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tailored to the local antibiogram, suspected source of infection, and patient age ( Table 10.5 ) Seasonal patterns in virus activity should also be considered and antiviral agents for influenza should be included in the initial antimicrobial regimen during influenza season Intramuscular administration of antibiotics should be considered if access to the IV or intraosseous route is delayed In addition to the common community-acquired pathogens, infants under to months are at risk for infections with group B Streptococcus, coagulase-negative Staphylococcus, Listeria monocytogenes, gram-negative organisms such as Escherichia coli and Haemophilus influenzae, and herpes simplex virus They are also at increased risk for central nervous system infections, so initial antibiotic choice should include coverage for these organisms and adequate doses to penetrate the central nervous system For anaphylactic shock, epinephrine is the definitive treatment, and epinephrine infusion may be needed for those with shock refractory to intermittent dosing of epinephrine Removal of the inciting allergen and administration of antihistamines and corticosteroids should occur concurrently PROTOCOL-BASED CARE FOR SEPTIC SHOCK Although the goal of rapid shock recognition and reversal applies to all types of shock, there has been a specific focus on improving recognition and care of pediatric patients with septic shock The following discussion is thus focused on sepsis, although the general principles likely apply to other shock types as well Timely Antimicrobial and Fluid Resuscitation Therapy Timely antimicrobial therapy and fluid resuscitation are essential in the treatment of severe sepsis and septic shock In critically ill adults with sepsis, evidence suggests that delays in appropriate antimicrobial therapy increase mortality Data also demonstrate that delays in antibiotic administration are associated with increased mortality and prolonged organ dysfunction in pediatric sepsis In addition, these studies demonstrate the importance of appropriate antibiotic selection in improving sepsis outcomes Institutional antibiograms can help to facilitate antibiotic selection in sepsis, and are typically based on host factors, suspected source, and local microbial susceptibility patterns In addition to antimicrobial therapy, rapid shock reversal via fluid resuscitation and appropriate vasoactive medications is essential to improve outcomes in septic shock Multiple studies have demonstrated improved survival after septic shock in adults with early goal-directed therapy aimed at reversing shock, though the optimal method by which to titrate resuscitation is not clear The ProCESS, PROMISE, and ARISE trials found no difference in outcomes whether shock