Community-acquired sepsis or septic shock in children 2 months or older in tropical regions of Australia

In tropical regions of Australia1, where infection with Burkholderia pseudomallei is possible, follow local protocols for sepsis and septic shock, if available. In the absence of local protocols, the following regimens may be appropriate.

For children 2 months or older with sepsis or septic shock who either present during the wet season or are at high risk of melioidosis2, useAbdul-Aziz, 2024Currie, 2015Dulhunty, 2024:

meropenem intravenously3 meropenem

child without suspected neurological infection or septic shock and not requiring intensive care support: 25 mg/kg up to 2 g, 8-hourly4

child with suspected neurological infection, but without septic shock and not requiring intensive care support, 40 mg/kg up to 2 g, 8-hourly; administer the dose over 3 hours5

child with septic shock or requiring intensive care support: 40 mg/kg up to 2 g, administered as a loading dose over 30 minutes. After 4 hours, administer 40 mg/kg up to 2 g, 8-hourly, as consecutive 8-hour infusions67

PLUS

vancomycin intravenously; for initial dosing, see Intermittent vancomycin dosing for young infants and children. vancomycin

For children 2 months or older in whom toxic shock syndrome is suspected8, add to the above regimen:

clindamycin 15 mg/kg up to 600 mg intravenously, 8-hourly for a minimum of 72 hours and until organ function has significantly improved9 clindamycin

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intravenous immunoglobulin (IVIg) 2 g/kg intravenously, as a single dose as soon as possible but not later than 72 hours. It is reasonable to give the dose in divided doses if it is not possible to give a single dose.

If meningitis is suspected, add to the above regimen:

dexamethasone 0.15 mg/kg up to 10 mg intravenously, preferably starting before the first dose of antibiotic, then 6-hourly10. For duration of therapy, see Overview of empirical therapy for adults and children 2 months or older with meningitis. dexamethasone

If herpes simplex encephalitis is suspected, add to the above regimens:

aciclovir intravenously, 8-hourly1112 aciclovir

child younger than 5 years: 20 mg/kg or 500 mg/m2

child 5 years to 12 years: 15 mg/kg or 500 mg/m2

child older than 12 years: 10 mg/kg.

If herpes simplex encephalitis is confirmed, seek expert advice. See also Herpes simplex encephalitis for subsequent management.

For children 2 months or older with sepsis or septic shock who are at lower risk of melioidosis (eg present during the dry season), the meropenem plus vancomycin regimen above is not usually required. In the absence of local protocols, select the appropriate regimen from those listed below (either a cefotaxime- or ceftriaxone-based regimen or, if at risk of infection with multidrug-resistant gram-negative bacteria, a meropenem-based regimen):

These empirical regimens are intended for initial therapy only (up to 48 hours). Modify therapy as soon as additional information is available (eg source of infection, results of Gram stain, culture and susceptibility testing). Evaluate the appropriateness of antimicrobial therapy daily, with consideration given to the patient’s clinical status and the principles of antimicrobial stewardship.

1 Tropical regions of Australia refer to regions north of 20°S latitude. This includes areas of Queensland north of Mackay, the Northern Territory north of Tennant Creek, and Western Australia north of Port Hedland.Return
2 Risk factors for melioidosis include diabetes, heavy alcohol consumption (including binge drinking), and chronic lung and kidney disease.Return
3 In patients with penicillin hypersensitivity, the rate of immune-mediated cross-reactivity with carbapenems is approximately 1%; therefore, meropenem can be considered in supervised settings. However, in patients with a history of a severe cutaneous adverse reaction (eg drug rash with eosinophilia and systemic symptoms [DRESS], Stevens–Johnson syndrome/toxic epidermal necrolysis [SJS/TEN]), consider meropenem only in a critical situation when there are limited treatment options.Return
4 Some centres use a meropenem dosage of 40 mg/kg up to 2 g intravenously, 8-hourly for children who are very unwell; however, no data are available to support the use of this dosage except in children with central nervous system infection or critical illness (ie those with septic shock or requiring intensive care support).Return
5 The modified dosage of meropenem for children with suspected neurological infection is recommended to ensure adequate drug exposure. Once the critical illness has resolved, consider switching to the standard dosage.Return
6 For patients with septic shock or requiring intensive care support, administering the total daily dose of meropenem over 24 hours (as 3 consecutive 8-hourly infusions) is preferred to ensure adequate drug exposure. If this is not possible (eg the patient is receiving other drugs via the same line), administer the dose (40 mg/kg up to 2 g 8-hourly) as an extended infusion over 3 hours. If a 3-hour infusion is not possible, administer over 30 minutes. For more information, see Practical information on using beta lactams: carbapenems.Return
7 The modified dosage of meropenem for patients with septic shock or those requiring intensive care support is recommended to ensure adequate drug exposure, because pharmacokinetics may be altered in patients with critical illness (eg because of enhanced kidney clearance or changes in volume of distribution). Once the critical illness has resolved, consider administering the dose over 3 hours or, if neurological infection has been excluded, switching to the standard dosage.Return
8 In children, signs of toxic shock syndrome include fever, hypotension, rash and evidence of organ dysfunction. For more information, see Streptococcal toxic shock syndrome.Return
9 There are more clinical and microbiological data to support the use of clindamycin than lincomycin. Intravenous lincomycin can be used at the same dosage if clindamycin is unavailable or if a local protocol recommends its use.Return
10 If dexamethasone is not available, hydrocortisone (4 mg/kg up to 200 mg intravenously) may be used for the initial dose.Return
11 Use the online calculator to determine body surface area.Return
12 Aciclovir dosing in obesity is poorly defined; however, limited data support dosing based on ideal body weight in children.Return