#129: It’s a Bundle: Pediatric Sepsis and the New Phoenix Criteria (Part 1)

January 15, 2025 | By Sam Masur

Audio

Summary:

Don’t let sepsis leave you feeling septic! Tune in to our next PedsCrit Podcast collaboration episode with Dr. Chris Horvat (Pittsburgh) as we diagnose the mysteries of pediatric sepsis, decode the Phoenix criteria, and treat you to a bundle of insights.

Sepsis Update Pearls

1. The Phoenix sepsis criteria provide a new definition of sepsis based on a point system that evaluates respiratory, cardiovascular, coagulation, and neurologic systems. A score of two or more indicates sepsis, while a score of six or more indicates septic shock.
2. The Phoenix sepsis criteria have shown improved sensitivity and positive predictive value compared to the previous definition.
3. The criteria are applicable to all pediatric patients, but further research is needed for the neonatal population.
4. Clinicians should consider the Phoenix score as a tool to guide management decisions, but individual patient assessment and clinical judgment are still crucial. The Phoenix criteria for sepsis diagnosis haven’t changed the approach to identification and management of sepsis, which still relies on recognizing the potential or identified infection, the patient’s host response, and the systems of care surrounding the patient.
5. Obtaining cultures before starting antibiotics is important for guiding de-escalation strategies and promoting antibiotic stewardship.
6. Inflammatory markers, such as C-reactive protein and procalcitonin, can be useful for risk stratification and guiding immunomodulation therapies.
7. Broad-spectrum antibiotics, such as Cefepime and Vancomycin, are recommended for initial treatment of sepsis in pediatric patients. The Phoenix criteria can be used as a tool for identifying patients with life-threatening infections and organ dysfunction.
8. Health disparities and inequities exist in sepsis care, particularly in relation to language barriers and medical complexity.

Sepsis Update Notes

Defining Pediatric Sepsis

Old Definition

Based on the 2005 International Pediatric Sepsis Consensus Criteria (Pediatric Critical Care Medicine 2005), which relied on SIRS (Systemic Inflammatory Response Syndrome) criteria.

• SIRS Criteria: Temp: >38°C (100.4°F) or <36°C (96.8°F), Heart rate: >90 bpm, Respiratory rate: >20 bpm or PaCO2 <32 mmHg, WBC count: >12,000/mL, <4,000/mL, or >10% bands
• Sepsis defined as 2 or more SIRS criteria in the setting of infection
• Criticism: Lacked positive predictive value and over-identified patients who did not have life-threatening infections.

New Definition

Based on 2024 Phoenix Criteria (JAMA 2024), which is a point-based system assessing four organ systems: respiratory, cardiovascular, coagulation, and neurologic (table listed below) in the setting of presumed infection.

• At least two points are needed to define sepsis. We’re awaiting further research to determine if a higher score has higher mortality, etc
• Septic shock defined as 2 points with at least 1 point coming from the cardiovascular criteria
• The updated score has demonstrated Improved positive predictive value for outcomes such as mortality or ECMO use
• Score technically applies to all children, but neonatal sepsis should prompt clinicians to follow the febrile infant guidelines

Table from 2024 Phoenix Criteria (JAMA 2024)

Clinical Pearls Using the Phoenix Criteria

• Clinical Pearl for Respiratory Box: supplemental oxygen is roughly 1 point, mechanically ventilated on low FiO2 is roughly 2 points, and mechanically ventilated on high FiO2 is roughly 3 points

• Clinical Pearl for Neurologic Box: use spontaneous awakening bundles for intubated and sedated patients. However, if they are already intubated, they likely meet sepsis criteria from the respiratory box alone.

• We are still working on how to best incorporate this definition at the bedside. The Surviving Sepsis Guidelines are still the recommended clinical guidelines for managing sepsis.
  • We have no recommendations to trend the score on daily basis because meeting sepsis criteria is enough to follow the Surviving Sepsis Guidelines

Recognizing Sepsis in Practice

• Dr. Horvat recommends thinking about sepsis “the moment someone has a possible infection and they need any sort of medical assistance at all”
• Core Principles: Sepsis recognition begins with identifying possible infections and organ dysfunction.
• Clinical Judgment: Hosts and Dr. Horvat discussed the “sick vs. not sick” dichotomy and its importance in early sepsis recognition.
• Limitations of Definitions: The Phoenix criteria may not change bedside practice for seasoned clinicians but offer standardization for research and global application.

