Characteristics of Young Children Hospitalized With Acute Respiratory Failure From Infection With Respiratory Syncytial Virus, SARS-CoV-2, or Both, November 2023–March 2024

Open Forum Infectious Diseases · 2026-02-28

Abstract Background Respiratory syncytial virus (RSV) and SARS-CoV-2 can cause acute respiratory failure in children. We compared characteristics and outcomes of children aged <2 years with respiratory failure from infection with RSV, SARS-CoV-2, or both viruses. Methods We used data from a US pediatric respiratory virus hospitalization surveillance network including children with ICU admission for acute respiratory failure (receiving high-flow oxygen or mechanical ventilation) with RSV and/or SARS-CoV-2 during November 2023–March 2024. Demographic, clinical characteristics, and hospitalization outcomes were stratified by a positive test for RSV, SARS-CoV-2, or both viruses, and compared using chi-squared or Kruskal–Wallis tests. Multivariable analyses assessed independent associations between outcomes and infection. Results Overall, 1406 children were included: 1253 (89.1%) for RSV, 105 (7.5%) for COVID-19, and 48 (3.4%) with RSV + SARS-CoV-2 detected. Children with RSV or RSV + SARS-CoV-2 had lower median ages (3.9 and 5.4 months, respectively) compared with those with SARS-CoV-2 (8.8 months; P < .001). Twenty percent of children with RSV and 43.8% with COVID-19 had an underlying medical condition. Among infants aged <1 year for whom preterm status was available, 31.5% with RSV and 50% with COVID-19 had either prematurity or a comorbidity. Children with SARS-CoV-2 were more likely to require invasive mechanical ventilation, receive vasoactive infusions, and die compared with RSV with and without SARS-CoV-2. Conclusions Critically ill children <2 years of age infected with SARS-CoV-2 had more severe illness presentation and outcomes and were older compared with those with RSV and RSV + SARS-CoV-2 codetection. Most children were previously healthy, highlighting the need for prevention measures.

External Validation, Molecular Signatures, and Therapeutic Relevance of Pediatric Sepsis-Associated Acute Kidney Injury Subphenotypes

Critical Care Medicine · 2026-03-30

OBJECTIVE: Sepsis-associated acute kidney injury (SAKI) is a heterogeneous condition that lacks disease-modifying treatments, and precision medicine approaches are needed. We previously derived two reproducible pediatric SAKI subphenotypes (pSAKI-1 and pSAKI-2) from readily available clinical data. We aimed to externally validate the prognostic relevance of these subphenotypes, evaluate their molecular signatures, and assess for heterogeneity of treatment effect (HTE) across subphenotypes with sepsis therapies. DESIGN: Secondary analysis of an ongoing multicenter, prospective, observational study of children. SETTING: Ten PICUs in the United States from January 2002 to February 2025. PATIENTS: Patients 1 week to 18 years old with early (day 1-2) SAKI. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Among 871 patients, 665 (76%) were assigned pSAKI-1 and 206 (24%) to pSAKI-2. On day 1-2, the pSAKI-2 cohort had greater severity of illness, including higher acute kidney injury stage and vasoactive burden, lower platelet counts, and higher lactate values and International Normalized Ratios. These pSAKI-2 patients also had uniformly worse outcomes, including independently higher odds of day 7 severe acute kidney injury (adjusted odds ratio [aOR] 3.2; 95% CI, 2.1-4.7; p < 0.001), death (aOR 2.7; 95% CI, 1.6-4.4; p < 0.001), and fewer PICU-free and vasoactive-free days (p < 0.001). The biomarker signature of pSAKI-2 was characterized by greater inflammation, endothelial dysfunction, and hyperreninemia. On propensity score matched (PSM) analysis, pSAKI-1 patients who received corticosteroids had more day 7 severe acute kidney injury (28% vs. 19%, p = 0.023), 2 fewer PICU-free days (p = 0.04) and greater mortality (10% vs. 3.7%, p = 0.008); no differences were seen in pSAKI-2 patients. Although no HTE was identified on PSM analysis for vasopressin, inverse probability treatment weighting analysis demonstrated a significant interaction between subphenotype-, vasopressin- and vasoactive-free days (p = 0.003). CONCLUSIONS: We externally validated the prognostic relevance of two pSAKI subphenotypes derived from readily available data. These subphenotypes have unique biomarker signatures and differential responses to treatment, representing a potential mechanism for bedside enrichment.

