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

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 (except liver)
  • Immunodeficiency
  • Immunosuppressive medications

Follow separate guidelines below that have been developed for specific populations:

Click here for guidelines in Oncology/BMT patients

Click here for sepsis guidelines for ICN patients

Click here for guidelines for patients with acute liver failure, end stage liver disease, biliary atresia, or < 2 months s/p liver transplantation.

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) 



Age 3mo-<12yo:17.5mg/kg/dose IV q6h (initial max 1g/dose)

Age >=12 yo: 15mg/kg/dose IV q6h (initial max 1g/dose)  

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


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) 


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

in place of Cefepime

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).