Paeds · infectious-diseases
Paediatric sepsis: diagnosis, antimicrobial treatment and source control
Also known as Paediatric sepsis · Septic shock in children · Phoenix sepsis criteria · Paediatric sepsis bundle · Source control in sepsis
A fellowship approach to paediatric sepsis covering Phoenix-criteria diagnosis, the first-hour recognition-to-resuscitation bundle, empiric and de-escalated antimicrobial therapy, judicious fluid and vasoactive support, source control, reassessment loops, special populations, and regional guideline boundaries.
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Target exams
Red flags
- Altered behaviour, reduced interaction or weak cry in a febrile child
- Tachycardia out of proportion to fever, weak pulses, prolonged capillary refill, mottling or cold peripheries
- Tachypnoea or increasing work of breathing that then becomes quiet (fatigue, not recovery)
- Lactate rising or failing to clear; metabolic acidosis; rising creatinine or falling urine output
- Persistent shock after fluid boluses, or new hepatomegaly, gallop or pulmonary crackles
- Non-blanching rash, purpura or rapidly evolving skin signs
- Sepsis in a neonate, immunocompromised child, or technology-dependent child
Life stages
Care settings
Clinical exam formats
Board mappings
- General and Community Paediatrics
- Current 2026 PREP curriculum — Learning Objective 2.2.1: Recognise, prioritise and manage an acutely ill infant, child or young person
- Current 2026 PREP curriculum — Learning Objective 2.2.3: Perform acute resuscitation and advanced life support
- Current 2026 PREP curriculum — Learning Objective 2.4.4: Assess and manage infants, children and young people with potential cardiac, respiratory or neurological emergencies or acute sepsis
- Current 2026 PREP curriculum — Learning Objective 2.4.5: Manage transfer of an unwell newborn, infant, child or young person
- Renewed curriculum for first-year trainees from 2027 — Learning goal 6: Clinical management – essential general paediatrics
- Renewed curriculum for first-year trainees from 2027 — Learning goal 11: Acute care and procedures
- Renewed curriculum for first-year trainees from 2027 — Learning goal 17: Acute care
- Clinical Applications
- Medical Sciences
- Long Cases
- Short Cases
- 4. Professional skills and knowledge: Patient management
- 7. Patient safety, including safe prescribing
- General Paediatrics: Resuscitates, stabilises and treats extremely unwell babies, children and young people, liaising with specialist teams, as necessary
- General Paediatrics: Assumes the role of Acute Paediatric Team Leader
- Foundation of Practice (FOP)
- Theory and Science (TAS)
- Applied Knowledge in Practice (AKP)
- Clinical
- History
- Communication
- Video
- General Pediatrics Content Outline — Domain 7: Emergency and Critical Care
- General Pediatrics Content Outline — Domain 9: Infectious Diseases
- General Pediatrics Content Outline — Universal Task 3: Diagnosis
- General Pediatrics Content Outline — Universal Task 4: Management and Treatment
- General Pediatrics EPA 7: Recognizing a Severely Ill Patient, Providing Initial Management, and Mobilizing Resources Needed for Continued Care
- Patient Care 3: Organize and Prioritize Patient Care
- Patient Care 4: Clinical Reasoning
- Patient Care 5: Patient Management
- Systems-Based Practice 1: Patient Safety
- Systems-Based Practice 2: Antimicrobial Stewardship
- Medical Expert
- Pediatrics: Foundations EPA #1 — Recognizing deteriorating and/or critically ill patients and initiating stabilization and management
- Pediatrics: Core EPA #2 — Resuscitating and stabilizing critically ill patients
Overview & Definition
A febrile child who has stopped interacting, a toddler with cold mottled limbs and a racing heart, and a neonate who will not feed are the clinical faces of paediatric sepsis. The diagnosis does not wait for microbiological proof. Sepsis is a syndrome: the child's own dysregulated response to infection has begun to injure their organs, and the team's job is to recognise that injury, reverse it, and treat the cause before it becomes irreversible. [1] [2] [12]
The 2024 Phoenix criteria redefined paediatric sepsis as suspected infection together with life-threatening organ dysfunction measured by a validated score. A child meets sepsis when the Phoenix score is two or more points, and meets septic shock when at least one of those points comes from cardiovascular dysfunction. These definitions replaced the old systemic inflammatory response syndrome (SIRS) framework because SIRS criteria had poor predictive properties and discriminated mortality badly compared with organ-dysfunction-based criteria. [1] [2] [5]
Four ideas run through this whole topic and bind it together. Recognise the syndrome early and escalate. Resuscitate the failing circulation and breathing. Treat the organism with timely, appropriate antimicrobials. Control the source by draining, debriding, or removing the infected focus. The four pillars must run in parallel, not sequence, and each is reassessed against the child's response rather than against a fixed target. [3] [10] [11]
From suspicion to source control in the first hour
- 1
0–15 min: recognise
Suspect sepsis from infection plus illness severity. Assign a leader, attach monitoring, weigh or estimate weight, and alert senior and PICU or retrieval teams.
