Re: Suspected sepsis: summary of NICE guidance: Risk of treatment delay in patients suspected of sepsis with moderate to high risk criteria
In the recently published NICE sepsis guidance (1) the authors outlined pathways of management stratified according to risk of severe illness and death.
Patients with one moderate to high risk criterium without a definitive condition identified have no recommendation for early antibiotic administration within an hour but a senior clinician review within 3 hours for consideration of antibiotics identified as a requirement. One such moderate to high risk criterium is that the child is behaving differently from usual. A child with fever and altered behaviour however could have encephalitis. Following the consensus guidelines of the Association of British Neurologists and the British Paediatric Allergy Immunology and Infection Group (2) “the constellation of a current or recent febrile illness with altered behaviour, personality, cognition or consciousness or new onset seizures or new focal neurological signs should raise the possibility of encephalitis (…) and should trigger appropriate investigations. The NICE sepsis guidance simply recommends blood tests in such patients within an hour. Suspected encephalitis however warrants according to the consensus guideline an urgent cerebral CT scan and if not contraindicated a lumbar puncture. Early administration of i.v. high dose aciclovir after confirmation of encephalitis or if delayed empirically may reduce morbidity and mortality if herpes encephalitis.
In patient with two or more moderate to high risk criteria these could include rigors and poor peripheral perfusion with prolonged capillary refill and cold hand and feet.
If such a patient has a lactate of less than 2 mmol/l and normal renal function and no focus of infection a review by a senior clinician is recommended within 3 hours for consideration of antibiotics. This approach however could lead to a delay of treatment of gram-negative bacteraemia: A recent study not available to the NICE guidance development group at the time of guidance design showed that in 314 female patients with acute pyelonephritis and gram-negative bacteraemia a lactate level of 1.4 mmol/l (i.e. at a level below 2 mmol/l) had a negative predictive value for bacteremia of 70.8% i.e. a false omission rate of 29.2% (3). Probably more than 30% of patients with bacteremia would have been missed if a cut-off of 2 mmol/l of lactate was applied and thus may not have received antibiotics within the “golden” first hour after contact with the emergency department. UTI may only be diagnosed after 48 hours when culture results are available as symptoms and signs may be non-specific particularly in young children and infants and pyuria may be attributed to the systemic inflammatory response itself rather than a bladder or kidney infection. UTI is the most common serious bacterial infection in children and urine dipstick may be negative. The sepsis guideline thus should advocate antibiotic administration in children with rigors and poor peripheral perfusion within an hour regardless of lactate or creatinine levels and particularly in the absence of localising symptoms or signs.
1. National Institute for Health and Care Excellence. Sepsis: recognition, diagnosis and early management (NICE guideline 51). 2016. www.nice.org.uk/guidance/ng51.
2. Kneen R, Michael BD, Menson E, Mehta B, Easton A, Hemongway C, Klapper PE, Vincent A, Lim M, Carrol E, Solomon T, on behalf of the National Encephalitis Guidelines Development and Stakeholder Groups. Management of suspected viral encephalitis in children-association of British neurologists and British Paediatric Allergy Immunology and Infection Group National Guidelines. Journal of Infection 2012; 64: 449-477.
3. Seo DY, Jo S, Lee JB, Jin YH, Jeong T, Yoon J, Park B. Diagnostic performance of initial serum lactate for predicting bacteremia in female patients with acute pyelonephritis. Am J Emerg Med 2016; 34: 1359-63.
Competing interests: No competing interests