Sepsis, N/IICU — Low Suspicion for Invasive Infection — Clinical Pathway: ICU and Inpatient

Suspected Sepsis Clinical Pathway — N/IICU

Low Suspicion for Invasive Infection

Infants in this category show some concerns for evolving infection, but not enough to initiate antibiotics. They require frequent re-assessment of their clinical status to identify whether they need to be reclassified as ‘suspect infection’ or ‘severe sepsis/septic shock.’

Consider labeling the infant as ‘low suspicion’ when:

  • Not high risk (see high-risk conditions below)
  • Sign or symptom of infection but reassuring physical exam
  • Possible alternative explanation exists for sign or symptom (e.g., medications, post-op SIRS)

Congenital heart disease can present similar to sepsis. For neonates under two weeks of age with perfusion abnormality and hypotension, consider evaluating for a ductal-dependent lesion and initiating PGE1 infusion.

Low Suspicion for Invasive Infection
Some Concern for Bacterial Infection (Single Symptom, Non-high-risk Infants)
Temperature Abnormalities > 38°C or ≤ 36°C
Antipyretic use may mask fever
Change in incubator support from baseline
Heart Rate Abnormalities Lack of variability in heart rate
More frequent bradycardia
Minor Changes in Respiratory Status Cardiorespiratory events (apnea, bradycardia, desaturations)
Slight increase in respiratory support and/or oxygen requirements
Minor Changes in Perfusion with Other Possible Causes
(e.g., Medications, Post-op SIRS)		 Cool extremities
Mottling
Flushing
Decreased urine output
Mild Hypotension with Other
Possible Causes
(e.g., Medications, Post-op SIRS)		 See heart rate and MAP table below
Minor Changes in Neurologic Status Decreased activity level
Irritability
Decreased tone
Changes in Feeding Tolerance Ileus
Feeding intolerance (emesis, abdominal distension)

High-risk Conditions

  • Corrected age < term (37 weeks)
  • Central line, especially if present for more than 2-3 weeks (risk increases with increasing dwell time)
  • Presence of hardware (e.g., Foley catheter, VP shunt, EVD, neurosurgical devices, ECMO, cardiac hardware, pleural or peritoneal drains)
  • Previous bloodstream infection
  • History of MSSA or MRSA colonization
  • Surgical anomalies
  • Congenital anomaly requiring surgery
  • Concerns with skin integrity
  • Lymphatic conditions
  • Metabolic conditions
  • Malignancy
  • Immunocompromised
  • Steroid use
  • Proton pump inhibitor or H2 blocker use
  • Asplenia
  • Static encephalopathy

Heart Rate and MAP

Evaluate prior baseline heart rate, as well as trend during 24 hours before symptom manifestation.

Age Heart Rate MAP
0 to 7 days 100-180 > 35*
7-30 days 100-160 > 40
31 days to < 1 yr 100-160 > 45
1 yr to < 2 yr 90-160 > 50

*Preterm Infants (< 37 Weeks Gestational Age)

  • First 72 hrs of life: MAP should be ≥ infant’s gestational age
  • After 72 hrs: MAP should be ≥ 30