Pedi Sepsis


Sepsis (bacteremia w/ clinical evidence of systemic infection) can rapidly progress to multiorgan failure & death.
Risk factors:
- Prematurity
- Immunocompromise
- Recent invasive procedure
- Indwelling foreign object ( e.g, catheters)

Clinical

  • Lethargy
  • Poor feeding
  • Irritability
  • Hypotonia
  • FEVER
  • Tachypnia
  • Tachycardia
  • AMS
  • Decreased Urine output
  • Prolonged capillary refill
  • Decreased peripheral pulses
  • Hypotension (Late manifestation)
 

Dx

  • Based on clinical features PLUS positive blood cultures
  • CBC, CMP, Cath UA w/ C&S, Blood cultures x2, Serum Sugar (finger stick), Lactic Acid.
  • CXR
  • LP
  • Stool studies (if diarrhea - c.diff toxin, ova & parasite, WBC)
 

ED Care & Disposition

  1. High-flow O2, cardiac monitor, IV/IO access immediately. ET intubation if respiratory failure.
  2. IV NS 20cc/kg boluses. Repeat boluses until vital signs, prefusion, & mental status & urine output improve, up to 100 cc/kg total volume.
  3. Treat Hypoglycemia
    • Neonates & young infants:  4-5 cc/kg 10% Dextrose.
    • Older infants & Children: 2 cc/kg 25% Dextrose.
  4. Initiate IV ABx as soon as IV access is achieved. DO NOT delay due to difficulty w/ procedures such as LP (see table below).
  5. Tx volume-refractory shock with
    • Dopamine 5-20 mcg/kg/min
      -OR-
    • Levophed 0.1 - 0.2 mcg/kg/min.

Consider the presence of drug-resistant organisms or immunocompetence and infection with unusual or opportunistic organisms.

 

Pedi Sepsis Algorithm

ABx Guideline

Suggested Guidelines for the Evaluation and Management of Neonates, Infants, and Children with Fever, Who Are Well Appearing, Have Had All Relevant Immunizations, and No Clinical Source for Fever
Age Group

ABx

Sepsis Meningitis
0–28 d*
38°C (100.4°F)


SBI incidence of ill appearing: 13%–21%;
if not ill appearing: <5%
Ampicillin 100 mg/kg/day q6h
and
Cefotaxime 50 mg/kg
or

Gentamicin 4 mg/kg/day q12h
Ampicillin 100 mg/kg/day q12h
and
Cefotaxime 50 mg/kg
or

Gentamicin 4 mg/kg/day q12h
29–56 d*
38.2°C (100.8°F) (Philadelphia Protocol)

SBI incidence of ill appearing: 13%–21%; if not ill appearing: <5%
Ampicillin 100mg/kg
PLUS
Cefotaxime 50mg/kg

OR

Ceftriaxone 50 mg/kg
PLUS consider
Vancomycin 15mg/kg
Ampicillin 100mg/kg
PLUS
Cefotaxime 100mg/kg

OR

Ceftriaxone100 mg/kg
PLUS 
Vancomycin 15mg/kg .
> 90 days Cefotaxime 50mg/kg
or
Ceftriaxome 50mg/kg
plus consider
Vancomycin 15mg/kg
Cefotaxime 100mg/kg
or
Ceftriaxome 100mg/kg
plus 
Vancomycin 15mg/kg

Admit Orders: Pedi Sepsis

1. Admit to:

2. Diagnosis: Suspected sepsis.

3. Condition:

4. Vital Signs: Call MD if:

5. Activity: Bed rest with bedside commode.

6. Nursing: Inputs and outputs, daily weights, cooling measures prn temp >38̊C, consent for lumbar puncture.

7. Diet:

8. IV Fluids: Correct hypovolemia if present; NS 10-20 mL/kg IV bolus, then IV fluids at 1-1.5 times maintenance.

9. Special Medications:

Term newborns <1 month old (Group B strep, E coli, Group D strep, gram negatives, Listeria monocytogenes): Ampicillin and gentamicin or cefotaxime

-Ampicillin IV/IM: <7 days: 150 mg/kg/day q8h; >7 days: 100 mg/kg/day q6h  AND

-Cefotaxime (Claforan) IV/IM: <7 days: 100 mg/kg/day q12h; >7 days: 150 mg/kg/day q8h OR

-Gentamicin (Garamycin) IV/IM: 4 mg/kg/day q12h.
 

Infant 1-2 months old (H. flu, strep pneumonia, N meningitidis, Group B strep):

-Ampicillin 100 mg/kg/day IV/IM q6h AND EITHER

-Cefotaxime (Claforan) 100 mg/kg/day IV/IM q6h OR

-Ceftriaxone (Rocephin) 50-75 mg/kg/day IV/IM q12-24hOR

-Gentamicin (Garamycin) 7.5 mg/kg/day IV/IM q8h
 

Children 2 months to 18 years old (S pneumonia, H flu, N. meningitidis):

-Cefotaxime (Claforan) 100 mg/kg/day IV/IM q6h, max 12 gm/day OR

-Ceftriaxone (Rocephin) 50-75 mg/kg/day IV/IM q 12-24h, max 4 gm/day.
 

Immunocompromised Patients (Gram negative bacilli, Pseudomonas, Staph, Strep viridans):

  -Ticarcillin (Ticar) 200-300 mg/kg/day IV/IM q6h, max 24 gm/day

-Ticarcillin/clavulanate (Timentin) 200-300 mg/kg/day of ticarcillin IV/IM q6-8h, max 24gm/day OR

  -Piperacillin (Pipracil) 200-300 mg/kg/day IV/IM q6h, max 24 gm/day OR

-Piperacillin/Tazobactam (Zosyn) 240 mg/kg/day of piperacillin IV/IM q6-8h, max 12 gm/day OR

 -Ceftazidime (Fortaz) 100-150 mg/kg/day IV/IM q8h, max 12 gm/day AND

 -Tobramycin (Nebcin) or Gentamicin (Garamycin) (normal renal function):

<5 year (except neonates): 7.5 mg/kg/day IV/IM q8h

5-10 year: 6.0 mg/kg/day IV/IM q8h.

>10 year: 5.0 mg/kg/day IV/IM q8h AND (if gram positive infection strongly suspected)

-Vancomycin (Vancocin) (central line infection) 40-60 mg/kg/day IV q6-8h, max 4 gm/day


10. Symptomatic Medications:

-Acetaminophen (Tylenol) 10-15 mg/kg PO/PR q4-6h prn temp >38̊C or pain.
AND/OR
-Ibuprofen (Advil) 5-10 mg/kg/dose PO q6h-8h prn temp >38̊C 
 

11. Extras and X-rays: CXR.

12. Labs: CBC, CMP. Blood culture and sensitivity x 2. UA w/ culture & Sensitivity, urine culture; antibiotic levels. Stool for Wright stain if diarrhea. RSV, Flu swab, ? Chlamydia, Rapid Strep.

CSF Tube 1: - Gram stain, culture and sensitivity for bacteria, antigen screen (1-2 mL), Enterovirus PCR

CSF Tube 2: - Glucose, protein (1-2 mL).

CSF Tube 3: - Cell count and differential (1-2 mL).