Sepsis, N/IICU — Cultures and Labs — Clinical Pathway: ICU and Inpatient

Suspected Sepsis Clinical Pathway — N/IICU

Cultures and Labs

Screening Labs

CBC, Platelet with Differential
  • Studies of diagnostic accuracy of CBC and initial CRP or procalcitonin in late-onset sepsis have shown low sensitivity and positive likelihood ratios for various cut-off levels
  • These screening labs should be obtained based on provider discretion, and discussion on a case-by-case basis
C-reactive Protein (CRP)
Procalcitonin

Considerations for Cultures

Blood
  • Obtain before initiating antibiotics
  • Attempt to obtain at least 1 mL volume for each blood culture from both central and peripheral sites (alternate considerations include adequate volume cultures from two central line lumens)
  • Follow best practices for obtaining sterile samples
  • Consider anaerobic cultures per provider discretion
  • Limit attempts per provider and escalate to more experienced provider if difficult to obtain
  • Do not delay blood cultures until scheduled phlebotomy draw
Urine
  • Catheterized specimen strongly recommended to minimize contamination
  • If difficult to obtain despite repeated catheterization attempts, discuss prioritization of timely antibiotic administration with care team
Respiratory
  • Consider respiratory culture (or tracheal aspirate in intubated infants) for bacterial studies if:
    • Respiratory symptoms present
    • Change in respiratory support
  • Antibiotic administration should not be delayed for respiratory tests
Cerebrospinal Fluid
  • Obtain LP for fever in infants < 28 days of life
  • Strongly consider if concerned for late-onset sepsis in VLBW infant and/or neurological changes
  • Attempt to obtain LP before initiating antibiotics
  • Consider HSV PCR testing (see below, in considerations for labs, for situations in which HSV testing would be recommended)

Considerations for Additional Diagnostic Tests

Urinalysis Catheterized specimen
Cerebrospinal Fluid
  • CSF Analysis:
    • Tube 1: Culture and Gram stain
    • Tube 2: Glucose, protein
    • Tube 3: Cell count and differential
    • Tube 4: Viral Studies or to be saved for further studies
RRP
  • PE evidence of URI, bronchiolitis, conjunctivitis
  • Nasopharyngeal aspirate is best source for RRP, even in intubated infants
Enterovirus
June-October		 Blood, CSF, urine for PCR
Herpes Simplex Virus
  • Consider in infants ≤ 21 days or for infants 22 to 40 days with ≥ 1 of the following:
    • Ill-appearance
    • Mom known to have primary HSV infection at delivery
    • Abnormal neurologic status, seizure
    • Vesicular rash
    • Hepatitis
  • HSV Testing
    • All Infants
      Blood, CSF PCR
    • SEM (Skin, Eye, Mouth)
      Add swabs from conjunctiva, buccal mucosa, rectum and any vesicular lesions
    • Disseminated Disease
      Add BMP, LFTs, PT/PTT, type and screen, chest X-ray
Stool Studies
  • Bacterial culture: consider if mucus or gross blood in the stool
  • Consider testing for norovirus, adenovirus, rotavirus
CXR
  • Consider if:
    • Concern for bacterial pneumonia
    • Suspected HSV infection with respiratory symptoms
    • Suspected chlamydia or pertussis
AXR
  • Consider if:
    • Feeding intolerance or other gastrointestinal symptoms
    • NEC
    • Abdominal surgical condition
    • Other intra-abdominal pathology