BMJ Best Practice 'Sepsis in Adult'

Sepsis in adults
The right clinical information, right where it's needed
Last updated: Jun 06, 2017

Table of Contents
Summary 3
Basics 4
Definition 4
Epidemiology 5
Aetiology 5
Pathophysiology 6
Classification 7
Prevention 9
Diagnosis 9
Case history 9
Step-by-step diagnostic approach 9
Risk factors 15
History & examination factors 16
Diagnostic tests 18
Differential diagnosis 21
Diagnostic criteria 22
Treatment 27
Step-by-step treatment approach 27

Treatment details overview 32
Treatment options 34
Follow up 47
Recommendations 47
Complications 47
Prognosis 49
Guidelines 51
Diagnostic guidelines 51
Treatment guidelines 51
Online resources 54
References 55
Images 66
Disclaimer 68
Summary
◊ Findings are generally non-specific and secondary to primary infection. They include malaise, leukocytosis,
tachypnoea, and pulse >90 bpm.
◊ Sepsis can progress rapidly to multi-organ failure and shock, and is often fatal. Survival is dependent on a high
index of suspicion of sepsis, early recognition and immediate intervention.
◊ Patients with evidence of sepsis, including signs of organ dysfunction, require immediate hospital assessment.
◊ Empirical broad-spectrum antibiotic therapy (based on the most probable pathogens) should be administered
as soon as possible, and always within the first hour following recognition.
◊ Blood cultures, as well as cultures of all wounds or other potentially infected body fluids, should be performed
as indicated by symptoms and the risk profile of the patient, ideally before the initiation of antimicrobial treatment.
◊ Any source of infection should be controlled as a matter of urgency, preferably within 6 hours following
recognition.
◊ Evidence of hypoperfusion or shock should be identified and treated with immediate intravenous fluid challenges,
if present. Shock that fails to respond to fluid challenges necessitates urgent critical care referral for consideration
of vasopressors and/or inotropes.
Sepsis in adults Basics
Definition
Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to an infection.[1] The
BASICS
definition of sepsis was updated in 2016 following publication of the Third International Consensus Definitions for Sepsis
and Septic Shock (Sepsis-3).[1]
The 2016 consensus definitions also recommend that the Sequential (or Sepsis-related) Organ Failure Assessment (SOFA)
criteria and 'quick' (q)SOFA criteria be used to identify sepsis, in place of the currently used systemic inflammatory response
syndrome (SIRS) criteria, which were the basis for the previous definition of sepsis.[1] [2] SOFA is an ICU-based mortality
score and qSOFA is a rapid, shortened version of SOFA designed for use outside the ICU. The SOFA scores are not in
themselves clinical predictors of sepsis, and they rely on clinical suspicion for the scores to be assessed. Furthermore,
qSOFA has not been prospectively validated, and its place in clinical practice has not been fully established. Although the
SIRS criteria are no longer recommended and have limitations, they are well established after many years of use.[3] At
present it is unclear which clinical score will best guide sepsis care; therefore, the SIRS criteria remain the current standard
for identifying sepsis and are likely to remain relevant in medical care, at least in the short term.
SIRS is a multi-system response that can result from infection (localised or general), as well as from non-infectious causes
(e.g., trauma, burns, or pancreatitis).[4] [5] [6] [7] [8] It is defined by the presence of 2 or more criteria from the following:
temperature >38.3°C (101°F) or <36.0°C (96.8°F); tachycardia >90 bpm; tachypnoea >20 breaths/minute or PaCO2 <4.3
kPa (32 mmHg); hyperglycaemia (blood glucose >7.7 mmol/L [>140 mg/dL]) in the absence of diabetes mellitus; acutely
altered mental status; leukocytosis (WBC count >12×10^9/L [12,000/microlitre]); leukopenia (WBC count <4×10^9/L
[4000/microlitre]); or a normal WBC count with >10% immature forms.[5] [Surviving Sepsis Campaign: evaluation for
severe sepsis screening tool]
When using the SIRS criteria, sepsis is the presence of SIRS (i.e., 2 or more SIRS criteria) resulting specifically from an
infection.
In the first international consensus definitions, which date from 1991, severe sepsis was defined as sepsis associated
with organ dysfunction, hypoperfusion, or hypotension; septic shock was defined as sepsis with hypotension despite
adequate fluid replacement.[5] These definitions remain clinically established in many clinical settings.
