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id.sepsis.peds.v1PRODUCTION
id.sepsis.peds.v1

Pediatric sepsis / septic shock

pediatricsacutepediatric
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12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Pediatric sepsis per Phoenix criteria 2024 / SSC peds 2020 — suspected infection + organ dysfunction (Phoenix score ≥2). Neonatal sepsis routes to neonatology.

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Pediatric sepsis pattern identified

Patient inputs (22)

Neonate vs <3 mo vs >3 mo drives empiric antibiotics and vital-sign thresholds (SSC 2020 age tiers)

All fluids, antibiotics, and vasopressors are weight-based (mL/kg, mg/kg, µg/kg/min) per SSC 2020

Age-based hypotension threshold (5th percentile) drives shock recognition (SSC 2020)

Age-based tachycardia and bradycardia (terminal sign in infants) per SCCM 2020 peds thresholds

Age-based tachypnea; respiratory failure recognition (SCCM 2020)

Fever / hypothermia (especially in infants) is a sepsis criterion (Phoenix criteria 2024)

Hypoxaemia drives oxygen support and intubation decisions (Phoenix respiratory score)

CRT >3 s + mottling = cold shock phenotype (prefer epinephrine; SSC 2020)

PCV / Hib / meningococcal coverage gaps drive empiric breadth (SSC 2020)

CLABSI risk; differential time-to-positivity sampling (SSC 2020)

Oncology, transplant, primary immunodeficiency → broad / atypical cover (SSC 2020)

MDRO risk → broaden empiric (SSC 2020)

Hour-1 bundle marker per SSC peds; clearance trend

Hypoglycaemia in infants / sepsis is common and dangerous (SSC 2020)

CBC + diff; bandemia + neutropenia / lymphopenia patterns (SSC 2020 workup)

AKI staging (pRIFLE / KDIGO peds) + drug dosing

Coag dysfunction + DIC + organ-dysfunction criterion (Phoenix criteria 2024)

Cultures BEFORE antibiotics if no delay (≤45 min per SSC peds)

<1 mL/kg/h (or <0.5 mL/kg/h adolescents) = AKI / shock marker (KDIGO peds)

AMS = pediatric organ dysfunction criterion + shock indicator (Phoenix criteria 2024)

MAP target by age (SSC peds: ≥5th percentile for age, conditional ≥50th)

Inflammation marker + de-escalation guidance (SSC 2020 procalcitonin-guided)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (13)

