Objective To study warning signs of serious infections in febrile children presenting to PED, ascertain their risk of having sepsis, and evaluate their management. Design Prospective observational study Setting a single paediatric emergency department (PED) Participants febrile children, aged 1 month – 16 years, with &= 1 warning signs of sepsis Interventions and Main outcome measures Clinical characteristics, including different thresholds for tachycardia and tachypnoea, and their association with 1) delivery of paediatric sepsis 6 (PS6) interventions, 2) final diagnosis of invasive bacterial infection (IBI), 3) the risk for paediatric intensive care unit (PICU) admission, and 4) death. Results Forty-one percent of 5,156 febrile children had warning signs of sepsis. 1,606 (34%) children had tachypnoea and 1,907 (39%) children had tachycardia when using APLS threshold values (table 1). Using the NICE sepsis guidelines thresholds resulted in 1,512 (32%) children having tachypnoea (kappa 0.56) and 2,769 (57%) children having tachycardia (kappa 0.66). Of 1,628 PED visits spanning 1,551 disease episodes, six children (0.4%) had IBI, with one death (0.06%), corresponding with 256 children requiring escalation of care according to sepsis guideline recommendations for each child with IBI. There were five additional PICU admissions (0.4%). 121 (7%) had intravenous antibiotics in PED; 39 children (2%) had an intravenous fluid bolus, inotrope drugs were started in one child. 440 children (27%) were reviewed by a senior clinician. In 4/11 children with IBI or PICU admission or death, PS6 interventions were delivered within 60 minutes after arriving. 1,062 (65%) visits had no PS6 interventions. Diagnostic performance of vital signs or sepsis criteria for predicting serious illness yielded a large proportion of false positives. Lactataemia was not associated with giving iv fluid boluses (p=0.19) or presence of serious bacterial infections (p=0.128). Conclusion Many febrile children (41%) present with warning signs for sepsis, with only few of them undergoing investigations or treatment for true sepsis. Children with positive isolates in blood or CSF presented in a heterogeneous manner, with varying levels of urgency and severity of illness. Delivery of sepsis care can be improved in only a minority of children with IBI or admitted to PICU.
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