However, the 2016 third international consensus (Sepsis-3) definitions state that the term 'severe sepsis' should be made
redundant in light of the revisions to the definition of sepsis.[1] Septic shock has also been redefined as a subset of sepsis,
in which profound circulatory, cellular, and metabolic abnormalities are associated with a greater risk of mortality than
with sepsis alone.[1]
In 2016, the National Institute for Health and Care Excellence (NICE) published guidance on the recognition, diagnosis,
and early management of sepsis, which highlighted that the Sepsis-3 international consensus definitions of sepsis have
limited use in the early identification of people at risk of sepsis.[9] The NICE guidelines propose a move away from using
the SIRS criteria, and do not immediately support the use of the SOFA/qSOFA criteria. Instead NICE proposes a risk
stratification approach to categorise patients into 3 groups according to their risk of severe illness or death from sepsis:
high risk; moderate to high risk; or low risk. The risk stratification is based on the patient’s: history (e.g., altered mental
state; urine output; impaired immunity; or recent trauma, surgery, or invasive procedure), appearance (e.g., signs of
potential infection; mottled or ashen appearance; cyanosis of skin, lips, or tongue; or non-blanching rash of skin), and
clinical evaluation (e.g., temperature, heart rate, respiratory rate, blood pressure, level of consciousness, and oxygen
saturation).
This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Jun 06, 2017.
4 BMJ Best Practice topics are regularly updated and the most recent version of the topics can be found on bestpractice.bmj.com . Use
of this content is subject to our disclaimer. © BMJ Publishing Group Ltd 2017. All rights reserved.
Epidemiology
In 2007, septicaemia was recorded as the 10th leading cause of death in the US.[11] In the US, there are as many as
BASICS
750,000 to 900,000 cases per year, resulting in around 200,000 deaths per year.[12] Most epidemiological studies find
sepsis to be more common in men than in women. Patients older than 65 years of age are particularly susceptible, with
one study finding almost two-thirds of cases to be in people over 65.[13] This study recorded 215,000 sepsis-associated
deaths (9.3% of all deaths in the US during the study period).
The population-based incidence of sepsis is estimated to be as high as 176 to 380 cases per 100,000 per year.[14] [15]
[16] [17] The annual incidence of sepsis in the EU has been estimated at 90.4 cases per 100,000 population.[18] However,
incidence rates depend on the definition of sepsis, with rates in Canada cited as 15.7 cases per 100,000 population per
year requiring admission to ICU.[19] Nonetheless, it is likely that there are as many as 20 million cases of sepsis annually
worldwide, with a mortality rate of around 35%. This equates to approximately 20,000 deaths per day and makes sepsis
the second leading cause of death after vascular disease.[20] The incidence of sepsis is likely to be rising. In England,
data from the Hospital Episode Statistics (HES) released by the Health and Social Care Information Centre (HSCIC) in 2015
shows there were nearly 123,000 cases of sepsis recorded alone in 2013/14.[21]
Aetiology
Causative agents vary significantly depending on the region, hospital size, season, and type of unit (neonatal,
transplantation, oncology, or haemodialysis units).[22] [23] [24] [25] [26] [27] [28] [29] [30] [31]
It should be noted that pathogenic organisms are identified in only around half of cases of sepsis.[32] Where organisms
are identified, bacteria (gram-positive and gram-negative) are identified as the causative organism in approximately 90%
of cases, with gram-positive bacteria and fungal infections increasing in frequency.[33] Since the mid-1980s, the frequency
of gram-positive sepsis (mainly caused by Staphylococcus aureus, coagulase-negative staphylococci, enterococci, and
streptococci) has surpassed that of gram-negative sepsis (mainly caused by Enterobacteriaceae, especially Escherichia
coli and Klebsiella pneumoniae, and by Pseudomonas aeruginosa). However, E coli remains the most prevalent pathogen
causing sepsis.[4] [19] [22] [34] [35] Some experts believe that the host response to some viral infections so closely
mimics sepsis that it should be considered as such.
In the majority of cases of sepsis arising in the community, the causative organisms will be sensitive, frequently endogenous
bacteria. In the UK, a report of the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) study in
sepsis published in November 2015 highlighted that nearly 75% of cases of sepsis arose as a result of community-acquired
infection.[32] However, it should be acknowledged that resistance patterns of organisms continue to change and can
differ greatly according to region. For example, in one large multi-centre European study, >50% of isolates in ICU were
methicillin-resistant S aureus (MRSA).[36] Over the last two decades, vancomycin-resistant enterococci (VREs) have
emerged, with >10% of enterococci being VREs.[37] Just as concerning is the significant number of E coli isolates that
are now resistant to amoxicillin/clavulanic acid (around 40%).[38] MRSA is increasingly prevalent in the community, with
community-acquired MRSA presenting as a severe pneumonia, often with cavitation, in patients with a recent coryzal
illness. In the UK, sepsis is the most common direct cause of maternal death, ahead of venous thromboembolism.[39]
Following pregnancy (in the 6-week postnatal period), group A streptococci are the most common causative agent.[40]
Studies tend to broadly concur on the relative frequencies of sources of infection.[10] [36] In the SOAP study, the
respiratory tract accounted for 60%; the bloodstream 20%; abdomen 26%; skin 14%; and urinary system 12%.[36] The
Surviving Sepsis Campaign observational study of over 15,000 patients showed slightly fewer patients with respiratory
BMJ Best Practice topics are regularly updated and the most recent version of the topics can be found on bestpractice.bmj.com . Use
5
sources (44.4%) and a greater frequency of urosepsis (20.8%).[10] However, in 20% to 30% of patients, a definite source
of infection is not found.[13]
The leading fungal pathogen causing sepsis has been identified as Candida.[22] In a European point-prevalence study,
BASICS
fungi were isolated from 17% of ICU patients with nosocomial infection.[41] Fungi are more prevalent as isolates in
patients with secondary or tertiary peritonitis, with Candida identified in up to 20% of patients with GI tract perforation.[42]
Risk factors include faecal soiling of the peritoneum, recurrent GI perforation, immunosuppressive therapy for neoplasm
or in post-transplant patients, and the presence of inflammatory diseases. These patients carry a high risk of mortality.[43]
Pathophysiology
Sepsis is a syndrome comprising an immune system-mediated collection of physiological responses to an infectious

agent. Clinical signs such as fever, tachycardia, and hypotension are common but the clinical course depends on the
type and resistance profile of infectious organism, the site and size of the infecting insult, and the genetically determined
or acquired properties of the host's immune system.
