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Sepsis guidelines suggest two-phase protocol for starting antibiotics :

April 1, 2020

The Academy has endorsed the first pediatric sepsis guidelines from the Surviving Sepsis Campaign.

The evidence-based guidelines, Surviving Sepsis Campaign International Guidelines for the Management of Septic Shock and Sepsis-Associated Organ Dysfunction in Children (, are from the Society of Critical Care Medicine, the European Society of Intensive Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.

The new guidelines “represent a milestone for children by bringing the comprehensive process of multistage literature review and scientific analysis to pediatric sepsis care,” said Michael S. D. Agus, M.D., FAAP, a co-author and an AAP liaison to the panel. “The methodical process served to highlight areas where prospective high-quality research has been conducted in kids, as well as the areas that remain in need of this level of clinical investigation.”

The guidelines diverge from the adult guidelines in areas such as choice of first-line vasoactive infusion, size of initial crystalloid resuscitation and use of hydrocortisone, he noted. They represent important differences in treatment recommendations, which reflect the physiologic differences in children vs. adults with sepsis.

For example, although adults are defined in clinical trials as anyone over 18 years, Dr. Agus said individuals enrolled in adult trials were ages 50-70 years and had comorbidities that are absent in childhood.

“Therefore, applying adult treatment guidelines to children is ill-advised, and support for pediatric clinical trials is imperative,” said Dr. Agus, immediate past chair of the AAP Section on Critical Care Executive Committee.

Among the recommendations, which apply to patients from 37 weeks’ gestation to 18 years, are the following:

  • Clinicians should establish a two-phase process for identifying and managing sepsis in children, including starting antibiotic therapy within one hour of evidence of septic shock. Those without symptoms should be evaluated further to confirm or rule out a diagnosis of sepsis. If results are positive, therapy should be started within three hours of the initial suspicion for sepsis (sooner if shock develops during the evaluation).
  • Obtain blood cultures before beginning antimicrobial therapy as long as it does not substantially delay antimicrobial treatment. Broad-spectrum antimicrobial therapy should be used to cover all likely pathogens that could be causing the infection, narrowing the therapy when the specific pathogen has been identified.

Forty-nine experts from 12 international organizations helped to develop the guidelines.

There are 1.2 million cases of childhood sepsis each year, with mortality ranging from 4% to 50%. Most of the 7,000 U.S. pediatric deaths result from refractory shock and/or multiple organ dysfunction syndrome. Because many children die within the initial 48-72 hours of treatment for sepsis, the guidelines emphasize early identification and appropriate resuscitation and management.

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