Paediatrics: Sepsis

Sepsis

Sepsis is bacterial infection of the bloodstream accompanied by signs of systemic toxicity. In this section we will consider the recognition and spe-cific treatment for sepsis.

Clinical assessment

Clinically, there may be fever in the older child, but be aware that fever or hypothermia can be the presenting feature in the infant. Perfusion is usually poor and there may be evidence of shock and coagulopathy (i.e. petechiae or purpura).

Investigations

All organ systems may be involved in sepsis so it is important to perform the following tests.

Blood

·  FBC with differential.

·  Coagulation state.

·  Serum electrolytes with urea and creatinine.

·  Liver function tests.

·  Arterial or capillary blood gas.

·  Inflammatory markers (e.g. CRP and erythrocyte sedimentation rate (ESR)).

Urine

Urinalysis.

Imaging

·  CXR.

·  Abdominal X-ray (AXR).

Sepsis screen

·  Blood culture: bacteria (aerobic and anaerobic), virus, fungi. (Remember that blood cultures may not be positive, so repeat when there is fever).

·  Urine culture.

·  Stool swab.

·  CSF.

·  Other cultures: respiratory; wound; and all ports of any indwelling catheters.

Monitoring

Ensure the ABCs. Then, the form and type of monitoring will be dictated by the patient’s condition. Start with:

·  Continuous pulse oximetry.

·  ECG monitoring.

·  Intermittent BP monitoring.

·  Hourly urine output.

Therapy

Antibiotics

·When: do not delay the first dose because of tests, but it is worthwhile trying to get a blood culture first.

·Should I do a lumbar puncture? This can wait until you have stabilized the child—you may even have to defer it if there is any coagulopathy.

·What: the choice of antibiotics you should use will depend on the patient, as well as your local microbial flora. In general, you can start with a third generation cephalosporin and use the following antibiotics for specific groups of patients.

Age <8 weeks

Consider group B streptococcus—ampicillin.

Indwelling catheter

Consider Staphylococcus aureus—anti-staphylococcal cover that is appro-priate in your institution.

Intra-abdominal cause

Consider gut anaerobes—metronidazole, gentamicin.

Immunosuppressed or oncological

·Pseudomonas: ceftazidime, gentamicin.

·Fungi: amphotericin B.

·Herpes, Varicella: aciclovir.

Cellulitis or fasciitis

Consider group A streptococcus—penicillin.