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Children presenting with pathogenic bacteria in a blood culture (bacteremia) manifest a wide spectrum of clinical signs and symptoms. The continuum from bacteremia to sepsis, severe sepsis, and septic shock depends on a complex series of interrelated factors that include the specific etiology, the inoculum of organisms, strain variations or virulence factors, extracellular components or toxin production, the site of infection, the immunologic competence of the host, and the host response to the infection. Bacteremia may be occult, a transient phenomenon not associated with a specific focus of infection, or it may result from the extension of an invasive bacterial infection originating in the genitourinary, gastrointestinal, upper or lower respiratory tracts, or skin and soft tissues. Specific secondary infection (meningitis, osteomyelitis, pyelonephritis, peritonitis, intra-abdominal abscess, or facial cellulitis) may also occur and affect management. Recurrent or persistent bacteremia may result from established infectious foci (endocarditis, abscess, foreign-body infection).

Systemic inflammatory response syndrome (SIRS) was defined by a consensus statement supported by the American College of Chest Physicians and Society of Critical Care Medicine in 1992.1 Following that, definitions of sepsis, severe sepsis, and septic shock were developed for adult patients. In 2005, the International Consensus Conference on Pediatric Sepsis defined SIRS, sepsis, severe sepsis, and septic shock in pediatric patients.

The diagnosis of SIRS in a pediatric patient requires either abnormal temperature and abnormal leukocyte count, or one of the former and one of the following: tachypnea or tachycardia (or bradycardia if younger than 1 year) (Table 223-1). Sepsis is defined as SIRS plus proven or probable infection. The infectious etiology may be bacterial, viral, fungal, or rickettsial. Severe sepsis requires sepsis criteria plus acute respiratory distress syndrome, cardiovascular dysfunction, or multiorgan dysfunction. Septic shock is sepsis and cardiovascular dysfunction.2

Table 223-1. Criteria for Pediatric Systemic Inflammatory Response Syndrome*

Epidemiologic factors that influence the incidence, etiology, morbidity, and mortality of bacteremia and sepsis in children include the site of acquisition, immunocompetence of the host, and the presence or absence of foreign material (central vascular, urinary, peritoneal, or intraventricular catheters or foreign material following complex congenital heart disease repair). As of the most recent available national vital statistics report in 2004, sepsis was the eighth leading cause of death in the first year of life.3

Neonatal bacteremia typically results from colonization and subsequent invasion of the neonate by organisms acquired from the maternal genital tract. In term newborns, early onset sepsis occurs in approximately 1 to 10 neonates ...

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