This document defines terms related to septicemia in children such as bacteremia, sepsis, severe sepsis, and septic shock. It describes the risk factors, common pathogens, clinical manifestations, diagnostic workup, and management of sepsis in children. Sepsis is diagnosed clinically based on signs of infection meeting two or more SIRS criteria. The most common infections are pneumonia, bloodstream, skin, and urinary tract infections. Treatment involves ABCDE approach, managing shock, administering early antibiotics, and providing supportive care.

1. SEPTICAEMIA IN CHILDREN
Dr Joyce Mwatonoka
MD, Mmed
Pediatrician: BMH
Lecturer: Department of Pediatrics and Child Health -
UDOM

2. Definition of terms
• Bacteremia; presence of bacteria in the blood.
Not all patients with bacteremia have signs of
sepsis
• Septicaemia; blood poisoning caused by the
presence and multiplication of bacteria in the
blood
• Sepsis is a clinical syndrome that complicates
severe infection and is characterized by the
systemic inflammatory response syndrome (SIRS),
immune dysregulation, microcirculatory
derangements, and end-organ dysfunction

3. Sepsis; severity
1. Sepsis; the systemic inflammatory response
syndrome in the presence of suspected or
proven infection constitutes sepsis
2. Severe sepsis; sepsis is considered severe
when it is associated with cardiovascular
dysfunction, acute respiratory distress
syndrome (ARDS), OR dysfunction in two or
more other organ systems

4. Cont…
3. Septic shock – Septic shock refers to sepsis
with cardiovascular dysfunction (as described
in the section on multiple organ failure below)
that persists despite the administration of ≥40
mL/kg of isotonic fluid in one hour

5. Cont…
4. End organ failure
• Cardiovascular; Hypotension, or reliance on a
vasoactive drug to maintain blood pressure, or
two of the following: metabolic acidosis, elevated
arterial lactate, oliguria, or prolonged capillary
refill
• Respiratory; arterial carbon dioxide tension
(PaCO2) >65 torr or 20 mmHg over baseline
PaCO2, need for >50% FiO2 to maintain oxygen
saturation ≥92%, or need for non-elective
mechanical ventilation

6. Cont…
• Neurologic – Glasgow coma score ≤11, or acute
change in mental status
• Hematologic – Platelet count <80,000/microL or
a decline of 50% from highest value recorded
over the past three days or DIC
• Renal; Serum creatinine ≥2 times upper limit of
normal for age or twofold increase in baseline
creatinine
• Hepatic – Total bilirubin ≥4 mg/dL (not applicable
to newborn) or ALT >2 times upper limit of
normal for age

7. Systemic inflammatory response
syndrome (SIRS)
• SIRS is a widespread inflammatory response
that may or may not be associated with
infection
• The presence of two or more of the following
criteria (one of which must be abnormal
temperature or leukocyte count) defines SIRS

8. SIRS Criteria
• Core temperature (measured by rectal, bladder,
oral, or central probe) of >38.5°C or <36°C
• Tachycardia
• Tachypnea
• Leukocyte count elevated or depressed for age,
or >10 percent immature neutrophils
NB: The presence of fever and tachypnea (75%) or fever and
abnormal WBC count (50%) are most common

10. Cont…
• Although inflammation is an essential host
response, the onset and progression of sepsis
center upon a "dysregulation" of the normal
response, usually with an increase in both
proinflammatory and antiinflammatory
mediators, initiating a chain of events that
leads to widespread tissue injury

11. Epidemiology
• The incidence of sepsis varies by region
• High in developing countries, lower in
developed countries
• Vaccinations have decreased the prevalence
• Respiratory infection and bloodstream
infections are found in almost two-thirds of
cases of severe sepsis worldwide

12. Risk factors
• Age younger than one month
• Serious injury (eg, major trauma, burns, or
penetrating wounds)
• Chronic debilitating medical condition (eg, CP
with quadriplegia and frequent aspiration
pneumonia, uncorrected CHD)

13. Cont…
• Host immunosuppression (malignancy, HIV
infection, severe malnutrition, congenital
immunodeficiency, SCD and other disease
with splenic dysfunction, chemotherapy)
• In-dwelling vascular catheters or other
invasive devices (eg, endotracheal tube, Foley
catheter, chest tube)
• Urinary tract abnormalities with frequent
infection

