Pediatric Guidelines: Severe Sepsis - Children with Healthcare Exposure or Comorbidities

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These guidelines are intended for patients who meet criteria for severe sepsis i.e. probable or documented infection with systemic inflammatory response criteria and specific evidence of hypo-perfusion or organ dysfunction not explained by an alternative process; these guidelines are not intended for "rule out" scenarios in clinically stable patients.
Condition Major Pathogens First Choice Therapy Alternative Therapy Comments

Severe sepsis, > 28 days old, preexisting medical comorbidities or healthcare exposure:

  • Central line
  • Solid organ transplant
  • Immunodeficiency
  • Immunosuppressive medications

Refer to guidelines below for severe sepsis in Oncology/BMT patients and click here for severe sepsis guidelines for ICN patients

Staphylococcus aureus

Gram negatives including Pseudomonas, Enterobacter, other MDR organisms

Enterococcus spp

Candida spp in certain risk groups

May also have community-acquired pathogens

Cefepime 50mg/kg/dose IV q8h (max 2g/dose) 

AND 

Vancomycin 15mg/kg/dose IV q6-8h (initial max 1g/dose)

ADD
Metronidazole 10mg/kg/dose IV q8h (max 500mg/dose) for suspected intra-abdominal infection

Consider: 

Caspofungin* 70mg/m2 first dose (max 70mg/dose) then 50mg/m2/dose IV q24h (max 50mg/dose) if patient on TPN, high dose steroids, or already on broad spectrum antibiotics

(Caspofungin dosing differs in children 1-3 months old - refer to Pediatric Antimicrobial Dosing Guideline)

If patient develops sepsis while on broad spectrum antibiotics:

Replace Cefepime with Meropenem 20mg/kg/dose IV q8h (max 1g/dose)

ID consult recommended

*ID/ASP approval required for Caspofungin

Severe beta lactam allergy:

Use Aztreonam 30mg/kg/dose IV q8h (max 2g/dose) 

AND 

Ciprofloxacin 15mg/kg/dose IV q12h (max 400mg/dose IV q8h)

in place of Cefepime

Severe sepsis, Oncology or BMT patient

Click here for full Oncology/BMT Inpatient Fever Guidelines

Click here for guidance on Fever and Neutropenia without severe sepsis

 

Staphylococcus aureus

Viridans group streptococci

Enterococcus spp

Gram negatives including Pseudomonas, Enterobacter, other MDR organisms

Candida spp

May also have community-acquired pathogens

Meropenem 20mg/kg/dose IV q8h (max 1g/dose)

AND

Vancomycin 15mg/kg/dose IV q6-8h (initial max 1g/dose)

AND

Ciprofloxacin 15mg/kg/dose IV q12h (max 400mg/dose IV q8h)

Consider:

Caspofungin* 70mg/m2 first dose (max 70mg/dose) then 50mg/m2/dose IV q24h (max 50mg/dose) if patient on TPN, high dose steroids, or already on broad spectrum antibiotics

(Caspofungin dosing differs in children 1-3 months old - refer to Pediatric Antimicrobial Dosing Guideline)

Severe beta lactam allergy:

Use Aztreonam 30mg/kg/dose IV q8h (max 2g/dose) in place of Meropenem

ID consult recommended

*ID/ASP approval required for Caspofungin

ED: Give Cefepime 50mg/kg IV x 1 dose (max 2g/dose) in place of Meropenem (per ED Oncology/BMT Fever Pathway)

These are guidelines only and not intended to replace clinical judgment. Modification of therapy may be indicated based on patient comorbidities, previous antibiotic therapy or infection history. Doses provided are usual doses but may require modification based on patient age or comorbid conditions. Refer to Pediatric Antimicrobial Dosing Guideline for further guidance on dosing in children, and Neonatal Dosing Guideline for infants < 1 month of age. Consult a pediatric pharmacist for individualized renal or hepatic dose adjustment. For additional guidance, please contact Pediatric Infectious Diseases (ID) or the Pediatric Antimicrobial Stewardship Program (ASP).