13 need judgement
  • informationallife_threateningfluid_refractory_shock_peds
    Persistent shock signs (hypotension, AMS, lactate >4, CRT >3 s, mottling) after 40-60 mL/kg fluid resuscitation
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningpurpura_fulminans
    Rapidly spreading purpura with shock — meningococcaemia or DIC
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningneonate_with_sepsis_signs
    Neonate with temperature instability, poor feeding, lethargy, apnoea, or shock
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningphoenix_criteria_high_mortality_band
    Phoenix sepsis score ≥ 4 with active vasopressor support — high-mortality stratum (~ 30% 90-d mortality) per Phoenix 2024 derivation cohort (Schlapbach JAMA 2024 PMID 38245901; Sanchez-Pinto JAMA 2024 PMID 38245890)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningcatecholamine_resistant_shock
    MAP < age-based threshold despite norepinephrine 0.1-0.5 µg/kg/min OR epinephrine 0.3 µg/kg/min — catecholamine-resistant septic shock (SCCM peds 2020)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningneonatal_hsv_features
    Age < 28 d + ≥ 1 of: vesicles, seizures, hypothermia, hepatitis pattern (AST/ALT > 100), encephalopathy, maternal genital HSV history — neonatal HSV until excluded (AAP Red Book 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecold_shock_phenotype
    Cold extremities + CRT >3 s + narrow pulse pressure + mottling
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverewarm_shock_phenotype
    Warm extremities + bounding pulses + flash CRT + wide pulse pressure
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverelactate_not_clearing_at_2h
    Lactate not down-trending after 2 h despite resuscitation
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverewarm_vs_cold_shock_undifferentiated_at_1h
    Clinical assessment cannot distinguish warm vs cold shock phenotype at 1 h post-bundle (mixed features OR ambiguous perfusion exam) — drives vasoactive selection ambiguity
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereantibiotic_timing_miss_peds
    Age-tiered empiric antibiotics not delivered within 1 h of sepsis recognition (or within 3 h for sepsis without shock per SSC peds 2020 Hour-1 bundle window)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatehypoglycaemia_in_septic_infant
    Glucose <60 mg/dL in septic infant (or <70 mg/dL in older child)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatefeast_context_low_resource
    Non-malaria-endemic + low-resource setting (no PICU, no ventilation, no continuous monitoring) + age ≥ 60 d — FEAST-trial-relevant context flag for fluid posture (Maitland NEJM 2011 PMID 21615299)
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Pediatric sepsis empiric antibiotics — age-tiered
axis: peds_sepsis_empirics_by_agestep neonate_under_28d - Neonate (<28 d) — cover GBS, E. coli, Listeria, HSV
Selected step "Neonate (<28 d) — cover GBS, E. coli, Listeria, HSV" — Neonate <28 d with suspected sepsis
  • ampicillin
    first line
    aminopenicillin
    50-100 mg/kg/dose IV q6-12h (age + weight dependent) • IV • q6-12h
    Listeria + GBS coverage (SSC 2020 neonatal tier)
    rxcui 733
  • gentamicin
    first line
    aminoglycoside
    4-5 mg/kg/dose IV q24-36h (extended interval per gestational age) • IV • q24-36h
    Gram-negative synergy with ampicillin (SSC 2020 neonatal tier)
    rxcui 1596450
  • cefotaxime
    first line
    cephalosporin_3rd
    50 mg/kg/dose IV q6-12h • IV • q6-12h
    triggers: suspected_meningitis, gentamicin_unavailable_or_renal_dysfunction
    Use cefotaxime not ceftriaxone in neonates (bilirubin displacement risk; SSC 2020)
    rxcui 2186
  • acyclovir
    add on
    antiviral
    20 mg/kg/dose IV q8h • IV • q8h
    triggers: HSV_risk_factors, CSF_pleocytosis_or_hepatitis_pattern
    Cover neonatal HSV until excluded; high mortality if missed (AAP Red Book 2024)
    rxcui 281
  • vancomycin
    add on
    glycopeptide
    15 mg/kg/dose IV q6-18h (gestational age dependent) • IV • per nomogram
    triggers: MRSA_risk, CONS_risk_central_line, severe_sepsis_with_skin_or_line_source
    Add-on for MRSA / CoNS in NICU / line settings (SSC 2020)
    rxcui 11124

outpatient playbook — drug actions (6)

  1. 1. IV-to-PO antibiotic continuation if course ongoing at discharge
    Pathogen + source specific PO step-down • PO • per agent
    trigger: Discharge with antibiotic course incomplete (e.g., osteomyelitis, endocarditis, complicated abdominal abscess)
    SSC peds 2020 stewardship — switch to PO when tolerating + improving + source-controlled
  2. 2. PCV15 or PCV20 catch-up if pneumococcal cause + behind schedule
    rxcui 2566310
    Per ACIP age-based schedule • IM • per ACIP
    trigger: Pneumococcal sepsis or meningitis + immunization behind schedule
    AAP Red Book 2024 + ACIP — catch-up before discharge or at first follow-up visit
  3. 3. Hib conjugate catch-up if Hib cause + < 5 yo + behind schedule
    Per ACIP age-based schedule • IM • per ACIP
    trigger: Hib invasive disease + immunization behind schedule
    AAP Red Book 2024 — Hib invasive disease does not confer reliable immunity; catch-up required
  4. 4. MenACWY + MenB if meningococcal cause + age-appropriate
    Per ACIP age-based schedule • IM • per ACIP
    trigger: Meningococcal sepsis or meningitis
    AAP Red Book 2024 — catch-up post-recovery; close-contact chemoprophylaxis already given
  5. 5. Influenza annual + COVID-19 per ACIP
    Per ACIP age-based schedule • IM • annual / per ACIP
    trigger: Every post-sepsis follow-up visit during season
    Reduce future respiratory-source-sepsis risk (ACIP)
  6. 6. IVIG if humoral immunodeficiency identified
    400-600 mg/kg q4 weeks • IV • q4 weeks
    trigger: Confirmed primary immunodeficiency + recurrent serious infections
    Clinical immunology consensus; referral required

