Pediatric sepsis is a life-threatening organ dysfunction caused by a dysregulated immune response to infection in children.
It’s a leading cause of pediatric mortality worldwide.
An estimated 25 million children experience sepsis worldwide annually, leading to more than 3 million deaths, with the highest burden in lower-resource settings and in children under 5 years.
Differences from adult sepsis:
Hypotension is a late and ominous sign.
Tachycardia and altered mental status often appear before blood pressure drops.
Normal vital signs vary a lot by age, so age-specific thresholds matter
Red flags for pediatric sepsis:
Fever or hypothermia Fast heart rate/breathing out of proportion to fever Poor perfusion — cold extremities, mottled skin, delayed cap refill (>2-3 sec)
Lethargy, irritability, or difficulty waking
Decreased urine output Petechiae or purpura/ especially concerning for meningococcemia
Management principles: Early recognition and screening tools in EDs Rapid fluid resuscitation (often 10-20 mL/kg boluses, reassessing for fluid overload) Antibiotics within 1 hour of recognition Vasoactive support (epinephrine or norepinephrine) if fluid-refractory Source control (identifying and treating the underlying infection) ICU-level monitoring
Common causes by age: Neonates: Group B strep, E. coli, Listeria Infants/young children: Strep pneumoniae, Neisseria meningitidis, viral (with bacterial superinfection) Immunocompromised/hospitalized: broader range including resistant organisms Severe systemic allergic/administration reactions and local injection-site reactions Respiratory tract infections (including pneumonia and bronchitis)
Definition and Diagnostic Criteria (2024 Phoenix Sepsis Score)
The Phoenix Sepsis Score is a composite 4-organ system score (range 0–13 points) assessing dysfunction in:
Respiratory — based on PaO₂/FiO₂ or SpO₂/FiO₂ ratio and respiratory support
Cardiovascular — based on age-adjusted hypotension, vasoactive medication use, or lactate ≥5 mmol/L
Coagulation — based on platelets, INR, D-dimer, and fibrinogen
Neurological — based on Glasgow Coma Scale
Diagnosis: Sepsis: Phoenix Sepsis Score ≥2 in a child with suspected/confirmed infection
Septic shock: Sepsis with ≥1 cardiovascular point (severe hypotension for age, lactate >5 mmol/L, or vasoactive use)
These criteria apply to children <18 years but not to neonates with postconceptional age <37 weeks.
In-hospital mortality for children meeting Phoenix sepsis criteria is 7.1% in higher-resource and 28.5% in lower-resource settings; for septic shock, 10.8% and 33.5%, respectively.
Septic shock: Initiate the sepsis bundle within 1 hour of recognition, including antimicrobials.
Sepsis without shock: Start antimicrobials as soon as possible, ideally within 3 hours, after a time-limited course of rapid investigation.
Antimicrobials
Obtain blood cultures before antibiotics unless this would substantially delay administration.
Administer empiric broad-spectrum therapy covering all likely pathogens; narrow once pathogen and susceptibilities are identified.
Fluid Resuscitation
Administer up to 40–60 mL/kg in bolus fluid (10–20 mL/kg per bolus) over the first hour, titrated to clinical markers of cardiac output.
Reassess after every bolus for fluid responsiveness and signs of fluid overload (pulmonary edema, hepatomegaly).
Use crystalloids (preferably balanced/buffered) rather than albumin for initial resuscitation.
Vasoactive Support
For fluid-refractory septic shock, either epinephrine or norepinephrine is reasonable as the initial vasoactive infusion.
Dopamine may be considered if epinephrine/norepinephrine are unavailable.
Adjunctive Therapies
Stress-dose corticosteroids may be considered for fluid-refractory shock requiring vasoactive support.
Blood lactate should be measured as part of initial evaluation and management.
Consider infectious disease consultation for documented bloodstream infections.
After hemodynamic stability, consider active measures (fluid restriction, diuretics) to mitigate fluid overload.
Cardiac and lung point of care ultrasound, are suggested to guide resuscitation.
Fluid bolus therapy should be avoided in children with sepsis unless they have hypotension.
For intubated children, supplemental oxygen titrated target a conservative range of PO2 88–92%, instead of more liberal target of greater than 94%.
Guidelines strongly recommend that hospitals implement a performance improvement program with standard operating procedures for pediatric sepsis treatment.y
The IPSO collaborative demonstrated that bundled care with timely treatment was associated with a 35.7% relative reduction in 30-day sepsis-attributable mortality across 40 children’s hospitals.