Diagnostics for Suspected Sepsis

• Key Labs: CBC, BMP, coagulation panel (PT/PTT), CRP, ferritin, and procalcitonin. Lactate levels are context-dependent.
  • Inflammatory Markers: Elevated CRP, procalcitonin, and ferritin can stratify risk and guide treatment.
• Blood Cultures: Emphasized the importance of obtaining cultures before administering antibiotics to enable targeted therapy.
• Other Cultures: Respiratory and urine cultures are situation-dependent, driven by clinical suspicion.
• Imaging: Chest X-rays are useful for respiratory complaints; POCUS can guide decisions around fluid responsiveness and lung involvement.
• MRSA nasal/skin/rectal swabs can be useful for de-escalating antibiotics, but literature is primarily in adult medicine

Treatment Strategies

• Antibiotics:
  • Emphasis on early, broad-spectrum antibiotics (e.g., cefepime and vancomycin) tailored to the patient’s risk factors and infection history.
  • Double Coverage for MRSA: Consider adding clindamycin or doxycycline for MRSA pneumonia until vancomycin is therapeutic (recommendation extrapolated from Randolph et al, 2019)
  • De-escalation: Guided by culture results and clinical response.
• Fluids:
  • Initial bolus: 20 mL/kg isotonic crystalloid (e.g., normal saline or balanced fluids).
  • Reassessment after each bolus for signs of fluid overload.
  • Active Research: Debates around fluid type and volume for different patient populations.
  • Guidelines recommend thinking about vasoactive medications after approximately 60 mL/kg
    • Norepinephrine is pressor of choice with presumably low systemic vascular resistance (SVR)
    • Epinephrine is pressor of choice with high SVR
• Timeliness:
  • Antibiotics within 1-3 hours of sepsis recognition. However, the data is confounded by how quickly people act when someone looks VERY sick and how early patients present to care.
  • Nuanced discussion about balancing urgency with avoiding overtreatment in less severely ill patients.
• Corticosteroids:
  • Recommended for anyone with adrenal insufficiency
  • For patients with pneumonia or refractory sepsis, we need more data in the pediatric population to make an official recommendation
• Source Control:
  • If there is a localized collection of bacteria amenable to drainage, surgical source control is paramount

Disparities

• Care bundles have decreased mortality across institutions, however language barriers can lead to delays in initiating these care bundles. Dr. Horvat recommends we recognize this bias and identify these encounters as dangerous situations requiring heightened awareness.
• Patients with medical complexity are also at higher risk for sepsis

Improving Sepsis

Check out the quality improvement work from IPSO (Improving Pediatric Sepsis Outcomes) Collaborative, who have successfully decreased mortality and improved outcomes in pediatric sepsis nationwide

Goal

Listeners will explain the pediatric sepsis definitions, diagnostics, and treatment. 

Learning Objectives

After listening to this episode listeners will…  

1. Understand the evolution from the IPSCC to the Phoenix Sepsis Criteria and the reasoning behind the new definition.
2. Recognize the core principles of sepsis identification, including the “sick vs. not sick” approach.
3. Learn the key diagnostic tools and tests used in pediatric sepsis evaluation.
4. Explore the importance of timely antibiotics and the nuances of fluid resuscitation in managing pediatric sepsis.
5. Appreciate the balance between antimicrobial stewardship and effective sepsis management.

Disclosures

Dr Horvat reports no relevant financial disclosures. The Cribsiders report no relevant financial disclosures. 

Citation

Masur S, Horvat C, Shanklin A, Hodges Z, Berk J, Chiu C. “#129: It’s a Bundle: Pediatric Sepsis and the New Phoenix Criteria (Part 1)”. The Cribsiders Pediatric Podcast. https:/www.thecribsiders.com/ January 15, 2025.