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Suspected infection + age-based vital sign derangement + organ dysfunction (Phoenix criteria, Schlapbach JAMA 2024); Age-based hypotension or shock signs (cap refill >3 s, mottling, AMS, cold extremities) per SSC 2020; Lactate >2 with infection in a child (SSC 2020 Hour-1 bundle).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Pediatric sepsis / septic shock** (id.sepsis.peds.v1).
Phenotype framing: Anaphylaxis, hypovolaemic shock, cardiogenic (myocarditis, congenital), obstructive (tamponade, tension pneumothorax), adrenal crisis, MIS-C / Kawasaki shock syndrome, intussusception with shock, severe DKA, toxic shock syndrome
Scope: Pediatric sepsis per Phoenix criteria 2024 / SSC peds 2020 — suspected infection + organ dysfunction (Phoenix score ≥2). Neonatal sepsis routes to neonatology.

No severity triggers fired against current inputs.

Plan

Regimen axis: **Pediatric sepsis empiric antibiotics — age-tiered** — step "Neonate (<28 d) — cover GBS, E. coli, Listeria, HSV".
1. ampicillin 50-100 mg/kg/dose IV q6-12h (age + weight dependent) IV q6-12h (aminopenicillin, first line) — Listeria + GBS coverage (SSC 2020 neonatal tier)
2. gentamicin 4-5 mg/kg/dose IV q24-36h (extended interval per gestational age) IV q24-36h (aminoglycoside, first line) — Gram-negative synergy with ampicillin (SSC 2020 neonatal tier)
3. cefotaxime 50 mg/kg/dose IV q6-12h IV q6-12h (cephalosporin_3rd, first line) — Use cefotaxime not ceftriaxone in neonates (bilirubin displacement risk; SSC 2020)
4. acyclovir 20 mg/kg/dose IV q8h IV q8h (antiviral, add on) — Cover neonatal HSV until excluded; high mortality if missed (AAP Red Book 2024)
5. vancomycin 15 mg/kg/dose IV q6-18h (gestational age dependent) IV per nomogram (glycopeptide, add on) — Add-on for MRSA / CoNS in NICU / line settings (SSC 2020)

Setting playbook (outpatient) — Post-PICU pediatric clinic + neurodevelopmental follow-up — 1-2 wk peds visit, 1 mo + 3 mo neurodev assessment (Bayley III / Ages-and-Stages), immunization catch-up per cause, hearing screen if meningitis, PT/OT if functional decline, mental-health screen for child + caregivers (PICU-Family syndrome), source-specific surveillance (TTE if endocarditis; repeat imaging for abdominal source); prevent post-sepsis sequelae (SSC peds 2020; Choong PEDAL series; Pinto Survivor Outcomes; AAP 2024 immunization catch-up)
6. IV-to-PO antibiotic continuation if course ongoing at discharge Pathogen + source specific PO step-down PO per agent — Discharge with antibiotic course incomplete (e.g., osteomyelitis, endocarditis, complicated abdominal abscess) (SSC peds 2020 stewardship — switch to PO when tolerating + improving + source-controlled)
7. PCV15 or PCV20 catch-up if pneumococcal cause + behind schedule Per ACIP age-based schedule IM per ACIP — Pneumococcal sepsis or meningitis + immunization behind schedule (AAP Red Book 2024 + ACIP — catch-up before discharge or at first follow-up visit)
8. Hib conjugate catch-up if Hib cause + < 5 yo + behind schedule Per ACIP age-based schedule IM per ACIP — Hib invasive disease + immunization behind schedule (AAP Red Book 2024 — Hib invasive disease does not confer reliable immunity; catch-up required)
9. MenACWY + MenB if meningococcal cause + age-appropriate Per ACIP age-based schedule IM per ACIP — Meningococcal sepsis or meningitis (AAP Red Book 2024 — catch-up post-recovery; close-contact chemoprophylaxis already given)
10. Influenza annual + COVID-19 per ACIP Per ACIP age-based schedule IM annual / per ACIP — Every post-sepsis follow-up visit during season (Reduce future respiratory-source-sepsis risk (ACIP))
11. IVIG if humoral immunodeficiency identified 400-600 mg/kg q4 weeks IV q4 weeks — Confirmed primary immunodeficiency + recurrent serious infections (Clinical immunology consensus; referral required)

