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South Australian Paediatric Clinical Practice Guidelines 

Sepsis in Children  
  Department for Health and Wellbeing, Government of South Australia. All rights reserved.  

INFORMAL COPY WHEN PRINTED  Page 1 of 10 

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Note:
This guideline provides advice of a general nature.  This statewide guideline has been prepared to promote and 
facilitate standardisation and consistency of practice, using a multidisciplinary approach.  The guideline is based 
on a review of published evidence and expert opinion.  
Information in this statewide guideline is current at the time of publication.  
SA Health does not accept responsibility for the quality or accuracy of material on websites linked from this site 
and does not sponsor, approve or endorse materials on such links. 
Health practitioners in the South Australian public health sector are expected to review specific details of each 
patient and professionally assess the applicability of the relevant guideline to that clinical situation. 
If for good clinical reasons, a decision is made to depart from the guideline, the responsible clinician must 
document in the patient s medical record, the decision made, by whom, and detailed reasons for the departure 
from the guideline. 
This statewide guideline does not address all the elements of clinical practice and assumes that the individual 
clinicians are responsible for discussing care with consumers in an environment that is culturally appropriate and 
which enables respectful confidential discussion. This includes: 

  The use of interpreter services where necessary, 
  Advising consumers of their choice and ensuring informed consent is obtained, 
  Providing care within scope of practice, meeting all legislative requirements and maintaining 

standards of professional conduct, and  
  Documenting all care in accordance with mandatory and local requirements 

 
Explanation of the aboriginal artwork: 
The aboriginal artwork used symbolises the connection to country and the circle shape shows the strong relationships amongst families and the aboriginal culture. 
The horse shoe shape design shown in front of the generic statement symbolises a woman and those enclosing a smaller horse shoe shape depicts a pregnant 
woman. The smaller horse shoe shape in this instance represents the unborn child. The artwork shown before the specific statements within the document 
symbolises a footprint and demonstrates the need to move forward together in unison. 

     

 

 

 

 

 

 
 
 
 
 
The term  Aboriginal  is used to refer to people who identify as Aboriginal, Torres Strait Islanders, or both Aboriginal and Torres Strait 
Islander.  This is done because the people indigenous to South Australia are Aboriginal and we respect that many Aboriginal people prefer the 
term  Aboriginal .  We also acknowledge and respect that many Aboriginal South Australians prefer to be known by their specific language 
group(s). 

 Cultural safety enhances clinical safety.  

To secure the best health outcomes, clinicians must provide a culturally safe health care 
experience for Aboriginal children, young people and their families. Aboriginal children 
are born into strong kinship structures where roles and responsibilities are integral and 
woven into the social fabric of Aboriginal societies. 

Australian Aboriginal culture is the oldest living culture in the world, yet Aboriginal 
people currently experience the poorest health outcomes when compared to non-
Aboriginal Australians. 
 
It remains a national disgrace that Australia has one of the highest youth suicide rates in 
the world.  The over representation of Aboriginal children and young people in out of 
home care and juvenile detention and justice system is intolerable. 
 
The cumulative effects of forced removal of Aboriginal children, poverty, exposure to 
violence, historical and transgenerational trauma, the ongoing effects of past and present 
systemic racism, culturally unsafe and discriminatory health services are all major 
contributors to the disparities in Aboriginal health outcomes. 
 
Clinicians can secure positive long term health and wellbeing outcomes by making well 
informed clinical decisions based on cultural considerations. 

 



Sepsis in Children 
 

 

 
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Purpose and Scope of PCPG 
The Sepsis in Children Paediatric Clinical Practice Guideline (PCPG) is primarily aimed at 
medical staff working in any of the primary care, local, regional, general or tertiary hospitals. It 
may however assist the care provided by other clinicians such as nurses.  

The information is current at the time of publication and provides a minimum standard for the 
assessment (including investigations) and management sepsis; it does not replace or remove 
clinical judgement or the professional care and duty necessary for each specific case. 