Executive Summary: Surviving Sepsis Campaign International Guidelines for the Management of Sepsis and Septic Shock in Children 2026

Pediatric Critical Care Medicine · 2026-03-23

The Surviving Sepsis Campaign International Guidelines for Management of Sepsis and Septic Shock in Children 2026 provide guidance on the identification and management of sepsis in pediatric patients with sepsis based on Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. This executive summary reviews the history, methodology, content, and major changes since the 2020 guidelines. HISTORY AND SPONSORSHIP OF THE GUIDELINES The first Surviving Sepsis Campaign (SSC) guidelines specific to pediatrics were published in 2020 as a joint effort of the Society of Critical Care Medicine (SCCM) and European Society of Intensive Care Medicine (ESICM) (1). The 2026 guidelines are an update from 2020 and focus on evidence published through July 2024 with key studies added if published later and identified by the panelists during the final evidence review. Studies that used either the 2005 severe sepsis or septic shock criteria, the 2024 Phoenix sepsis or septic shock criteria, or a more general definition of severe infection leading to life-threatening organ dysfunction were included in the evidence review. These guidelines were funded by SCCM and ESICM with methodological support by the Guidelines in Intensive Care Development and Evaluation group. In addition, 14 professional societies have either sponsored or endorsed these guidelines. There was no industry funding. Details about selection of the 68-person panel and the management of conflict of interests are detailed in the full guidelines document. METHODOLOGY Evidence Synthesis Population, Intervention, Control, and Outcome (PICO) questions addressed in the 2020 guidelines were reviewed for continued relevance, and new PICO questions were developed with input from each subgroup. Only PICO questions that were specific to sepsis or septic shock and determined likely to have substantial new evidence published on the topic were included. Individual studies were assessed for risk of bias using the Cochrane Risk of Bias-2 tool or the Clinical Advances through Research and Information Transfer (CLARITY) Risk of Bias tool for randomized controlled trials or cohort studies, respectively (2,3). We used the GRADE methodology to rate the certainty of evidence as high, moderate, low, or very low considering the risk of bias, inconsistency, indirectness, imprecision, publication bias, of the total available evidence (4–8). The panel considered evidence for each PICO question in a hierarchy of indirectness. Studies focusing on children with sepsis or septic shock were prioritized, although studies inclusive of more general pediatric populations (all PICU patients) were considered on a case-by-case basis. Evidence synthesized for the concurrent adult SSC guideline was considered according to an a priori framework to determine appropriateness of including indirect evidence (Fig. 1). Evidence from adult studies was generally downgraded due to the indirectness of the evidence.Figure 1.: Framework to determine the appropriateness of using indirect evidence from studies of children without sepsis or from adults.Types of Recommendation Statements Recommendations were specified as strong or conditional (previously referred to a “weak” recommendations in prior guidelines) as outlined in Table 1. We used the language “we recommend” for strong recommendations and “we suggest” for conditional recommendations. A strong recommendation indicates that most, if not all, individuals in the relevant clinical situation should receive (or avoid) the intervention. In contrast, a conditional recommendation acknowledges that the balance between desirable and undesirable may vary depending on patient values, clinical circumstances, or resource availability. Conditional recommendations may not be universally implementable and are less likely to be suitable for rigid performance metrics or enforcement. Flexibility and local context should guide their adaptation into policy. Good practice statements (GPSs) were developed in accordance with GRADE guidance when the panel judged unequivocal benefit (or harm) was present but there was an absence of direct evidence. Where there was insufficient evidence to formulate a recommendation, but the panel felt that some guidance based on current practice patterns may be appropriate, we issued an “in our practice” statement summarizing the results of the panel’s practice. We required a minimum 75% response rate and 80% agreement among eligible panelists for all statements to be included in these guidelines. TABLE 1. - Types of Recommendation Statements and Implications of the Strength of Recommendation Category Strength Quality of Evidence Implications to Patients Implications to Clinicians Implications to Policymakers Strong recommendation Strong High or moderate Most individuals in this situation would want the recommended course of action, and