14. Pathogens
• Bacteria
• Viruses; Viral pathogens can mimic bacterial
sepsis. HSV, enterovirus and adenovirus infection
in neonates and young infants can be
indistinguishable from bacterial sepsis
• Parasites eg malaria
• Fungi; Fungal infections, especially candida
species, have been reported in 10% of pediatric
patients with severe sepsis and septic shock

15. Risk factors for fungal sepsis
• Malignancy or other immunocompromising
medical conditions
• Indwelling vascular catheters
• Prolonged neutropenia (>4 to 7 days)
• Recent broad-spectrum antibiotic use

16. Culture-negative sepsis
• Approximately 30 – 75% of children with
sepsis have no infectious etiology identified
• This "culture-negative" sepsis may indicate
host response to bacterial components, such
as endotoxin, in the circulatory system or
result from antibiotic treatment prior to
obtaining bacterial cultures
• Also diagnostic tests may not be sufficiently
sensitive, eg PCR> culture

17. Clinical manifestations
• Signs of Infection; Infection is typically
suggested by physical findings such as fever,
cough, hypoxemia, etc
-Infections can also be proven by positive
culture, tissue stain, or polymerase chain
reaction test
• Systemic inflammatory response syndrome ;
as defined above

18. Cont…
• Shock
• Other physical findings
-Toxic or ill appearance, Signs of dehydration,
Rigors, Altered mental status, Convulsions,
Decreased tone in neonates and infants,
Respiratory depression or failure, Petechiae or
purpura (meningococcemia), Macular
erythema (toxic shock syndrome), etc

19. Laboratory studies
• RBG
• ABG; hypoxemia, acidosis
• FBP
• Blood lactate (>2.0 mmol/L
(18 mg/dL) suggests
hypoperfusion)
• Serum electrolytes; eg,
hyponatremia,
hyperkalemia, hypokalemia,
and hypophosphatemia
• BUN and serum creatinine
• Total bilirubin and ALT
• Fibrinogen and D-dimer
(DIC)
• Blood culture
• Urinalysis and urine culture
• Other cultures; CS, pus, etc
• Serologic testing (for
viruses)
• Other diagnostic testing (eg,
viral culture, PCR, rapid
immunoassay antigen test,
etc

20. Cont…
• Inflammatory biomarkers
-C-reactive protein
-Procalcitonin
-ESR
• Imaging; if indicated, eg tachypnea, rales,
wheezing, hypoxemia, or WBC count of >
20,000/mm3 warrant a CXR

21. Diagnosis
• Sepsis is primarily a clinical diagnosis
• Dx; Suspected or proven infection who meet
two or more criteria for SIRS
• Pneumonia, bloodstream, skin, or urinary
tract infections, and, less commonly,
meningitis comprise the most common
infections in children with sepsis

22. Cont…
• Clinical manifestations typically progress along
a continuum of severity from sepsis to severe
sepsis (sepsis plus cardiac, respiratory, or
dysfunction in two or more other organ
systems), septic shock (persistent
hemodynamic instability despite initial fluid
therapy), and multiple organ failure

23. Differential Diagnosis (depends on
presentation)
• Hypoglycemia
• CHD, particularly left-
sided obstructive lesions
(eg, aortic coarctation,
hypoplastic left heart
syndrome)
• Cardiac arrhythmias
(primarily SVT)
• Myocarditis or primary
cardiomyopathy
• Inborn errors of
metabolism
• Acute bilirubin
encephalopathy
• Intussusception
• Pyloric stenosis
• Posterior urethral valves
• Necrotizing enterocolitis
• Gastroenteritis with
dehydration
• Toxic exposures
• Child abuse

24. Management
• ABCDE
• Manage danger signs
• Manage shock if present
• Antibiotics ASAP, First line Tz guideline; Ampiclox
(50-100mg/kg 6hourly + Gentamycin 7.5 mg/kg
OD for 10days)
• Antifungal/antiviral if required
• Supportive treatment; IV fluids, feeding, oxygen,
antipyretics

25. QUESTIONS?