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Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.

Sepsis recognition and antimicrobial timing

Paediatrics and child health · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

RapidFull
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High-risk suspected sepsis

Suspected infection with any age-specific high-risk criterion can progress rapidly to shock and organ dysfunction. Hypothermia, altered behaviour or poor perfusion may be more important than fever, especially in babies or immunocompromised children.

Action: Call a senior paediatric decision maker, start continuous monitoring, obtain venous blood including culture, gas, glucose and lactate, and give broad-spectrum parenteral antimicrobial within 1 hour of the high-risk criterion. Support airway and breathing, give carefully reassessed isotonic fluid when indicated, find the source and involve critical care or the relevant procedural team early.

Synopsis

Recognise paediatric sepsis across age groups, translate NICE risk criteria into timed assessment and treatment, give age-appropriate antimicrobials and fluid safely, and secure early source control and escalation.

  • Sepsis is life-threatening organ dysfunction caused by a dysregulated response to infection; neither fever nor a positive culture is required at the moment treatment must begin.
  • Use exact age bands: under 5 years, 5 to 11 years and 12 to 15 years have different NICE physiological thresholds. Record observations rather than writing only 'sepsis screen'.
  • First-line assessment is temperature, heart rate, respiratory rate, mental state and oxygen saturation; add capillary refill under 12 and blood pressure at 12 to 15, and measure it earlier when circulation is abnormal.
  • Any high-risk criterion in hospital triggers urgent senior assessment, consultant discussion, the full venous test set and broad-spectrum antimicrobial without delay, within 1 hour of identification.
  • Two or more moderate-to-high-risk criteria trigger venous testing and clinician review within 1 hour. In a child under 12, lactate above 2 mmol/L promotes management to the high-risk pathway.
  • For age 12 to 15 with two or more moderate-to-high-risk criteria, either lactate above 2 mmol/L or acute kidney injury promotes management to the high-risk pathway.
  • One moderate-to-high-risk criterion requires clinician review within 1 hour and tests when indicated; unresolved illness then needs repeated structured observation and senior review of antibiotics within 3 hours.
  • Take blood and source samples before antimicrobials when this causes no harmful delay. Never postpone treatment of high-risk sepsis for lumbar puncture, urine collection or imaging.
  • For community-acquired sepsis from 28 days to under 16 years, NICE specifies ceftriaxone 80 mg/kg intravenously once daily, maximum 4 g, unless the context requires another regimen.
  • Newborns use the neonatal infection pathway. Ceftriaxone has corrected-gestation and intravenous-calcium restrictions; babies under 3 months also require listeria-active cover such as ampicillin or amoxicillin.
  • When fluid resuscitation is needed, use glucose-free isotonic crystalloid 10 mL/kg over under 10 minutes, maximum 250 mL per bolus after the neonatal period, and reassess after every bolus.
  • Antibiotics alone are incomplete treatment: seek pneumonia, urine, meningeal, skin, line, bone, joint and abdominal sources, and obtain drainage or device management as soon as appropriate.

Key red flags

Reduced consciousness, no response to social cues, weak or absent cry, new seizure, focal neurology or rapidly altered behaviour is a high-risk neurological phenotype.

Apnoea, grunting, severe recession, cyanosis, oxygen saturation below the age-specific threshold or a rapidly increasing oxygen need indicates respiratory compromise.

Mottled or ashen colour, prolonged capillary refill, cold extremities, weak pulses, oliguria, hypotension or a rising lactate suggests impaired perfusion; hypotension is late in children.

A non-blanching rash, neck stiffness or bulging fontanelle with illness requires immediate meningitis and meningococcal management while sepsis treatment proceeds.

Impaired immunity plus any moderate-to-high-risk criterion requires emergency transfer from the community under NICE NG254, not routine review.

Failure to improve within 1 hour of an intervention in a high-risk child requires an attending consultant and early paediatric critical-care involvement.

Investigation priorities

01
First-line: structured observations and PEWSFirst stepFirst line

Assign risk, detect organ dysfunction and establish a repeatable baseline.

02
First-line microbiological samplingFirst line

Identify an organism and permit antimicrobial narrowing.

Management branches

CommunityTransfer high-risk illness immediately

Suspected infection meets any high-risk criterion, or impaired immunity accompanies a moderate-to-high-risk feature.

  1. Arrange emergency transfer, usually by 999 ambulance, and pre-alert the receiving paediatric service.
  2. Support airway, breathing and circulation while awaiting transport and check glucose when possible.
  3. In remote settings with transfer and handover over 1 hour, use the commissioned pre-hospital antibiotic mechanism without delaying departure.

Key medicines

CeftriaxoneFrom 28 days to under 16 years with suspected community-acquired sepsis, give 80 mg/kg intravenously once daily, maximum 4 g daily, unless source, allergy or microbiology requires another regimen.Do not apply this regimen to a newborn, hospital-acquired infection or known ceftriaxone-resistant colonisation. Check severe beta-lactam allergy, calcium-containing intravenous solutions, hepatic and renal dysfunction and meningitis requirements.
Neonatal empirical antimicrobialsFor a baby under 28 days, use the current neonatal sepsis protocol by postnatal and corrected gestational age; cefotaxime 50 mg/kg every 6 to 12 hours is used when ceftriaxone is unsuitable.Confirm early versus late onset, maternal microbiology, renal function and exact local neonatal regimen. Ceftriaxone is restricted at 40 weeks corrected gestation or below and during intravenous calcium infusion.
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Sources and review status5 sources · checked 27 Aug 2026 · clinical review pending+
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

  • NICE NG254 face-to-face assessmentAge-specific observations, examination and limitations of temperature in suspected sepsis.
  • NICE NG254 evaluating sepsis riskHigh and moderate-to-high risk classification for under-fives, ages 5–11 and ages 12–15.
  • NICE NG254 managing suspected sepsisTransfer, one-hour assessment and antimicrobials, lactate pathways, monitoring and senior escalation.
  • NICE NG254 antibiotics fluids and oxygenCeftriaxone and neonatal distinctions, listeria cover, crystalloid boluses and oxygen.
  • NICE NG29 paediatric intravenous fluidsResuscitation-fluid composition, 10 mL/kg bolus, reassessment and volume-risk modifiers.

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom