Every hospital paediatric sepsis guideline appraised came out low quality

Design

Cross-sectional appraisal using AGREE II with concordance assessment against a reference standard

Population

14 hospital-specific paediatric sepsis clinical practice guidelines from 13 countries across five continents

Primary outcome

AGREE II domain scores and overall quality; consistency and concordance across 12 key treatment recommendations

Effect

All 14 rated low quality; rigour of development 0–50%; concordance with Surviving Sepsis Campaign 2020 42–100%; consistency 43% (steroids) to 93% (antibiotic timing, fluid bolus volume, initial labs)

Fourteen hospital-specific paediatric sepsis guidelines from 13 countries across five continents were appraised with AGREE II and compared against the Surviving Sepsis Campaign 2020 recommendations. All fourteen were rated low methodological quality. The weakest domains were rigour of development (0–50%) and editorial independence (0–58%).

Concordance with Surviving Sepsis Campaign 2020 ranged from 42% to 100% across the guidelines. Consistency across the 12 key treatment recommendations was highest for the time-critical elements — initial laboratory investigations, time to antibiotics, and fluid bolus volume all at 93% — and lowest for steroid indications at 43%. Fluid resuscitation composition also varied clinically importantly.

The reassuring reading is that the things that have to happen in the first hour are broadly agreed. The uncomfortable reading is that local guidelines are being written without the methodological machinery that guideline development is supposed to involve, and diverging exactly where the evidence is weakest. A clinician following a local protocol should know which of its recommendations rest on evidence and which rest on whoever wrote it.

• Look up when your unit's sepsis guideline was last revised and against which reference standard.
• Check specifically what it says about steroid indications and fluid composition — these are where hospitals diverge most.
• Do not assume a local protocol reflects current international guidance simply because it exists.
• Where a local guideline conflicts with Surviving Sepsis Campaign on a time-critical element, raise it rather than working around it.
• Adaptation to local resources is legitimate; undocumented divergence is not, and the difference should be visible in the document.

Why it matters

Clinicians treat a local protocol as authoritative, and this is how those protocols were actually made.

Don't overread it

Fourteen guidelines from hospitals that volunteered for an international study are not a representative sample of guidelines worldwide.

The statistics, in plain English

AGREE II scores the process of writing a guideline, not whether its recommendations are right — a low-quality document can still give good advice, which is exactly what the concordance figures suggest happened. The 42% to 100% concordance range is the more worrying number: it means that following a local protocol somewhere in this sample could mean departing from the reference standard on more than half of its key recommendations.

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