Non-pharmacologic actions:
- Physical therapy referral if functional decline (FSS worsening vs pre-illness) (Choong PEDAL series)
- Occupational therapy referral if fine-motor / ADL decline (Choong PEDAL series)
- Speech / language therapy if dysphagia post-intubation OR speech delay post-CNS sepsis (AAP)
- Developmental peds referral if Bayley / ASQ delays > 1 SD below mean (Choong PEDAL series)
- Mental health referral if PHQ-9-A ≥ 10 OR SCARED elevated OR caregiver PHQ-9 ≥ 10 OR PCL-5 elevated (PICU-Family syndrome; Pinto Survivor Outcomes)
- School / daycare plan — 504 / IEP update if cognitive or functional changes; nurse trained for any residual medical needs (AAP school-care guidance)
- Caregiver education — return precautions (fever > 38.5 in immunocompromised, recurrent symptoms, new neurological signs), source-specific recurrence risk, infection-prevention hygiene (SSC peds 2020)
- Family adherence support — caregiver education + psychosocial barrier identification + sibling-anxiety screen (PICU-Family syndrome)
- Social work referral if family resource gaps (transportation, insurance, housing) impede follow-up (AAP)

AVOID / contraindication checks:
- Ceftriaxone avoid under 1 month or with calcium IVF (SSC 2020; AAP 2024)
- Fluoroquinolone avoid pediatric unless no alternative (AAP 2024)
- Vancomycin renal function q48h (IDSA 2020)
- Gentamicin extended interval per gestational age neonate (SSC 2020)
- Fluid bolus 10 to 20 mL per kg reassess avoid routine 30 (SSC 2020; FEAST Maitland NEJM 2011)

Monitoring

Regimen monitoring:
- lactate q2-4h until normalised (SSC 2020)
- MAP continuous age-based target (SSC 2020)
- UOP >=1 mL/kg/h infant >=0.5 adolescent (SSC 2020)
- glucose q1-2h initially in neonate/infant (SSC 2020)
- vancomycin trough or AUC q48-72h (IDSA 2020)
- daily pSOFA or PELOD-2 (Schlapbach JAMA 2024)
- procalcitonin q48-72h for de-escalation (SSC 2020)
- daily DDx review at 24-72h (SSC 2020)

Setting (outpatient) monitoring:
- Peds visit q3 mo × 1 yr (1-2 wk, 1 mo, 3 mo, 6 mo, 12 mo) then per pre-illness schedule (SSC peds 2020)
- Neurodevelopmental re-assessment at 6 mo + 12 mo + 24 mo for < 5 yo (Choong PEDAL series)
- FSS at every visit × 1 yr — track functional recovery (Choong PEDAL series)
- Mental health re-screen at 3 mo + 6 mo + 12 mo for child + caregivers (Pinto Survivor Outcomes)
- Immunization status audit at every visit until caught up (AAP Red Book 2024)
- Source-specific surveillance per cause (TTE at 4-6 wks if endocarditis; repeat imaging at 1 mo if abscess) (SSC peds 2020)

Follow-up plan: Post-sepsis goals-of-care discussion; PICS-p screen at 1-3 months; cognitive / functional rehab; review and de-escalate abx; outpatient ID f/u for endocarditis / osteomyelitis; immunisation catch-up
- Close-out criterion: Post-discharge plan documented

