Suspected sepsis in under 16s: recognition, diagnosis and early management

  • NICE guideline
  • NG254
  • Published: 

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Managing suspected sepsis

1.6 Outside acute hospital settings

NICE has produced a visual summary on managing risk of severe illness or death outside acute hospital settings.

When to transfer immediately to an acute hospital setting

1.6.1

Refer people under 16 with suspected sepsis for emergency medical care if:

  • they meet any high risk criteria (see tables 1 to 3 on criteria for stratification of risk from sepsis) or

  • their immunity is impaired by drugs or illness and they meet any moderate to high risk criteria.

    Use the most appropriate means of transport (usually 999 ambulance).

    Emergency care requires facilities for resuscitation to be available and, depending on local services, may be emergency department, medical admissions unit, and paediatric ambulatory unit or paediatric medical admissions unit. [2016]

1.6.2

Pre-alert secondary care (through GP or ambulance service) when any high risk criteria are met in a person under 16 with suspected sepsis outside of an acute hospital, and transfer them immediately. [2016]

Managing the condition while awaiting transfer

1.6.3

In remote and rural locations where transfer time to emergency department is routinely more than 1 hour, ensure GPs have mechanisms in place to give antibiotics to people under 16 with high risk criteria in pre-hospital settings. For high risk criteria, see tables 1 to 3 on criteria for stratification of risk from sepsis. [2016, amended 2024]

1.6.4

In remote and rural locations where combined transfer and handover times to emergency department are greater than 1 hour:

If immediate transfer is not required

1.6.5

Assess people under 16 who are outside acute hospital settings with suspected sepsis and any moderate to high risk criteria to:

  • make a definitive diagnosis of their condition

  • decide whether their condition can be treated safely outside hospital.

    If a definitive diagnosis is not reached or the person's condition cannot be treated safely outside an acute hospital setting, refer them urgently for emergency care. [2016]

1.7 In acute hospital settings

NICE has produced a visual summary on managing risk of severe illness or death in acute hospital settings.

Initial investigations to find the source of infection

1 or more high risk criteria

Assessment, blood tests and antibiotics
1.7.2

For people under 16 who have suspected sepsis and meet 1 or more high risk criteria:

  • arrange for the senior clinical decision maker to urgently assess the person's condition and think about alternative diagnoses to sepsis

  • carry out a venous blood test, including for:

    • blood gas, including glucose and lactate measurement

    • blood culture

    • full blood count

    • C-reactive protein

    • urea and electrolytes

    • creatinine

    • liver function tests

    • a clotting screen

  • give a broad-spectrum antimicrobial without delay (within 1 hour of identifying that they meet any high risk criteria), if antibiotics have not already been given for this episode of sepsis

  • discuss with a consultant.

    Also see the recommendations on finding and controlling the source of infection and choice of antibiotic therapy. [2016, amended 2024]

1.7.3

Ensure urgent assessment mechanisms are in place to deliver antibiotics when any high risk criteria are met in a person under 16 in secondary care (within 1 hour of meeting a high risk criterion in an acute hospital setting). [2016]

1.7.4

Give parenteral antibiotics to children under 3 months as follows:

  • children younger than 1 month with fever

  • all children aged 1 to 3 months with fever who appear unwell

  • children aged 1 to 3 months with white blood cell count less than 5×109/litre or greater than 15×109/litre.

    [This recommendation is from NICE's guideline on fever in under 5s.] [2007, amended 2013]

Intravenous fluids
1.7.5

For children under 12 with suspected sepsis, any high risk criteria and lactate over 4 mmol/litre:

  • give intravenous fluid bolus without delay (within 1 hour of identifying that they meet any high risk criteria), in line with recommendations on intravenous fluids for people with suspected sepsis and

  • refer to a critical care specialist or team for them to review the management of the person's condition, including their need for central venous access and initiation of inotropes or vasopressors.

    Referral may be a formal referral process or discussion with a specialist in intensive care or intensive care outreach team. [2016]

1.7.6

For young people aged 12 to 15 with suspected sepsis, any high risk criteria and either lactate over 4 mmol/litre or systolic blood pressure of 90 mmHg or less:

  • give intravenous fluid bolus without delay (within 1 hour of identifying that they meet any high risk criteria), in line with recommendations on intravenous fluids for people with suspected sepsis and

  • refer to a critical care specialist or team for them to review the management of the person's condition, including their need for central venous access and initiation of inotropes or vasopressors.

