Approach to managing sepsis and septic shock from a urinary tract source in children

For advice on early recognition of sepsis or septic shock in children, see Approach to assessing sepsis or septic shock in neonates and children, and for advice on early management, see Resuscitation of patients with sepsis or septic shock.

For children with sepsis or septic shock from a urinary tract source, start antibiotic therapy within 1 hour of presentation to medical care or, for ward-based patients, development of sepsis or septic shock. Antibiotics should be administered immediately after blood samples are taken for culture. Collect a urine sample as soon as possible; however, do not delay antibiotic administration to do so. Urgently perform imaging to exclude urinary obstruction or kidney stone disease for children with septic shock from a urinary tract source; consider imaging for children with sepsis.

Recognising sepsis in neonates and children younger than 3 months is challenging because signs of sepsis may be subtle and often include clinical features that are similar to other infections. Always consider meningitis in neonates and children younger than 3 months who present with fever, because classical signs observed in older children and adults are often absent.

Note: Signs of sepsis may be subtle in neonates and children younger than 3 months; meningitis must be considered because classical signs are often absent.

Treat neonates and children younger than 3 months as for sepsis or septic shock of unknown source, until differential diagnoses including meningitis are excluded. To find the appropriate empirical antibiotic regimen for:

Empirical regimens for children with sepsis or septic shock from a urinary tract source should be based on local protocols, where available, and informed by susceptibilities of expected pathogens in the local antibiogramNelson, 2024World Health Organization (WHO), 2022. Also consider the patient’s recent culture and susceptibility test results, and risk factors for infection with a multidrug-resistant gram-negative bacterium, including recent antibiotic use and maternal history of colonisation or infection with a multidrug-resistant gram-negative bacteriumDuffy, 2013Osthoff, 2015Steinke, 2001.

Aminoglycosides continue to be recommended in these guidelines for empirical therapy for sepsis or septic shock from a urinary tract source in children without risk factors for infection with multidrug-resistant gram-negative bacteria; rates of aminoglycoside resistance in community-associated gram-negative pathogens (eg Escherichia coli) are low and the balance of benefits and harms favours their use in life-threatening infectionAustralian Commission on Safety and Quality in Health Care (ACSQHC), 2023. An aminoglycoside in combination with ceftriaxone or cefotaxime is recommended to treat septic shock from a urinary tract source, to broaden the spectrum of empirical therapy while awaiting susceptibility resultsWorld Health Organization (WHO), 2022.

There is worldwide emergence of multidrug-resistant E. coli, particularly extended-spectrum beta-lactamase (ESBL)-producing strains, causing urinary tract infections (UTIs) and associated bacteraemias. Data from 2023 suggest that the rate of ESBL-producing E. coli strains among isolates from blood samples varies significantly across Australia (eg from 6% in Tasmania to 25% in the Northern Territory)Australian Group on Antimicrobial Resistance (AGAR), 2024. Infection with susceptible ESBL-producing E. coli isolates can be treated with an aminoglycoside; however, susceptibility is variable, and the choice of aminoglycoside should be informed by susceptibilities in the local antibiogram. Meropenem is recommended in these guidelines for empirical therapy for children with sepsis or septic shock from a urinary tract source who are at risk of infection with multidrug-resistant gram-negative bacteriaNelson, 2024.

Carbapenemase-producing Enterobacterales (eg E. coli) remain uncommon in Australia but are a growing concernAustralian Group on Antimicrobial Resistance (AGAR), 2024CDC, 2019. If infection with a carbapenem-resistant organism is suspected or confirmed, seek expert advice. See Antimicrobials with and without activity against carbapenemase-producing Enterobacterales for information on the effectiveness of various antimicrobials against bacteria that produce these enzymes.

Note: Empirical regimens for sepsis or septic shock are intended for initial therapy only (up to 48 hours) – modify as soon as additional information is available.

Empirical regimens for sepsis and septic shock from a urinary tract source in children 3 months or older are included in this topic; see:

The empirical regimens in this topic may not be appropriate for children with hospital-acquired infection; follow local protocols, or advice from clinical microbiologists or infectious diseases specialists.

The empirical regimens in this topic are intended for initial therapy only (up to 48 hours). Modify therapy as soon as additional information is available (eg results of Gram stain, culture and susceptibility testing of urine or blood samples). Evaluate appropriateness of antibiotic therapy daily, with consideration given to the child’s clinical status and the principles of antimicrobial stewardship.

For children with sepsis or septic shock from a urinary tract source who have an indwelling urinary catheter, remove or replace the catheter. Antibiotic therapy is often only transiently effective if the catheter is not removed or replaced, because most antibiotics penetrate poorly into catheter biofilm.