect Dis2001: United States. p. 204-13.
13. Han, Y.Y., et al., Early reversal of pediatric-neonatal septic shock by community physicians is associated with improved
outcome. Pediatrics, 2003. 112(4): p. 793-9.