SSC Children 2026 — Part 1: Recognition, Screening & Antimicrobial Therapy

This section covers the initial recognition, screening, and antimicrobial management of sepsis in children, including institutional performance improvement programs, blood lactate measurement, blood cultures, molecular diagnostics, antimicrobial timing for septic shock and sepsis without shock, empiric broad-spectrum therapy, beta-lactam infusion strategies, antimicrobial de-escalation, procalcitonin-guided therapy, and infectious diseases consultation. These recommendations apply to pediatric patients from 37 weeks gestational age at birth through 18 years of age with possible, probable, or confirmed sepsis or septic shock.

1. Sepsis Screening

Recommendation 1 — Systematic Screening Programs

There is insufficient evidence to recommend for or against the use of systematic sepsis screening in addition to clinical identification protocols.

No recommendation (insufficient evidence)

Change from 2020: Updated.

Rationale: While systematic screening tools have been developed for pediatric populations, the evidence remains insufficient to determine whether formalized screening programs in addition to existing clinical identification protocols improve patient outcomes. Clinical vigilance and institutional protocols remain the foundation for early sepsis recognition in children.

2. Performance Improvement

Recommendation 2 — Performance Improvement Programs

For hospitals treating children with sepsis, we recommend implementing a performance improvement program including standard operating procedures for the management of sepsis.

Strong recommendation, low certainty evidence

Change from 2020: Updated.

Rationale: Performance improvement programs that include standard operating procedures for sepsis recognition and treatment have been associated with improvements in process-of-care metrics and clinical outcomes. Standardized institutional approaches ensure consistent early identification and timely initiation of evidence-based therapies. Programs should be adapted to local resources and patient populations, and should include regular auditing and feedback mechanisms.

3. Blood Lactate

Recommendation 3 — Blood Lactate Measurement

For children with sepsis or septic shock, we recommend measuring blood lactate as part of the initial evaluation.

Strong recommendation, very low certainty evidence

Change from 2020: Updated.

Rationale: Blood lactate is an indirect marker of tissue hypoperfusion and global oxygen delivery-demand mismatch. Elevated lactate levels (greater than or equal to 2 mmol/L) are independently associated with increased mortality in pediatric sepsis. Lactate concentrations greater than 5 mmol/L meet the Phoenix Sepsis Criteria threshold for cardiovascular dysfunction.¹

Lactate should be interpreted in clinical context, recognizing that elevated levels may reflect hypoperfusion, impaired clearance, or increased aerobic glycolysis. Serial measurements may assist in assessing response to resuscitation, though no pediatric RCT has evaluated lactate-guided resuscitation strategies specifically.

4. Blood Cultures

Recommendation 4 — Blood Culture Collection

Clinicians should obtain blood cultures before initiating antimicrobial therapy where this does not substantially delay antimicrobial administration.

Good practice statement

Change from 2020: No change (carried over).

Rationale: Identification of the causative organism enables targeted antimicrobial therapy, supports antimicrobial stewardship, and improves outcomes. Blood cultures should be obtained before antimicrobial administration whenever possible, but collection must not meaningfully delay the initiation of antimicrobials, particularly in patients with hemodynamic instability or suspected septic shock.

5. Molecular Testing

Recommendation 5 — Molecular Pathogen Detection

There is insufficient evidence to recommend for or against the routine use of molecular testing for pathogen detection and identification in children with sepsis or septic shock.

No recommendation (insufficient evidence)

Change from 2020: New recommendation.

Rationale: Recent advances in molecular testing technologies — including multiplex PCR panels, metagenomic next-generation sequencing, and targeted nucleic acid amplification tests — offer the potential for more rapid pathogen identification than conventional culture-based methods. However, the diagnostic scope of these technologies varies considerably across platforms, and their impact on clinical outcomes in pediatric sepsis has not been established. Molecular testing may complement but does not replace standard microbiological cultures, which remain essential for antimicrobial susceptibility testing.

6. Antimicrobial Timing

Recommendation 6 — Antimicrobial Timing in Septic Shock

For children with suspected septic shock, we recommend starting antimicrobial therapy as soon as possible, ideally within 1 hour of recognition.

Strong recommendation, very low certainty evidence

Change from 2020: Updated.

Rationale: A large retrospective study of 19,515 children across 51 US emergency departments demonstrated that both early antimicrobial administration (less than 30 minutes from recognition) and late administration (greater than 330 minutes) were associated with increased mortality, suggesting a time-dependent relationship. In the setting of septic shock, where hemodynamic compromise is present, delays in antimicrobial administration carry unacceptable risk. The 1-hour target reflects the urgency of treating suspected septic shock while allowing adequate time for culture collection and appropriate antimicrobial selection.

Recommendation 7 — Antimicrobial Timing in Sepsis Without Shock

For children with probable sepsis without shock, we suggest a time-limited rapid investigation with initiation of antimicrobial therapy within 3 hours if the concern for sepsis is substantiated.

Conditional recommendation, very low certainty evidence

Change from 2020: Updated.

Rationale: In children with probable sepsis who are hemodynamically stable, a brief period of focused evaluation allows clinicians to refine the diagnosis, obtain cultures, and select appropriate antimicrobials. The 3-hour window balances the need for diagnostic accuracy against the risk of delayed treatment. If clinical concern for sepsis is substantiated during this evaluation period, antimicrobials should be initiated promptly. If an alternative diagnosis becomes more likely, antimicrobials may be deferred while continuing close monitoring.

Recommendation 8 — Antimicrobial Timing When Evaluation Is Difficult

For children with probable bacterial sepsis in whom timely evaluation is difficult to achieve, clinicians should consider administering antimicrobials as soon as possible.

Good practice statement

Change from 2020: New recommendation.

Rationale: In settings where rapid clinical evaluation, laboratory testing, or specialist consultation is not readily available — such as resource-limited environments, remote locations, or overwhelmed emergency departments — the risk of delayed treatment may outweigh the risk of potentially unnecessary antimicrobial exposure. This GPS acknowledges that the 3-hour evaluation window described in Recommendation 7 may not be achievable in all clinical contexts.

7. Empiric Therapy

Recommendation 9 — Broad-Spectrum Empiric Coverage

Clinicians should administer empiric broad-spectrum therapy with one or more antimicrobials to cover all likely pathogens.

Good practice statement

Change from 2020: No change (carried over).

Rationale: Empiric antimicrobial selection should account for the most likely pathogens based on patient age, immune status, suspected source of infection, local epidemiology, and recent antimicrobial exposures. Broad-spectrum coverage ensures activity against the causative organism while susceptibility data are pending. The choice of agent(s) should follow institutional antibiograms and local resistance patterns.

Recommendation 10 — Multidrug Therapy for Immunocompromised or MDR-Risk Patients

For children with immune compromise and/or those at high risk for multidrug-resistant pathogens, we suggest empiric multidrug antimicrobial therapy.

Conditional recommendation, very low certainty evidence

Change from 2020: No change (carried over).

Rationale: Immunocompromised children — including those with malignancy, transplantation, congenital or acquired immunodeficiency, or immunosuppressive therapy — are at increased risk for atypical and resistant organisms. Similarly, children with recent healthcare exposure, prior antimicrobial therapy, or known colonization with resistant organisms may require broader empiric coverage. Multidrug regimens should be tailored to cover the spectrum of likely pathogens, including consideration of antifungal and antiviral agents where appropriate.

8. Beta-Lactam Infusion Strategies

Recommendation 11 — Continuous or Extended Beta-Lactam Infusion

For children with confirmed bacterial sepsis being treated with beta-lactam antibiotics, there is insufficient evidence to recommend continuous or extended infusion over intermittent dosing.

No recommendation (insufficient evidence)

Change from 2020: New recommendation.

Rationale: Continuous or extended beta-lactam infusion strategies aim to optimize the pharmacokinetic-pharmacodynamic parameter of time above the minimum inhibitory concentration (fT>MIC). In pediatric data, the relative risk for mortality with continuous/extended infusion was 0.58 (95% CI 0.17-2.01), which did not reach statistical significance. A large adult meta-analysis demonstrated a mortality benefit with continuous/extended infusion (RR 0.91), and the adult SSC 2026 guidelines now strongly recommend prolonged beta-lactam infusion based on the BLING III trial.² However, direct pediatric evidence remains insufficient to issue a formal recommendation. Pharmacokinetic differences in children — including higher volumes of distribution and faster renal clearance — may affect the applicability of adult data.

9. Antimicrobial De-Escalation

Recommendation 12 — Narrowing to Pathogen-Directed Therapy

Once the pathogen and antimicrobial susceptibilities are known, clinicians should narrow empiric antimicrobial coverage to pathogen-directed therapy.

Good practice statement

Change from 2020: No change (carried over).

Rationale: Targeted antimicrobial therapy reduces unnecessary antimicrobial exposure, limits selection pressure for resistance, decreases the risk of adverse drug effects, and supports antimicrobial stewardship. De-escalation should occur as soon as susceptibility data are available, provided the patient is demonstrating clinical improvement.

Recommendation 13 — Narrowing or Stopping Without Identified Pathogen

If no pathogen is identified, clinicians should narrow or stop antimicrobial therapy according to the clinical presentation, suspected site of infection, risk factors, adequacy of clinical improvement, and in consultation with infectious disease or microbiological expertise.

Good practice statement

Change from 2020: No change (carried over).

Rationale: Many children with suspected sepsis will have negative cultures. In these cases, clinicians should reassess the initial clinical suspicion, consider alternative diagnoses, and use clinical trajectory to guide antimicrobial duration. Ongoing antimicrobial therapy in the absence of an identified pathogen should be justified by a clear clinical rationale and reviewed regularly.