only a small proportion would not Most individuals should receive the recommended course of action. Formal decision aids are not likely to be needed to help individuals make decisions consistent with their values and preferences Can be adapted as policy in most situations, including for use as performance indicators Conditional recommendationa Weak Any The majority of individuals in this situation would want the suggested course of action, but many would not Different choices are likely to be appropriate for different patients, and therapy should be tailored to the individual patient’s circumstances, such as patients’ or family’s values and preferences Policies will likely be variable Good practice statement Strong Ungraded Same as strong recommendation Same as strong recommendation Same as strong recommendation In our practice statement Not a recommendation NA NA NA NA NA = not applicable.aConditional recommendations were previously categorized as “weak recommendation” in prior guideline iterations. Scope These guidelines apply to all patients from greater than or equal to 37 weeks of gestation at birth to 18 years with probable or confirmed sepsis or suspected or confirmed septic shock. For these guidelines, sepsis is defined as severe infection leading to life-threatening organ dysfunction and septic shock is defined as a subset of sepsis that includes life-threatening cardiovascular the of sepsis may be in clinical we language for sepsis and suspected septic shock all and with with organ dysfunction are included in this For we will use the to to and in these guidelines. TABLE - Sepsis in This Sepsis leading to life-threatening organ inclusive of patients with septic shock Septic shock of sepsis with cardiovascular dysfunction not to a concurrent or sepsis Clinical consistent with but infection not confirmed septic shock Shock of but suspected to be to infection Septic shock with Sepsis with of recommendations apply to children with sepsis or septic shock specific subset with are included in the We that sepsis as a and some children without organ dysfunction may benefit from as with organ Recommendations were developed to be that of and and will determine the of these guidelines. These guidelines not or when with clinical OF THE 2026 SSC GUIDELINES The 2026 guidelines statements and management of infection and and and were strong were conditional were and were statements of insufficient evidence to a with the 2020 guidelines, recommendations are were for new were reviewed but not and were based on of the panel that new evidence was not Only recommendations were based on or moderate of evidence. “in our practice” statements were included the panel’s practice as determined of the panel These statements are not an of a specific but panelists by absence of or clinical key recommendations to the of children with probable sepsis or suspected septic guide for in children with probable sepsis without shock or suspected septic shock. A summary of key recommendations for and with of the of recommendations. therapy and should be = = practice = = The 2026 guidelines statements new questions not in the 2020 - 2026 Recommendation and management of infection For children with probable sepsis or septic there is insufficient evidence to a recommendation for or for or for was addressed for the first in the 2026 guidelines. studies in pediatrics clinical trials in have an between and clinical the panel of and to there about the of with for or and about the required for of these therapy For children with confirmed sepsis with there is insufficient evidence to for or using a with for were addressed for the first in the 2026 guidelines. a of clinical trials in with sepsis a small in at for of with pediatric are and is required to including of and recommendation of in clinical practice. For children with sepsis or septic shock with we not using to guide of therapy when are in recommendation, moderate certainty of The of was not addressed in the prior of guidelines. For the 2026 guidelines, the panel issued a conditional recommendation to not use to guide of for this statement from and pediatric randomized clinical in or of use with a for with that included The added of a such as is likely on the context and on the of and For children with sepsis or septic shock with we or for management recommendation, very low certainty of For children with sepsis or septic shock without there is insufficient evidence to provide a recommendation about should The of or was not addressed in the prior of guidelines. For the 2026 guidelines, the panel that studies the of for children with have including and the of was felt to be most relevant for patients with confirmed in and is that some patients without a infection would benefit from such there was insufficient evidence to a for children with sepsis or septic shock should be by clinical of of including of and from shock to that be by in of and In a prior this guidance was only included as a For although there insufficient pediatric to a GRADE