- 2
15–30 min: sample and drug
Draw blood cultures and a lactate before antibiotics only if it does not delay them. Give the first broad-spectrum, weight-based antimicrobial within one hour of recognition.
- 3
30–60 min: resuscitate
Give judicious fluid aliquots for shock, reassessing after each and stopping at the ceiling. Start vasoactives early for cold or warm shock rather than waiting for refractory shock.
- 4
60 min and beyond: source and reassess
Identify and control the source by imaging, drainage, debridement or device removal. De-escalate antimicrobials to the organism and sensitivities, and reassess after every intervention.
References16ShowHide
- [1]Sanchez-Pinto LN, Bennett TD, DeWitt PE, et al. Development and Validation of the Phoenix Criteria for Pediatric Sepsis and Septic Shock. JAMA, 2024.PMID 38245897
- [2]Schlapbach LJ, Watson RS, Sorce LR, et al. International Consensus Criteria for Pediatric Sepsis and Septic Shock. JAMA, 2024.PMID 38245889
- [3]Weiss SL, Peters MJ, Oczkowski SJW, et al. Surviving Sepsis Campaign International Guidelines for the Management of Sepsis and Septic Shock in Children 2026. Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies, 2026.PMID 41869844
- [4]Weiss SL, Peters MJ, Alhazzani W, et al. Surviving Sepsis Campaign International Guidelines for the Management of Septic Shock and Sepsis-Associated Organ Dysfunction in Children. Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies, 2020.PMID 32032273
- [5]Goldstein B, Giroir B, Randolph A International pediatric sepsis consensus conference: definitions for sepsis and organ dysfunction in pediatrics. Pediatric critical care medicine : a journal of the Society of Critical Care Medicine, the World Federation of Pediatric Intensive and Critical Care Societies, and the Latin American Society of Intensive Care, 2005.PMID 15636651
- [6]Singer M, Deutschman CS, Seymour CW, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA, 2016.PMID 26903338
- [7]Weiss SL, Fitzgerald JC, Pappachan J, et al. Global epidemiology of pediatric severe sepsis: the sepsis prevalence, outcomes, and therapies study. American journal of respiratory and critical care medicine, 2015.PMID 25734408
- [8]Maitland K, Kiguli S, Opoka RO, et al. Mortality after fluid bolus in African children with severe infection. The New England journal of medicine, 2011.PMID 21615299
- [9]Inwald DP, Canter R, Woolfall K, et al. Restricted fluid bolus volume in early septic shock: results of the Fluids in Shock pilot trial. Archives of disease in childhood, 2019.PMID 30087153
- [10]Evans IVR, Phillips GS, Alpern ER, et al. Association Between the New York Sepsis Care Mandate and In-Hospital Mortality for Pediatric Sepsis. JAMA, 2018.PMID 30043064
- [11]Paul R, Niedner M, Riggs R, et al. Bundled Care to Reduce Sepsis Mortality: The Improving Pediatric Sepsis Outcomes (IPSO) Collaborative. Pediatrics, 2023.PMID 37435672
- [12]Bjorklund A, Resch J, Slusher T Pediatric Shock Review. Pediatrics in review, 2023.PMID 37777656
- [13]Rutman L, Richardson T, Auletta J, et al. Association between Child Opportunity Index and paediatric sepsis recognition and treatment in a large quality improvement collaborative: a retrospective cohort study. BMJ quality & safety, 2026.PMID 40345682
- [14]Alpern ER, Scott HF, Balamuth F, et al. Derivation and Validation of Predictive Models for Early Pediatric Sepsis. JAMA pediatrics, 2025.PMID 41082207
- [15]Scott HF, Sevick CJ, Colborn KL, et al. Clinical Decision Support for Septic Shock in the Emergency Department: A Cluster Randomized Trial. Pediatrics, 2025.PMID 40490252
- [16]Balamuth F, Weiss SL, Long E, et al. Balanced Fluid or 0.9% Saline in Children Treated for Septic Shock. The New England journal of medicine, 2026.PMID 42028918