Despite progress thanks to vaccinations, sepsis remains a major contributor to neonatal and paediatric mortality worldwide, frequently resulting in long-term sequelae for survivors and their families. A recent meta-analysis estimated that each year, approximatively 3 Million neonates and over 1 Million children suffer from sepsis (1). Over the past decade, several large epidemiological studies, mostly focussed on high-income countries (2-4), have described epidemiology and burden of sepsis around the world, and in Australia and New Zealand (5). These studies have observed that while epidemiology of sepsis has changed – in recent years staphylococcal and streptococcal infections have taken over from meningococcal infections as leading pathogen (6); and a high proportion of children have major comorbidities (7) –, the survival for children with sepsis has not substantially improved in comparison to other diseases requiring PICU admission. In Australia, particularly high rates for sepsis and invasive infections persist in children of Aboriginal and Torres Strait Islander background, contributing to the excessive childhood mortality seen in this population (8,9).

In view of the burden of sepsis on child health, it is imperative to have robust guidelines in place that provide evidence-based recommendations on best sepsis care in children, reduce variability of care, and lead to better patient-centred outcomes. Previously, paediatric sepsis treatment recommendations have been published as part of the overall Surviving Sepsis Campaign (SSC) guidelines (10,11), and through the American College of Critical Care Medicine guidelines (12). More recently, the Society of Critical Care Medicine and the European Society of Intensive and Critical Care Medicine, with sponsorship from a number of societies internationally, decided to form a dedicated task force to develop, publish and disseminate a new evidence-based guideline for the management of sepsis and septic shock in neonates and children. While this work has been led by SCCM and ESICM, with Co-Chairs representing each of the two lead societies (Dr. Kissoon and Dr. Tissieres, with Vice Co-Chairs Dr. Weiss and Dr. Peters), the Australian and New Zealand Intensive Care Society (ANZICS) has supported the work and I had the pleasure to contribute to the work as group head on Recognition and Management of Sepsis. 

In late 2017, a multidisciplinary international team of >40 experts in the field of paediatric critical care, severe infections, and sepsis from Europe, the United States, Asia, Africa, South America, and Australia was selected to work on the first paediatric-specific SSC guidelines. PICO (Population-intervention-control-outcome) questions were selected on key topics pertinent to the management of sepsis in children, ranging from recognition and initial resuscitation interventions to adjunctive therapies. The working groups reviewed a large body of abstracts and full texts for the evidence extraction process, supported by librarians and methodologists from McMaster University in Hamilton, Canada. 

A face-to-face meeting at SCCM in San Antonio in February 2018 helped to clarify methodological questions. Using the GRADE process, published studies were reviewed in relation to the methodological quality and the strength of findings was assessed. A second panel meeting held in Hamilton in November 2018 was conducted to finalize recommendations and to guide the final manuscript preparation, which is now in the process of being completed.

In recent years, several studies have demonstrated the importance of bundled care to improve outcomes for sepsis (13-20), the largest demonstrating substantial mortality reduction associated with the N.Y. State mandate on sepsis care in children (21). Several studies have highlighted approaches to rapid identification and the feasibility of rapid risk stratification in children presenting with severe infections (22-25). Observational studies support the key importance of timely delivery of treatment, in particular intravenous antibiotics (26). Yet, in contrast to critically ill adult patients with sepsis (27,28), lack of high quality evidence persists for many areas of paediatric sepsis. Indeed, since the FEAST trial on fluid boluses in an African population (29), and the RESOLVE trial on activated protein C30 published over a decade ago, no large multicenter RCT in paediatric septic shock has been published. While a number of smaller RCTs have been published (31-33) or are underway, there is an urgent need for large international trials on children with sepsis and septic shock to improve accurate recognition, and timely and more effective treatment. The literature review by the panel on paediatric sepsis faced some additional challenges due to the discrepancy between the 2005 International Pediatric Sepsis Consensus Definition based on systemic inflammatory response syndrome (34), and the recent Sepsis-3 definitions which were designed for adult patients (35), emphasizing the importance of organ dysfunction as a feature of sepsis (36). The development of the paediatric SSC guidelines has been taking all these aspects into account.

In conclusion, I would like to thank ANZICS for the support received over the past 12 months and the honor to represent ANZICS on the paediatric SSC panel. In order to meet the goals stated by the WHO resolution on sepsis (37), there remains ongoing urgency on health care systems to implement, improve, and sustain processes for sepsis recognition and treatment in children. We hope that the paediatric Surviving Sepsis Campaign guidelines can help to inform such strategies and improve best practice targeted to children with sepsis. In Australia, the recent National Action Plan on sepsis led by The George Institute has highlighted the urgent need for improved coordination at the national level to achieve these aims.

Associate Professor
Luregn Schlapbach