Sepsis, N/IICU — Suspect Infection but No Organ Dysfunction — Clinical Pathway: ICU and Inpatient

Suspected Sepsis Clinical Pathway — N/IICU

Suspected Infection, No Shock

Infants in this category show high concern for infection, necessitating initial workup (cultures, other labs as indicated), IV access and initiation of IV antibiotics. They require frequent re-assessment of their clinical status to identify whether they need to be reclassified as ‘severe sepsis or septic shock.’

Consider labeling the infant as 'suspect infection':

  • Signs or symptoms of infection present (but not yet meeting severe sepsis/septic shock criteria)
  • Lower threshold to consider infection in infants at high-risk (see high-risk conditions below)

Congenital heart disease can present similar to sepsis. For neonates under 2 weeks of age with perfusion abnormality and hypotension, consider evaluating for a ductal dependent lesion and initiating PGE1 infusion.

Suspect Infection but No Organ Dysfunction (Multiple Symptoms, High-risk Infant)
Temperature Abnormalities > 38°C or ≤ 36°C
Antipyretic use may mask fever
Change in incubator support from baseline
Heart Rate Abnormalities Sustained abnormal level > 30 min
Lack of variability in heart rate
More frequent bradycardia
Changes in Respiratory Status Change from baseline apnea, bradycardia, or desaturations
Increased respiratory support and/or oxygen requirements
Perfusion Abnormalities Decrease urine output
Cool extremities
Capillary refill > 3 sec
Diminished pulses
Mottling
Flushing
Warm extremities
Bounding pulses
Flash capillary refill
Hypotension See heart rate and MAP table below
Changes in Neurologic Status Lethargy
Irritability
Decreased responsiveness
Decreased tone
Seizures
Coagulation Abnormalities New bleeding/oozing, thrombocytopenia, altered coagulation profile, DIC
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