Important points  
&gt; Sepsis is a syndrome of life-threatening organ dysfunction caused by a 

dysregulated host response to infection (Sepsis-3 International Consensus 
Definition). These features distinguish it from an uncomplicated infection. 

&gt; Sepsis in the paediatric population can be particularly difficult to recognise given the large 
number of mimics and the fact that children will often appear very unwell, including 
significantly abnormal physiology, when febrile. 

&gt; Sepsis is the primary cause of long-term morbidity and mortality from infection. 

&gt; Clinician judgement is currently the best tool we have for early recognition of 
sepsis. 

&gt; Recognition of sepsis therefore mandates urgent attention. 

&gt; There are presently no clinical criteria, laboratory features or diagnostic tests that uniquely 
identify a septic patient. 

&gt; Initial management includes urgent vascular access, early empiric antibiotics, careful fluid 
resuscitation with early progression to inotropic or vasopressor support where required. 

&gt; In an unwell child, procedures such as urinalysis and lumbar puncture should not delay 
resuscitation and empiric antibiotics. 

Common Pathogens 

&lt; 3 months of age: Escherichia Coli, Group B Streptococcus, Listeria 
monocytogenes 

&gt; 3 months of age: Neisseria meningitidis, Streptococcus pneumoniae, Group A 
Streptococcus, Staphylococcus aureus, Methicillin Resistant Staphylococcus aureus 

 

  



Sepsis in Children 
 

 

 
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Flowchart - Paediatric Sepsis Pathway 
 
  

NO or UNSURE 

RE
SP

ON
D 

AN
D 

ES
CA

LA
TE

 
Co

m
m

en
ce

 a
ll 

el
em

en
ts

 w
ith

in
 1

 h
ou

r 

LIKELY SEPSIS 
1. Send For Help 0 min 

 
2. Assess Airway/Breathing &lt;5 min 

 

? Apply oxygen if required to keep SaO2 ?92% 
? Attach cardiorespiratory monitoring 
? Senior operator if intubation required 

 
3. Vascular Access &lt;15 min 

 

? Perform IO after 2 failed IV attempts 
? Send bloods: blood gas (lactate, BSL), FBE, blood 

cultures, UEC/LFTs, CRP, sterile site PCR, +/- coags, +/- 
procalcitonin 
 

4. Empiric Antibiotics +/- Antivirals &lt;30 min 
 

? See Page 7 for empiric antimicrobial guidelines 
? If no IV/IO access, consider IM antibiotics 

 
5. Cautious Fluid Resuscitation 
6. Consider Early Inotropic Support 

&lt;30 min 
&lt;60 min 

 

? Careful fluid resuscitation: Senior clinician to decide on 
need for fluid bolus (10-20 ml/kg 0.9% NaCl). 

? Each time assess response 
o Aim: improved HR, mentation, perfusion 
o Overload: hepatomegaly, crepitations, 

oedema 
? Decide need for early inotropic/vasopressor support 

for persisting circulatory failure. See Page 2 for 
inotropic guidelines. 

? Treat hypoglycaemia (2 ml/kg 10% dextrose) 
 

7. Further Investigations 
 

Safely perform appropriate investigations seeking potential 
source (e.g. CXR, urine, NPA, LP, stool, wound swabs, etc.) 

1. Repeated Medical Review Every hour 
 

2. Repeat Observations Every 30 mins 
 

3. Consider Differential Diagnoses 
 

? Anaphylaxis 
? Cardiac causes 
? Toxins/Ingestion 
? Metabolic conditions (incl. DKA) 
? Trauma/NAI 
? Surgical causes (incl. intussusception) 
? Paediatric Multisystem Inflammatory Syndrome 

 

? ANY Purple Zone observation on RDR chart 
OR 

? TWO OR MORE Red Zone observations 
OR 

? Additional response criteria (on Rapid Detection and 
Response Chart) 
OR 

? SERIOUS CLINICAL CONCERN 

 Child UNWELL? Concerned with observations? 
CONSIDER SEPSIS 

Box A    Risk Factors for Sepsis 
? Age &lt;3 months 
? Indwelling medical device 
? Indigenous 
? Unimmunised 
? Immunocompromised 
? Chronic disease or congenital disorder 
? Recent trauma, surgery, invasive procedure or 

wound 
? Known malignancy 

Note that the absence of risk factors DOES NOT exclude 
sepsis 

CONSULT SENIOR DOCTOR  
COULD THIS CHILD HAVE SEPSIS? 