    Referral may be a formal referral process or discussion with a specialist in intensive care or intensive care outreach team. [2016]

Monitoring and escalation
1.7.9

Monitor people under 16 with suspected sepsis who meet any high risk criteria continuously, or a minimum of once every 30 minutes depending on setting. Use physiological track and trigger systems. [2016]

1.7.10

Monitor the mental state of people under 16 with suspected sepsis. Consider using the Glasgow Coma Scale (GCS) or AVPU ('alert, voice, pain, unresponsive') scale. [2016]

1.7.11

Alert a consultant to attend in person if a person under 16 with suspected sepsis and any high risk criteria does not respond within 1 hour of any intervention. [2016, amended 2024]

2 or more moderate to high risk criteria

Children under 12
1.7.12

For children under 12 with suspected sepsis and 2 or more moderate to high risk criteria:

  • carry out a venous blood test, including for:

    • blood gas, including glucose and lactate measurement

    • blood culture

    • full blood count

    • C-reactive protein

    • urea and electrolytes

    • creatinine

    • liver function tests

    • a clotting screen

  • arrange for a clinician to review the child's condition and venous lactate results within 1 hour of meeting 2 or more moderate to high risk criteria.

    A 'clinician' should be a medically qualified practitioner or equivalent who has antibiotic prescribing responsibilities. [2016, amended 2024]

1.7.13

For children under 12 with suspected sepsis who meet 2 or more moderate to high risk criteria and have lactate over 2 mmol/litre, treat their condition as if it met one or more high risk criteria. [2016]

1.7.14

For children under 12 with suspected sepsis who meet 2 or more moderate to high risk criteria, have lactate of 2 mmol/litre or lower, and in whom a definitive condition cannot be identified:

  • repeat structured assessment at least hourly

  • ensure a senior clinical decision maker reviews the child's condition and their need for antibiotics within 3 hours of meeting 2 or more moderate to high risk criteria. [2016]

Young people aged 12 to 15
1.7.15

For young people aged 12 to 15 with suspected sepsis and either 2 or more moderate to high risk criteria or systolic blood pressure 91 to 100 mmHg:

  • carry out a venous blood test, including for:

    • blood gas, including glucose and lactate measurement

    • blood culture

    • full blood count

    • C-reactive protein

    • urea and electrolytes

    • creatinine

    • liver function tests

    • a clotting screen

  • arrange for a clinician to review the person's condition and venous lactate results within 1 hour of meeting 2 or more moderate to high risk criteria.

    A 'clinician' should be a medically qualified practitioner or equivalent who has antibiotic prescribing responsibilities. [2016, amended 2024]

1.7.16

For young people aged 12 to 15 with suspected sepsis who meet 2 or more moderate to high risk criteria and have either lactate over 2 mmol/litre or evidence of acute kidney injury, treat their condition as if it met 1 or more high risk criteria. [2016]

For a definition of acute kidney injury, see NICE's guideline on acute kidney injury. [2016]

1.7.17

For young people aged 12 to 15 with suspected sepsis who meet 2 or more moderate to high risk criteria, have lactate of 2 mmol/litre or lower, have no evidence of acute kidney injury, and in whom a definitive condition cannot be identified:

  • repeat structured assessment at least hourly

  • ensure a senior clinical decision maker reviews the person's condition and need for antibiotics within 3 hours of meeting 2 or more moderate to high risk criteria. [2016]

1 moderate to high risk criterion

1.7.18

For people under 16 with suspected sepsis who meet only 1 moderate to high risk criterion:

  • arrange for clinician review within 1 hour of meeting a moderate to high risk criterion and

  • perform blood tests if indicated.

    A 'clinician' should be a medically qualified practitioner or equivalent who has antibiotic prescribing responsibilities. [2016, amended 2024]

1.7.19

For children under 12 with suspected sepsis who meet only 1 moderate to high risk criterion and in whom a definitive condition cannot be identified:

  • repeat structured assessment at least hourly

  • ensure a senior clinical decision maker reviews the child's condition and need for antibiotics within 3 hours of meeting a moderate to high risk criterion. [2016]

1.7.20

For young people aged 12 to 15 with suspected sepsis who meet only 1 moderate to high risk criterion, have lactate of less than 2 mmol/litre and no evidence of acute kidney injury, and in whom a definitive condition cannot be identified:

No high risk or moderate to high risk criteria

1.7.21

For people under 16 who have suspected sepsis and meet no high risk or moderate to high risk criteria:

  • arrange for clinician review

  • use clinical judgement to manage their condition.

    A 'clinician' should be a medically qualified practitioner or equivalent who has antibiotic prescribing responsibilities. [2016]

Discharge