10. Procalcitonin-Guided De-Escalation

Recommendation 14 — Procalcitonin for Antimicrobial De-Escalation

For children with sepsis or septic shock, we suggest not using procalcitonin routinely to guide antimicrobial de-escalation when effective antimicrobial stewardship programs are in place.

Conditional recommendation, moderate certainty evidence

Change from 2020: New recommendation.

Rationale: The evidence for procalcitonin-guided de-escalation in pediatric sepsis is based on one neonatal RCT and one large multisite pediatric RCT. These trials demonstrated no differences in mortality (RR 0.52; 95% CI 0.20-1.33) or total antibiotic duration between procalcitonin-guided and standard de-escalation approaches. Given the availability of antimicrobial stewardship programs, which use multidisciplinary review, clinical assessment, and microbiological data to guide de-escalation decisions, the incremental benefit of routine procalcitonin measurement for this purpose appears limited.

Remarks: This recommendation does not preclude the use of procalcitonin as one element in clinical decision-making. In settings without robust antimicrobial stewardship infrastructure, procalcitonin may provide additional support for clinicians considering de-escalation.

11. Infectious Diseases Consultation

Recommendation 15 — ID Consultation for Documented Bloodstream Infection

For children with sepsis or septic shock who have a documented bloodstream infection, we suggest that hospitals implement routine infectious diseases or medical microbiology consultation.

Conditional recommendation, very low certainty evidence

Change from 2020: New recommendation.

Rationale: A meta-analysis of studies evaluating routine infectious diseases consultation for confirmed bloodstream infections demonstrated an association with improved mortality (RR 0.51; 95% CI 0.28-0.92). ID consultation provides expertise in antimicrobial selection, optimization of dosing, identification of metastatic complications, guidance on duration of therapy, and recommendations for source control. Institutional implementation of routine ID consultation pathways for documented bloodstream infections may improve consistency of care and outcomes.

Recommendation 16 — ID Consultation Without Documented Bloodstream Infection

For children with sepsis or septic shock without a documented bloodstream infection, there is insufficient evidence to recommend routine infectious diseases consultation.

No recommendation (insufficient evidence)

Change from 2020: New recommendation.

Rationale: While ID consultation may be beneficial in complex cases — such as those involving immunocompromised hosts, unusual pathogens, or failure to improve on empiric therapy — the evidence is insufficient to recommend routine ID consultation for all children with sepsis in the absence of a documented bloodstream infection. Clinical judgment should guide consultation decisions in these cases.

Quick Reference: Recognition, Screening & Antimicrobial Therapy

RECOGNITION, SCREENING & ANTIMICROBIALS — AT A GLANCE (Recs 1-16)

1. SCREENING & RECOGNITION
   —  Systematic sepsis screening (beyond clinical protocols)        [Insufficient evidence]
   ✓✓ Performance improvement program with SOPs                      [Strong, low CoE]
   ✓✓ Measure blood lactate in initial evaluation                    [Strong, very low CoE]
      • Lactate ≥2 mmol/L → increased mortality risk
      • Lactate >5 mmol/L → meets Phoenix cardiovascular criterion

2. DIAGNOSTICS
   GPS Obtain blood cultures before antimicrobials (if no delay)     [GPS]
   —  Routine molecular pathogen testing                             [Insufficient evidence]

3. ANTIMICROBIAL TIMING
   ✓✓ Septic shock → antimicrobials ASAP, ideally within 1 hour     [Strong, very low CoE]
   ✓  Sepsis without shock → investigate, start within 3 hours       [Conditional, very low CoE]
   GPS Probable sepsis + difficult evaluation → give ASAP            [GPS]

4. EMPIRIC THERAPY
   GPS Broad-spectrum coverage for all likely pathogens              [GPS]
   ✓  Immunocompromised/MDR risk → empiric multidrug therapy         [Conditional, very low CoE]
   —  Continuous/extended beta-lactam infusion in children            [Insufficient evidence]

5. DE-ESCALATION
   GPS Narrow to pathogen-directed therapy when susceptibilities known [GPS]
   GPS No pathogen → narrow/stop based on clinical course + ID advice [GPS]
   ✓  Do not routinely use PCT for de-escalation (if ASP in place)   [Conditional, moderate CoE]

6. INFECTIOUS DISEASES CONSULTATION
   ✓  Documented BSI → routine ID/microbiology consultation          [Conditional, very low CoE]
   —  No documented BSI → routine ID consultation                    [Insufficient evidence]

KEY: ✓✓ = Strong recommendation ("we recommend")
     ✓  = Conditional recommendation ("we suggest")
     GPS = Good practice statement
     —  = No recommendation / insufficient evidence
     CoE = Certainty of evidence

References