RE
CO

GN
IS

E 

Does your patient have ANY of the following signs or 
symptoms of infection? 
? Fever (?38 C) or hypothermia (&lt;36 C) 
? Altered conscious state  
? Marked or persistent tachycardia 
? Signs of toxicity: 

Decreased alertness, arousal or activity; pale or 
mottled; cool peripheries; weak cry; grunting; rigors; 
bounding or weak pulses; wide pulse pressure 

? Non-blanching rash 
? Hypotension 
? Lactate 2-4 mmol/L concerning, &gt;4 mmol/L high risk 
? Unexplained generalised pain 

AND 

IF SEPSIS THOUGHT LIKELY, 
COMMENCE SEPSIS MANAGEMENT 

Consider Risk Factors 
(See Box A) 



Sepsis in Children 
 

 

 
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Table of Contents 
 

Purpose and Scope of PCPG .................................................................................................... 2 

Important points ......................................................................................................................... 2 

Common Pathogens .............................................................................................................. 2 

Flowchart - Paediatric Sepsis Pathway ..................................................................................... 3 

Abbreviations ............................................................................................................................. 5 

Definitions .................................................................................................................................. 5 

Summary of Practice Recommendations .................................................................................. 6 

When to suspect Sepsis ........................................................................................................ 6 

Suspected Sepsis .................................................................................................................. 6 

Suspected Septic Shock ........................................................................................................ 6 

Management for suspected sepsis and suspected septic shock .......................................... 6 

No response to initial treatment ............................................................................................. 8 

Ongoing Monitoring................................................................................................................ 8 

Ongoing Investigations, Treatment and Management........................................................... 9 

Document Ownership &amp; History ............................................................................................... 10 

 

  



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Abbreviations   
CRP C-Reactive Protein 

CSF Cerebrospinal Fluid 

CXR Chest x-ray 

DKA Diabetes Ketoacidosis 

EUC Electrolytes, Urea, Creatinine 

FBC Full Blood Count 

HSV Herpes Simplex Virus 

IM Intramuscular 

IO Intraosseous  

IV Intravenous 

kg Kilogram 

LFT Liver Function Test 

LP lumbar puncture 

MC&amp;S Microscopy, Culture &amp; Sensitivity 

Mg Magnesium 

NAT Nucleic Acid Testing 

NPA Nasopharyngeal Airway 

PCR Polymerase Chain Reaction 

PCT Procalcitonin 

PICU Paediatric Intensive Care Unit 

WCH Women s and Children s Hospital 

Definitions 

Inotropes Medicines that change the force of your heart's contractions (such as 
adrenaline or a beta-blocker). There are 2 kinds of inotropes: 

1. Positive inotropes strengthen the force of the heartbeat.  
2. Negative inotropes weaken the force of the heartbeat 

ISBAR ISBAR (Identify, Situation, Background, Assessment and 
Recommendation) is a mnemonic created to improve safety in the transfer 
of critical information. It originates from SBAR, the most frequently used 
mnemonic in health and other high risk environments such as the military. 
The  I  in ISBAR is to ensure that accurate identification of those 
participating in handover and of the patient is established. 

Vasopressors A drug or other agent which causes the constriction of blood vessels. 



Sepsis in Children 
 

 

 
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Summary of Practice Recommendations  

When to suspect Sepsis  

Sepsis is a life-threatening condition that arises when the body s response to infection injures 
its own tissue.  