recommendation to use clinical of to guide and new evidence benefit to an the panel that a more statement was needed that should be by clinical of of For children with sepsis or septic we using and to guide not using to guide if local and recommendation, low certainty For children with sepsis or septic help to and In the prior the of to guide was not have that is to of shock and and all be present during septic shock. the of and management on patient that is an in many and to clinical of and with some evidence of benefit to patient the panel issued a new conditional recommendation to use and to guide if local and For children with septic there was insufficient evidence to a recommendation on either or of The prior included a that is to of at that were from studies that in children with septic shock with to of the first of from small pediatric randomized trials either or of therapy not in proportion with or to of or clinical between but that patients with less the absence of a benefit on the of to the of the panel that there was insufficient evidence to a recommendation and that is to either or of For children with septic shock with with there was insufficient evidence to a recommendation for with with was not addressed in the prior of guidelines. For the 2026 guidelines, studies were identified on the use of for pediatric septic but all were small or and not of to a recommendation about with for children with septic shock with with For children with septic shock with with there was insufficient evidence to a recommendation for with with was not addressed in the prior of guidelines. For the 2026 guidelines, to as to management in for septic shock in a This a more in in the with but in and there was no in The of indirect adult and pediatric not provide evidence to a recommendation for with for children with with For children with sepsis or septic shock we to a a more conditional recommendation, moderate certainty of The prior guideline not for For from in in children not to of of and when was to on these the panel issued a new conditional recommendation to a a more for children The conditional recommendation during the of and in specific of children with severe of low organ dysfunction that includes and For children with sepsis or septic shock and there was insufficient evidence to a recommendation on the use of with was not addressed in the prior of guidelines. For the 2026 guidelines, no pediatric and only studies the of for in children were for with was not with A that was with only among patients with and low is low in and there was not evidence to a GRADE recommendation for or in children with sepsis or septic shock with and support is to to total and in of is and changes to The prior of guidelines not to For the 2026 guidelines, the panel considered that studies have to be with of and of was to a due to the of that as a major for There were no pediatric studies that the of sepsis on there was insufficient evidence available to a GRADE recommendation and the panel that is to to total and to in of is and changes to For children with sepsis or septic there was insufficient evidence to a recommendation on the use of with than was not addressed in the prior of guidelines. For the 2026 guidelines, a of the not provide evidence to a recommendation on the use of to or The panel that a published based on from small studies, suggested be to children with septic with organ dysfunction or organ when shock was to the of this a for and the of in the panel that are to a GRADE For children with sepsis or septic there was insufficient evidence to a recommendation on to or The to for was not addressed in the prior of guidelines. children for are at risk for of sepsis and of the response may be for or of a risk of there was insufficient evidence on the of during sepsis in children to a GRADE For children with sepsis or septic shock with evidence of or there was insufficient evidence to a recommendation on the use of an The with for children with sepsis or septic shock with evidence of or was not addressed in the prior of guidelines. In studies, of have with in children with including organ and of small in children have that be with no studies have that with clinical a GRADE recommendation not be For children with sepsis or septic shock and there was insufficient evidence to a recommendation on the use of The use of for children with sepsis or septic shock and was not addressed in the prior of guidelines. may be by and in some children with with and that may benefit evidence the use of in children with sepsis and and most available were from small studies at risk for bias with of criteria, and a GRADE recommendation not be For children with sepsis or septic we an during the than not using a recommendation, very low certainty and were not addressed in the prior of guidelines. For the 2026 guidelines, the panel that pediatric sepsis is with and and there were no studies on for children with general studies of children were with with of of and without an in most studies of