Monitoring phase: Lactate q2-4h until normalised, MAP continuous, UOP ≥1 mL/kg/h infants / ≥0.5 mL/kg/h adolescents, vasopressor dose, daily pSOFA, procalcitonin q48-72h for de-escalation, daily DDx review at 24-72h

Disposition

Current setting: outpatient — Post-PICU pediatric clinic + neurodevelopmental follow-up — 1-2 wk peds visit, 1 mo + 3 mo neurodev assessment (Bayley III / Ages-and-Stages), immunization catch-up per cause, hearing screen if meningitis, PT/OT if functional decline, mental-health screen for child + caregivers (PICU-Family syndrome), source-specific surveillance (TTE if endocarditis; repeat imaging for abdominal source); prevent post-sepsis sequelae (SSC peds 2020; Choong PEDAL series; Pinto Survivor Outcomes; AAP 2024 immunization catch-up)

Disposition criteria:
- Sustained recovery — FSS at pre-illness baseline, neurodev assessments within age-appropriate range, immunization catch-up complete, mental-health screens negative, no recurrent infection in 12 mo, family demonstrating return-precaution knowledge (SSC peds 2020; AAP)

Escalation triggers (move to higher acuity):
- New fever > 38.5 OR recurrent symptoms within 4 weeks of discharge → return to ED, blood culture, source-directed workup (SSC peds 2020)
- New focal neurological signs OR seizures → urgent neuro + neuroimaging; route to peds.status_epilepticus.v1 if seizures (AAP)
- Functional decline at follow-up (FSS worsening) → developmental peds + PT/OT urgent (Choong PEDAL series)
- Caregiver PCL-5 elevated or PHQ-9 ≥ 15 → mental-health urgent referral; child PICU-Family syndrome support (Pinto Survivor Outcomes)
- Suspected immunodeficiency (≥ 2 serious infections in 12 mo OR unusual pathogen) → clinical immunology urgent referral (AAP)
- Hearing loss confirmed on audiology post-meningitis → ENT + audiology + speech therapy + early-intervention referral (IDSA meningitis 2024; AAP)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Persistent shock signs (hypotension, AMS, lactate >4, CRT >3 s, mottling) after 40-60 mL/kg fluid resuscitation
- [LIFE_THREATENING] Rapidly spreading purpura with shock — meningococcaemia or DIC
- [LIFE_THREATENING] Neonate with temperature instability, poor feeding, lethargy, apnoea, or shock

Citations

- Surviving Sepsis Campaign Pediatrics 2020 (Weiss et al, Pediatr Crit Care Med 2020) + Phoenix sepsis criteria 2024 (Schlapbach + Sanchez-Pinto JAMA 2024) + PALS 2020/2024 + FEAST trial contextualisation [PMID:26323041](https://pubmed.ncbi.nlm.nih.gov/26323041/)
- Cited evidence (PMID 25148597) [PMID:25148597](https://pubmed.ncbi.nlm.nih.gov/25148597/)
- Cited evidence (PMID 34599691) [PMID:34599691](https://pubmed.ncbi.nlm.nih.gov/34599691/)
- Cited evidence (PMID 24635773) [PMID:24635773](https://pubmed.ncbi.nlm.nih.gov/24635773/)
- Cited evidence (PMID 25272316) [PMID:25272316](https://pubmed.ncbi.nlm.nih.gov/25272316/)

Last reconciled with current guidelines: 2026-05-22.
References
  • Surviving Sepsis Campaign Pediatrics 2020 (Weiss et al, Pediatr Crit Care Med 2020) + Phoenix sepsis criteria 2024 (Schlapbach + Sanchez-Pinto JAMA 2024) + PALS 2020/2024 + FEAST trial contextualisation — PMID:26323041
  • Cited evidence (PMID 25148597) — PMID:25148597
  • Cited evidence (PMID 34599691) — PMID:34599691
  • Cited evidence (PMID 24635773) — PMID:24635773
  • Cited evidence (PMID 25272316) — PMID:25272316