&gt; Potential sepsis should be considered in any paediatric patient who shows 
signs/symptoms of infection AND have any purple zone observation or ?2 observations 
within the red zone OR additional response criteria as per rapid detection and response 
chart OR if there is a serious clinical concern (See Paediatric Sepsis Pathway flowchart).  

&gt; Potential septic shock should be considered if the patient fulfils the above criteria and is 
haemodynamically unstable.  

Suspected Sepsis  

All potential sepsis patients should be alerted to the team leader of the area where the patient 
is being cared for. The senior doctor (eg. paediatric registrar) must be notified and the patient 
reviewed as soon as possible.  

Suspected Septic Shock  

All potential septic shock patients should be attended emergently by a response team 
according to local hospital protocols  

Management for suspected sepsis and suspected septic shock  

If sepsis is suspected: 

1. Send for Help 

2. Assess Airway/Breathing 

  Medical and nursing staff to begin a systematic assessment (See Paediatric Sepsis 
Pathway flowchart). 

  Ensure airway patency is maintained. 
  Maintain oxygen saturations ?92% and administer oxygen as required.  

3. Obtain Urgent Vascular Access 

  Ensure IV access is obtained as soon as possible. 
  If unsuccessful after 2 attempts (maximum 90 seconds for 2 attempts at paediatric 

cannulation in APLS), perform intraosseous access to ensure rapid blood sampling 
and for fluid/antibiotic administration.  

The following blood samples should be collected;  

? Blood gas (venous or arterial. If an IO sample is taken, notify lab) 

? Lactate (note that a normal lactate does not exclude sepsis) 

? Blood glucose level 
 

 



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? Blood cultures; should be collected PRIOR to antibiotic administration and sent 
to the laboratory. However if it is difficult to obtain, do not delay administration of 
IV antibiotics. 

*If the patient has a central venous access device (CVAD), obtain one set 
from the CVAD and one set peripherally.  

? FBC, EUC, CRP (or PCT if available), LFTs, sterile site NAT (if available) and 
where relevant, coagulation studies. 

*Note that a sterile site NAT must be collected and put in a separate tube. 
The sample requires 0.5mls of blood to be placed in the EDTA (purple) tube 
and sent to the laboratory.  

4. Administer Empiric Antibiotics   Antivirals 

  Antibiotics should be prescribed and initiated within 30-60 minutes of sepsis 
recognition. DO NOT wait for investigation results to be available prior to 
commencing the first dose.  

  &lt;2 months old: 

? Amoxicillin 50 mg/kg (max 2 g) IV/IO/IM PLUS  
? Cefotaxime 50 mg/kg IV/IO/IM (max 2 g). If Cefotaxime is not available and the 

patient is between ages 28 days to 2 months, Ceftriaxone 100mg/kg (max 4 g) 
IV/IO/IM can be given. 

  &gt;2 months old: 

? Cefotaxime 50 mg/kg (max 2 g) IV/IO/IM or Ceftriaxone 100 mg/kg (max 4 g) 
IV/IO/IM PLUS 

? Vancomycin 30 mg/kg (max 2 g) IV/IO (do not give IM) 
? IF critically ill, ADD Gentamicin (7.5 mg/kg ? 10 years (max 320 mg), 7 

mg/kg &gt;10 years (max 560 mg)) IV/IO/IM 
? IF bacterial meningitis is suspected clinically then add Dexamethasone 

0.15mg/kg/dose up to 10 mg IV before or with the first dose of antibiotics 
and continue steroid only if proven S.Pneumoniae or H.Influenzae. 

For patients with a documented penicillin or cephalosporin allergy, consult with 
Infectious Diseases at your closest tertiary hospital. 

  IF child has an altered consciousness state AND/OR clinically suspect HSV: 
? ADD Aciclovir IV/IO (20 mg/kg ?5 years, 15 mg/kg &gt;5 years) (do not give IM). 

5. Cautious Fluid Resuscitation 

  Senior clinician to decide on need for fluid bolus (10-20 ml/kg 0.9% sodium chloride).  