are from studies have that are in with low PICU and have to be when is For children with sepsis or septic there was insufficient evidence to for or to of children sepsis that for to there is that of help by to new or there were no studies on children with sepsis or septic evidence from trials in general PICU populations that included children with sepsis that a was with less and for the and the low proportion of sepsis in these studies, the certainty of evidence was insufficient to for or for children with sepsis or septic shock. For children sepsis or septic is risk for the and on the of and for Children with of and organ of and are at risk of and is needed to determine the by to support children sepsis and their the panel issued a to children for risk with provide to patients, their and relevant about the of and to for new these are more likely than not to have an on the continued of children sepsis or septic shock. = practice GRADE = Grading of Recommendations, Assessment, Development, and = = randomized controlled = The 2026 guidelines statements questions that were from the 2020 guidelines. of these statements were from prior guidance for new the were not statements included in the 2020 guidelines were not reviewed and not included in the 2026 guidelines, these statements either referred to general that were not specific to shock or have addressed by guidelines or and management - 2026 Recommendation and management of infection 1. In children are there was insufficient evidence to sepsis in to clinical for the of sepsis and septic shock. In the prior of the guidelines, the panel issued a conditional recommendation to for of sepsis and septic shock. 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Statements that were reviewed but not an and in contrast, by - 2026 Recommendation 2020 to 2026 and management of infection Clinicians should therapy in this not therapy Clinicians should therapy with or more to all likely the and are therapy should be no is should or therapy according to clinical of risk and of clinical in with For children for sepsis or septic shock with are at risk for we using therapy recommendation, very low of should be as as a of an infection to a For children with sepsis or septic we of that are confirmed to be the of sepsis or septic shock and depending on the and the of a recommendation, low certainty of therapy For children with septic shock in with we to in the first of no recommendation, low certainty For children with sepsis without in with no we using recommendation, certainty For children with septic shock with in with no we to in the first of no therapy recommendation, low certainty should be therapy should be to clinical of and if shock or if of 2020 For the of children with sepsis or septic we using than recommendation, moderate certainty of For children with septic shock with we with or recommendation, very low certainty of For children with sepsis or septic there was insufficient evidence to a recommendation about to at the or for For children with septic shock we either or recommendation, low certainty of For children with septic shock and dysfunction with there was insufficient evidence to a recommendation about an For children with septic shock in be with and we the use of recommendation, low certainty of For children with septic there was insufficient evidence to a recommendation about to in the absence of For children with sepsis or septic we using when recommendation, low certainty of For children with sepsis or septic we the use of conditional recommendation, very low certainty For children with sepsis or septic we the use of conditional recommendation, very low certainty For children with sepsis or septic we the of in the absence of clinical recommendation, very low certainty of and For children with sepsis or septic there was insufficient evidence to a recommendation about to or For children with sepsis or septic shock in a we the use of in children with septic shock and organ dysfunction recommendation, low certainty of and support For children with sepsis or septic shock for the organ there was insufficient evidence to a recommendation on to with For children with sepsis or septic we using when is present recommendation, very low certainty of For children with septic we using as a therapy only if shock is to all recommendation, very low certainty of For children with sepsis or septic we the use of recommendation, low certainty of The use of is not patients, such as with or with low may benefit from such = = practice = This executive summary the of the 2026 pediatric Surviving Sepsis guidelines and and The guidelines all statements and to or We the to the guidelines from our patient and we the support of the Society of Critical Care Medicine in the guidelines including and of the Surviving Sepsis Campaign Children and and and and and and and and and Critical Care Critical Care of of of Society of European Society for and Intensive Society of Sepsis and of Intensive and Critical Care for and Society of Intensive

