HIV Infection In Children

Sepsis is life threatening organ dysfunction caused by a dysregulated host response to infection. In children, deterioration can be rapid, and hypotension is a late sign. Early recognition depends on identifying abnormal perfusion, altered mental state, respiratory compromise, reduced urine output and other evidence of evolving organ dysfunction.

Common sources include pneumonia, meningitis, urinary infection, intra abdominal infection, skin and soft tissue infection, osteoarticular infection and bloodstream infection. Infants may present nonspecifically with poor feeding, lethargy, temperature instability or apnoea.

Features include:

• Fever or hypothermia
• Tachycardia
• Tachypnoea
• Altered mental state
• Poor feeding
• Reduced urine output
• Delayed capillary refill
• Weak peripheral pulses
• Cool mottled extremities or, in distributive shock, warm peripheries with bounding pulses
• Respiratory distress
• Hypoxaemia
• Hypotension in advanced disease

Red flags include:

• AVPU below Alert
• Persistent capillary refill prolongation
• Oliguria
• Lactate elevation
• Progressive respiratory failure
• Purpuric rash
• Recurrent seizures
• Shock

Sepsis is primarily a clinical diagnosis. Do not delay treatment while waiting for laboratory confirmation.

Obtain where feasible:

• Blood cultures before antibiotics if this causes no meaningful delay
• FBC
• Glucose
• Electrolytes and renal function
• Blood gas
• Lactate
• Liver function
• Coagulation profile in severe disease
• Urine microscopy and culture
• CSF where meningitis is suspected and lumbar puncture is safe
• Imaging directed at the suspected source

A normal initial white cell count does not exclude sepsis.

Repeated assessment is more important than a single laboratory result.

Stabilize airway, breathing and circulation immediately.

Give oxygen where hypoxaemia or respiratory compromise is present.

Establish IV or IO access.

Correct hypoglycaemia.

Obtain cultures rapidly, then give appropriate broad spectrum IV antibiotics without delay in septic shock or strongly suspected severe bacterial infection.

Empirical choice depends on age, source, prior antimicrobial exposure and local resistance. A commonly used regimen in an older infant or child with undifferentiated severe bacterial sepsis is:

Ceftriaxone 50 mg/kg IV every 12 hours, maximum 4 g/day

Adjust immediately when the source or microbiology becomes clearer.

For suspected staphylococcal infection, add appropriate antistaphylococcal therapy such as flucloxacillin.

Give isotonic crystalloid cautiously in shock, commonly 10 to 20 mL/kg per aliquot, with reassessment after every bolus. Do not continue fluid blindly when hepatomegaly, pulmonary oedema or worsening respiratory status develops.

Start vasoactive support early if shock persists despite appropriate fluid resuscitation or further fluid is unsafe.

Source control is essential. Drain abscesses, infected pleural collections or other drainable foci promptly.