  Each time assess response 
? Aim: improved HR, mentation, perfusion 

? Overload: hepatomegaly, crepitations, oedema 
  If blood glucose level is &lt;2.5mmol/L, treat with 2ml/kg 10% glucose 

  



Sepsis in Children 
 

 

 
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6. Consider Early Inotropic Support 

  Decide the need for early inotropic/vasopressor support for persisting circulatory 
failure after 40ml/kg fluid resuscitation. Consider early commencement of inotropic 
support for children with limited response to fluid resuscitation. 
? Adrenaline for cold shock (0.05-0.2 micrograms/kg/min). 

? Noradrenaline for warm shock (0.05-0.2 micrograms/kg/min). 

? For children ?28 days old, see the SA Statewide Neonatal Medication guidelines 
for Adrenaline and Noradrenaline. 

  Inotropes and vasopressors may be safely administrated via a peripheral IV during 
initial resuscitation. 

  Cold shock is due to myocardial dysfunction due to sepsis, and is more common in 
infants and neonates. Children present with cardiovascular collapse. 

  Warm shock is due to peripheral vasodilation/vasoplegia, and is more common in 
older children. Children present with a wide pulse pressure, flushed, with a rapid 
capillary refill and bounding pulses. 

7. Further Investigations 

Decide which of the following investigations are appropriate for that patient:: 

  Urine (MC&amp;S)  
  Chest x-ray  
  Throat swab (MC&amp;S, enterovirus and respiratory virus PCR)  
  CSF (Micro, C&amp;S, sterile site multiplex PCR)  

? Consider contraindications for LP 
  Cutaneous virology (HSV I, HSV II and varicella zoster)  
  Faeces (MC&amp;S, enterovirus and viruses PCR)  
  Skin swab (MC&amp;S)  

No response to initial treatment  

a) If patient is critically unwell or does not respond to the above, make an urgent request 
for MedSTAR Kids consultation and seek immediate advice for further management.  

b) Update all team members using ISBAR (See Clinical Handover Procedure).  

Ongoing Monitoring  

Patients with presumed sepsis are at a high risk of deteriorating despite initial resuscitation 
with intravenous antibiotics and fluids. These patients require a management plan which 
needs to be discussed with the admitting consultant paediatrician . This plan needs to be 
communicated to the paediatric registrar, team leader, allocated nursing staff, patient and 
patient s family.  

Ensure vital signs are performed at a minimum every 30 mins or until instructed otherwise by 
a Medical Officer. Re-assess for response to therapy and monitor for signs of deterioration 
which may include one or more of the following;  

&gt; Tachypnoea (Red or Purple zone)  
&gt; Persistent tachycardia (Red or Purple zone), slow capillary refill (&gt;2 seconds) and 

hypotension  

&gt; Decreased or no improvement in level of consciousness 






Sepsis in Children 
 

 

 
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&gt; Urine output less than 1 ml/kg/hour 
&gt; Acidosis, increasing serum lactate or procalcitonin 
&gt; Hypoglycaemia, leucopenia or abnormal coagulation 

If patient is deteriorating, escalate as per local escalation protocols to ensure prompt review 
of the patient. 

Reassess the patient regularly. Ensure senior clinician review on regular basis during the 
admission and more frequent medical reviews if any deterioration to the patient s clinical 
condition.  

Ensure adequate handover of patient s condition and plan of care are delivered at each 
handover times (see Clinical Handover Procedure). 

Ongoing Investigations, Treatment and Management  

In regards to ongoing investigations, management and treatment of the following must be 
addressed, particularly within the first 48 hours;  

&gt; Lactate must be repeated at 4 hours and 8 hours post initial lactate, unless otherwise 
instructed by the treating medical team. 

&gt; Repeat biochemistry as required.  
&gt; Strict fluid balance must be maintained.  
*Balances must be calculated 4 hourly with hourly urine output also calculated at this time and 
reported to the medical officer until instructed otherwise by the treating medical team. 

&gt; Ongoing fluid to be given either via intravenous, nasogastric or oral route to ensure 
adequate hydration.  