Surviving Sepsis Campaign International Guidelines for the Management of Sepsis and Septic Shock in Children 2026

Pediatric Critical Care Medicine · 2026-03-23 · 4 citations

OBJECTIVES: To update evidence-based management recommendations for clinicians caring for children (including infants, school-aged children, and adolescents) with sepsis or septic shock. DESIGN: A panel of 68 international experts, representing 13 international organizations, as well as six methodologists, was convened. A formal conflict-of-interest policy was developed at the onset of the process and applied throughout. Teleconferences and electronic-based discussion among the chairs, co-chairs, methodologists, and subgroup leads as well as within subgroups, served as an integral part of the guideline development process. METHODS: New priority topics and recommendations from the prior guideline iteration were used to identify Population, Intervention, Control, and Outcomes (PICO) questions likely to have new or updated evidence. We conducted a systematic review to identify the best available evidence, summarized the evidence, and then assessed the quality of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation approach. We used the evidence-to-decision framework to formulate recommendations as strong or conditional, or as a good practice statement. "In our practice," statements were included when evidence was inconclusive to issue a recommendation but the panel felt that some guidance based on practice patterns may be appropriate. RESULTS: The panel provided 61 statements on the management of children with sepsis or septic shock. Overall, five were strong recommendations, 24 were conditional recommendations, and ten were good practice statements. For 22 PICO questions, no recommendations could be made, but, for seven of these, "in our practice" statements were provided. Compared with the 2020 guidelines, 20 recommendations were new, 13 were updated for clarity and/or new evidence, six were reviewed but not changed, and 22 were carried forward based on consensus of the panel that new evidence was not available. Only three recommendations were based on high or moderate certainty of evidence. CONCLUSIONS: Updated management guidelines were issued by a panel of international experts for the best care of children with sepsis or septic shock, acknowledging that most aspects of care continue to have relatively low quality of evidence.

Executive Summary: Surviving Sepsis Campaign International Guidelines for the Management of Sepsis and Septic Shock in Children 2026

Universität Zürich, ZORA · 2026-04-01

Surviving Sepsis Campaign International Guidelines for the Management of Sepsis and Septic Shock in Children 2026

Intensive Care Medicine · 2026-03-23 · 1 citations

National Estimates of Pediatric Sepsis in US Hospitals Using Clinical Data

JAMA · 2026-03-22 · 2 citations

Importance: Pediatric sepsis causes substantial morbidity and mortality, but population surveillance relies on administrative codes with limited and variable accuracy. Objective: To estimate US national incidence, mortality, and trends of sepsis in nonneonatal children using a Pediatric Sepsis Event (PSE) definition adapted from the 2024 Phoenix criteria for scalable electronic health record (EHR)-based surveillance using routinely captured clinical data. Design, Setting, and Participants: Retrospective cohort study of 3.9 million hospitalizations (age, >30 days to 17 years) in 2 EHR datasets: Epic Cosmos (245 health care systems, 2016-2023) and HCA Healthcare (146 hospitals, 2018-2023). Secondary datasets were analyzed to assess feasibility of implementation and face validity across heterogeneous settings. The PSE was validated through medical record reviews of 581 high-risk encounters at 3 geographically diverse hospitals. Exposures: A PSE required presumed infection with concurrent organ dysfunction using Phoenix-derived thresholds adapted for routine EHR data. Septic shock was defined as a PSE with cardiovascular dysfunction. Main Outcomes and Measures: Sepsis incidence, characteristics, and in-hospital mortality were calculated. Sensitivity and specificity of PSE for physician-adjudicated Phoenix sepsis were compared with administrative codes for severe sepsis/septic shock. National sepsis case counts and deaths in 2022 and temporal trends from 2016 to 2022 were estimated using regression models. Results: Among 3 925 809 pediatric hospitalizations from 2016 to 2023, 51 542 sepsis cases (mean age, 6.6 [SD, 6.0] years; 22 840 [44.3%] female) were identified (1.3% incidence); 37 405 (72.6%) were community onset and 31 744 (61.6%) had septic shock. In-hospital mortality was 10.1% and sepsis was present in 17.8% of hospitalizations that culminated in death. Incidence, characteristics, and mortality were broadly consistent across secondary datasets. On medical record review, the PSE definition had 69.9% sensitivity (95% CI, 58.1%-79.8%) and 93.1% specificity (95% CI, 89.6%-95.7%), with higher sensitivity than and comparable specificity with administrative codes. National estimates for 2022 were 18 231 sepsis cases (95% CI, 16 129-20 334) and 1877 deaths(95% CI, 1629-2126). Neither sepsis cases nor deaths changed significantly from 2016 to 2022 (annual change, 0.2% [95% CI, -2.2% to 2.7%] and 0.3% [95% CI, -3.1% to 3.8%], respectively). Conclusions and Relevance: An EHR-based definition for pediatric sepsis demonstrated strong validity compared with physician-adjudicated Phoenix sepsis and identified sepsis in 1.3% of pediatric hospitalizations with 10% mortality, corresponding to more than 18 000 cases and more than 1800 deaths annually in the US.

