Sepsis Identification and Management

• While simple definitions of sepsis have a role in identifying septic patients in clinical practice, none are perfect, and clinical judgement should be exercised in their application.
• Always carry out a structured clinical assessment and consider sepsis in any patient with suspected or proven infection, or unexplained clinical deterioration (e.g. NEWS2 score 5 or more).
• Fever need not be present.
• Pay attention to clinical or carer concern.

The NICE guidelines for suspected sepsis (NG51) were updated in March 2024 and place greater emphasis on the use of the National Early Warning Score (NEWS2) to help recognise sepsis/organ dysfunction and guide urgency of response – PHYSIOLOGY FIRST.

Any patients with suspected sepsis meeting the high-risk criteria should rapidly be assessed by a senior physician and urgently treated for sepsis within an hour unless there is a clear alternative diagnosis.

Septic shock is a subset of sepsis with persistent hypotension and elevated lactate (greater than 2mmol/L) despite appropriate fluid therapy (e.g. 30 ml/kg or more). Mortality is ~50%.

Any patients with suspected sepsis meeting the moderate-risk criteria should be assessed as soon as possible, and have a full set of bloods taken, cultures and VBG. It is strongly advised to consider senior assessment and if antimicrobials are required, they are given within three hours.

The OUH Sepsis Agent uses electronic data from SEND and EPR to create a “suspected sepsis” alert for patients with evidence of infection and evidence of organ dysfunction or other markers of severe illness, according to a simple algorithm.

The Sepsis Alert appears in the EPR/FirstNet Tracking lists (ED, EAU, SEU) and on the patient whiteboard and clinical worklist (all clinical areas). See the Sepsis page on the OUH intranet for further details. 

Note: The Sepsis Agent is a simple tool based on existing guidelines to assist clinicians in rapidly identifying and prioritising patients with suspected sepsis. However it does not replace a proper clinical assessment. It will not identify all patients with sepsis, and some patients without sepsis will be flagged as suspected sepsis. Please use the sepsis alerts judiciously alongside your clinical judgement. 

Sepsis is a medical emergency. Time is Life – prompt action saves lives.

The Sepsis Six management bundle should be delivered as quickly as possible, and within 1 hour for all cases of confirmed sepsis, or in those meeting the NICE ‘high risk criteria’ criteria for suspected sepsis.

Sepsis Six Bundle

1. Ensure senior clinician attends
2. Give O_2­ if required (SpO₂ greater than 94% [greater than 88% if at risk of hypercarbia])
3. Obtain IV access, take blood cultures and full set of bloods including lactate ^*
4. Give IV antibiotics
5. Give IV fluids guided by clinical assessment and lactate 
6. Monitor (NEWS2, urine output ^†, lactate)

^* Remember source control = e.g. drainage of collection, removal of infected line, debridement of necrotizing fasciitis, etc. 

† Start recording fluid input and output using EPR fluid balance chart, to allow ongoing assessment of urine output and treatment response. Consider urethral catheter if urine output poor, difficult to measure, or septic shock. Review catheters daily. 

Use the Adult Sepsis PowerPlan to quickly and simply prescribe fluids, oxygen and antibiotics and request relevant tests from a single interface.

Antibiotic regimens 

See empirical antimicrobial guidelines:

•  Systemic sepsis of UNKNOWN source
•  Neutropenic sepsis
•  Ante-natal or post-partum - severe sepsis / septic shock
•  Systemic sepsis after organ transplantation
•  Urosepsis

Further management will be guided by the individual presentation, and should include:

• Senior doctor review
• Frequent observations
• Blood tests: FBC, U&E, CRP, LFT, clotting, ± serial lactate measurement
• Investigations to identify sepsis source
• Source control if indicated
• Documentation of sepsis diagnosis in patient notes (e.g. “severe sepsis secondary to pneumonia")
• Investigation/exclusion of other diagnoses

Discuss with consultant and/or ICU all cases of septic shock or potentially reversible deterioration despite aggressive medical management. Prompt referral to ICU improves outcome.

Consider Micro/ID review if complex, immunosuppressed or not responding appropriately to initial treatment.

Review antibiotics daily in the light of further results and clinical progress. Consider switch to oral antibiotics, or stopping antibiotics, if no longer indicated. See IV-to-Oral Switch (IVOS) guideline

1. NICE Guideline 51: Sepsis: recognition, diagnosis and early management (Published July 2016 updated in March 2024) LINK 
2. UK Sepsis Trust Clinical Toolkits LINK