Severe Sepsis - Children with Healthcare Exposure or Comorbidities

Patient Population: Pediatric

These guidelines are intended for patients who meet criteria for severe sepsis: 

Probable or documented infection AND 

Systemic inflammatory response criteria AND 

Specific evidence of hypo-perfusion or organ dysfunction not explained by an alternative process: 

Cardiovascular dysfunction, OR 

Acute respiratory distress syndrome, OR 

Dysfunction in two or more other organ systems  

Refer to consensus definitions for additional detail   

These guidelines are not intended for "rule out" scenarios in clinically stable patients; patients presenting with signs and/or symptoms of infection but not meeting criteria for severe sepsis should either be monitored without antibiotic therapy in appropriate circumstances or receive empiric antibiotics selected based on the suspected source and risk factors.  

Condition Major Pathogens  First Choice Therapy Alternative Therapy Comments

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

Central line 

Solid organ transplant (except liver, see specific guidelines below) 


Immunosuppressive medications 

Follow separate guidelines below that have been developed for specific populations

Fever in Oncology/BMT patients (BCH SF) 

Sepsis guidelines for ICN patients (BCH SF) 

Guidelines for patients with acute liver failure, end stage liver disease, biliary atresia, or < 2 months s/p liver transplantation (BCH SF) 

Staphylococcus aureus 

Gram-negative bacteria including Pseudomonas, Enterobacter, other MDR organisms 

Enterococcus spp 

Candida spp in certain risk groups 

May also have community-acquired pathogens 


50 mg/kg/dose (max 2000 mg/dose) IV q8h  



(follow link for dosing & monitoring)   
Consult a clinical pharmacist for patient-specific Vancomycin recommendations if there is evolving kidney injury 


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

For patients on TPN, high-dose steroids, or already on broad spectrum antibiotics, consider echinocandin antifungal, specific agent per hospital formulary:  


Micafungin 3 mg/kg/dose (max 150 mg/dose) IV q24h 


70 mg/m2 first dose (max 70 mg/dose), then 50 mg/m2/dose (max 50 mg/dose) IV q24h (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
20 mg/kg/dose (max 1000 mg/dose) IV q8h  


Penicillin or cephalosporin allergy with higher risk for allergic reaction

Use Aztreonam 30 mg/kg/dose (max 2000 mg/dose) IV q8h  


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

in place of Cefepime 

(with Vancomycin) 

ID consult recommended 

Review patient’s past microbiology history and ensure coverage of any recent (within the past 3 months) multidrug resistant organisms  

*ID/ASP approval required for Micafungin or Caspofungin 

Antibiotic therapy should be re-evaluated at <= 48 hours and narrowed to target the identified source/pathogen.  If a specific source or pathogen is not identified it is still recommended to de-escalate  therapy in most circumstances.  

If Vancomycin was initiated, it should be discontinued at this time unless a resistant gram-positive pathogen is identified OR there is a clinically documented source of infection with higher likelihood of resistant gram-positive etiology.  

Expanded gram-negative therapy (e.g. second gram negative agent or carbapenem) should be narrowed in most cases if cultures do not reveal a resistant gram-negative organism 

If Micafungin or Caspofungin was initiated, it should be discontinued if yeast/Candida is not isolated from blood culture or other normally sterile site within 48-72 hours  

Pediatric Empiric Antimicrobial Therapy Guidelines

This is a subsection of the UCSF Benioff Children’s Hospitals Empiric Antimicrobial Therapy Guidelines, developed by the Pediatric Antimicrobial Stewardship Programs at each campus to inform initial selection of empiric antimicrobial therapy for children at the UCSF Benioff Children’s Hospitals and affiliated outpatient sites. 

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. Durations provided are usual recommendations for patients who are responding appropriately to therapy. For additional guidance, please contact Pediatric Infectious Diseases (ID) or the Pediatric Antimicrobial Stewardship Program (ASP) at the campus where your patient is receiving care.  

For questions or feedback about these guidelines, please email primary content owners, Rachel Wattier, Pediatric ASP Medical Director at BCH SF and Prachi Singh, Pediatric ASP Medical Director at BCH OAK. 

The content of these guidelines was updated in July 2021. See Summary and Rationale for Changes (password login to Box needed) for detailed explanations of the content changes.