Balanced Fluid or 0.9% Saline in Children Treated for Septic Shock

New England Journal of Medicine · 2026-04-23 · 1 citations

BACKGROUND: Whether treatment with balanced crystalloid fluid leads to better outcomes than 0.9% saline in children treated for septic shock is debated. METHODS: In this pragmatic clinical trial conducted at 47 emergency departments in five countries, patients (2 months to <18 years of age) with suspected septic shock and abnormal perfusion were randomly assigned to receive fluid resuscitation with either balanced fluid or 0.9% saline for up to 48 hours. The primary outcome was a major adverse kidney event (a composite of death, new renal-replacement therapy, or persistent kidney dysfunction) at 30 days after enrollment or hospital discharge, whichever occurred first. RESULTS: Of 9041 enrolled patients, 277 (6.1%) in the balanced-fluid group and 282 (6.2%) in the 0.9%-saline group withdrew from the trial, leaving 4235 and 4247 patients, respectively, for analysis. A primary-outcome event occurred in 137 patients (3.4%) in the balanced-fluid group and in 124 (3.0%) in the 0.9%-saline group (difference, 0.4 percentage points; 95% confidence interval [CI], -0.5 to 1.3; risk ratio, 1.10; 95% CI, 0.88 to 1.40; P = 0.85). The median number of hospital-free days during 28 days after enrollment was 23 (interquartile range, 19 to 25) in both groups. Hyperchloremia occurred in 868 patients (31.4%) in the balanced-fluid group and in 1383 (49.0%) in the 0.9%-saline group; hypernatremia in 52 (1.8%) and 89 (3.1%), respectively; and hyperlactatemia in 260 (19.8%) and 228 (16.7%). No differences in other safety outcomes or adverse events were seen. CONCLUSIONS: Among children treated for septic shock, no significant difference was seen in the incidence of death, new renal-replacement therapy, or persistent kidney dysfunction when fluid resuscitation was administered with balanced fluid as compared with 0.9% saline. (Funded by Eunice Kennedy Shriver National Institute of Child Health and Human Development and others; PRoMPT BOLUS ClinicalTrials.gov number, NCT04102371.).

Surviving Sepsis Campaign International Guidelines for the Management of Sepsis and Septic Shock in Children 2026

Universität Zürich, ZORA · 2026-03-23

Post-hurricane fluid conservation measures fail to reduce IV fluid use in critically ill children

Pediatric Nephrology · 2025-08-19 · 2 citations

BACKGROUND: There are risks associated with excessive intravenous fluid (IVF) administration in critically ill children. Previous efforts have described opportunities to reduce positive cumulative fluid balance (CFB) in this population but have not been widely implemented. In the wake of Hurricane Helene, a national IVF shortage led to the implementation of IVF conservation guidelines. We sought to determine if this was associated with a reduction in IVF use and CFB. METHODS: The present study is a four-site cohort study of critically ill children utilizing a federated data collection framework to extract patient age, sex, weight, and daily fluid intake/output for days 1-4 of all admissions 28 days prior to and 28 days after the implementation of IVF conservation guidelines. Guidelines were individualized per institution. Total fluid intake, total IVF intake, % intake from IVF, and % CFB were compared between pre- and post-IVF conservation groups. RESULTS: All sites had similar conservation recommendations. There were 633 patients admitted pre- and 619 patients admitted post-IVF conservation guideline implementation, with similar age and weight distributions. There was no significant difference in IVF use pre- and post-IVF conservation; 29-35% of patients had > 5% CFB on day 1 pre-IVF conservation while 27-39% did post-conservation, with increasing numbers on day 2. CONCLUSIONS: Even in the setting of a national IVF shortage, simple recommendations without structured change were insufficient to change IVF administration practices. This indicates additional practices will be needed to reduce IVF intake and % CFB in this vulnerable population.