*When administering IV fluids, monitor for signs of fluid overload, pulmonary oedema and/or 
inappropriate antidiuretic hormone.  

&gt; Ongoing administration of antibiotics until instructed otherwise by the treating medical 
team.  

&gt; Pain relief and anti-pyretic administered as required as per paediatric medication chart.  
&gt; If the source of sepsis is clear, change the antibiotics to target the source and seek 

infectious diseases advice as needed.  

It is important to consider the following in a patient s ongoing management;   

&gt; Confirm diagnosis and consider other causes of deterioration.  
 

  eg. Dehydration, hypovolaemia, haemorrhage or overdose/over-sedation.  

&gt; Once a diagnoses is confirmed, document source of sepsis in the health care record.  
&gt; Actively seek microbiology/investigation results and review.  
&gt; Discuss with on- call paediatric consultant if further advice required.  
&gt; Consider seeking advice from the ID physician.  
&gt; Document plan to continue, change or cease antibiotics.  
&gt; Obtain approval for restricted antibiotics.  
&gt; Continue monitoring for deterioration including urine output.  

It is absolutely imperative that parents/caregivers and the patient, if of an appropriate age, are 
updated regularly in regards to the care that is being provided to the patient and that ongoing 
support is offered to the patient and family members as required. 




Sepsis in Children 
 

 

 
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References 

1. SEPSIS   assessment and management, Royal Children s Hospital Clinical Practice 
Guidelines, 
https://www.rch.org.au/clinicalguide/guideline_index/SEPSIS_assessment_and_management
/, viewed 1 May 2020. 

2. Sepsis   Recognition and emergency management in children, Queensland Paediatric 
Guidelines, https://www.childrens.health.qld.gov.au/guideline-sepsis-recognition-and-
emergency-management-in-children/, viewed 1 May 2020. 

3. Paediatric Sepsis 6, Great Ormond Street Hospital, 
https://www.gosh.nhs.uk/file/21501/download, viewed 1 May 2020. 

4. Paediatric Sepsis Pathway, Women s and Children s Hospital, 
http://inside.wchn.sa.gov.au/webs/gov/documents/sepsis/Paediatric_SEPSIS_Pathway.pdf, 
viewed 1 May 2020. 

 

Acknowledgements 
The South Australian Child and Adolescent Health Community of Practice gratefully 
acknowledge the contribution of clinicians and other stakeholders who participated throughout 
the guideline development process particularly:  

Write Group Leads 
Dr Adrian Ting 
Dr Cindy Soon 

Major Contributors 
Dr Noha Soliman 
Dr Simon Chu 
Megan Arcadiou 
Rachel Wilson 

SA Paediatric Clinical Practice Guideline Reference Group Members 

Document Ownership &amp; History 
Developed by: SA Child &amp; Adolescent Health Community of Practice 
Contact: Health.PaediatricClinicalGuidelines@sa.gov.au 
Endorsed by:  Commissioning and Performance, SA Health 
Next review due:  21/10/2025    
ISBN number:  978-1-76083-286-5 
PDS reference:  CG336  
Policy history: Is this a new policy (V1)?  Y  
 Does this policy amend or update and existing policy?   N 
 If so, which version? 
 Does this policy replace another policy with a different title?  N 
 If so, which policy (title)? 
 

Approval 
Date Version 

Who approved  
New/Revised Version Reason for Change 

21/10/20 V1 
Deputy CE, Commissioning and 
Performance, SA Department for 
Health and Wellbeing 

Original Commissioning 
and Performance approved 
version 

 









	Purpose and Scope of PCPG
	Important points
	Common Pathogens

	Flowchart - Paediatric Sepsis Pathway
	Abbreviations
	Definitions
	Summary of Practice Recommendations
	When to suspect Sepsis
	Suspected Sepsis
	Suspected Septic Shock
	Management for suspected sepsis and suspected septic shock
	No response to initial treatment
	Ongoing Monitoring
	Ongoing Investigations, Treatment and Management

	Document Ownership &amp; History

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