Immune-system activation:
• Pathogen entry and survival is facilitated by tissue contamination (surgery or infection), foreign body insertion
(catheters), and immune status (immunosuppression).[44]
• The innate immune system is activated by bacterial cell wall products, such as lipopolysaccharide, binding to host
receptors, including Toll-like receptors (TLRs).[45] [46] These are widely found on leukocytes and macrophages,
and some types are found on endothelial cells.[47] At least 10 TLRs have been described in humans. These have
specificity for different bacterial, fungal, or viral products, and genetic polymorphisms are associated with a
predisposition to shock with gram-negative organisms.[48]
• Activation of the innate immune system results in a complex series of cellular and humoural responses, each with
amplification steps:[7]
• Pro-inflammatory cytokines such as tumour necrosis factor (TNF)-alpha and interleukins 1 and 6 are released,
which in turn activate immune cells.
• Reactive oxygen species, nitric oxide (NO), proteases, and pore-forming molecules are released, which bring
about bacterial killing. NO is responsible for vasodilatation and increased capillary permeability, and has
been implicated in sepsis-induced mitochondrial dysfunction.[49]
• The complement system is activated, and mediates activation of leukocytes, attracting them to the site of
infection where they can directly attack the organism (phagocytes, cytotoxic T lymphocytes), identify it for
attack by others (antigen presenting cells, B lymphocytes), ‘remember’ it in case of future infection (memory
cells, B lymphocytes), and cause the increased production and chemotaxis of more T helper cells.[50]
The endothelium and coagulation system:
• The vascular endothelium plays a major role in the host’s defence to an invading organism, but also in the
development of sepsis. Activated endothelium not only allows the adhesion and migration of stimulated immune
cells, but becomes porous to large molecules such as proteins, resulting in the tissue oedema.
• Alterations in the coagulation systems include an increase in procoagulant factors, such as plasminogen activator
inhibitor type I and tissue factor, and reduced circulating levels of natural anticoagulants, including antithrombin
III and activated protein C (APC), which also carry anti-inflammatory and modulatory roles.[51] [52]
BASICS
Inflammation and organ dysfunction:
• Through vasodilatation (causing reduced systemic vascular resistance) and increased capillary permeability (causing
extravasation of plasma), sepsis results in relative and absolute reductions in circulating volume.
• A number of factors combine to produce multiple organ dysfunctions. Relative and absolute hypovolaemia are
compounded by reduced left ventricular contractility to produce hypotension. Initially, through an increased heart
rate, cardiac output increases to compensate and maintain perfusion pressures, but as this compensatory mechanism
becomes exhausted, hypoperfusion, and shock may result.
• Impaired tissue oxygen delivery is exacerbated by pericapillary oedema. This means that oxygen has to diffuse a
greater distance to reach target cells. There is a reduction of capillary diameter due to mural oedema and the
pro-coagulant state results in capillary microthrombus formation.
• Additional contributing factors include disordered blood flow through capillary beds, resulting from a combination
of shunting of blood through collateral channels and an increase in blood viscosity secondary to loss of red cell
flexibility.[53] As a result, organs may become hypoxic, even though gross blood flow to an organ may increase.
These abnormalities may lead to lactic acidosis, cellular dysfunction, and multi-organ failure.[54]
• Cellular energy levels fall as metabolic activity begins to exceed production. However, cell death appears to be
uncommon in sepsis, implying that cells shut down as part of the systemic response. This could explain why relatively
few histological changes are found at autopsy, and the eventual rapid resolution of severe symptoms, such as
complete anuria and hypotension, once the systemic inflammation resolves.[55]
Classification
Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)
(2016)[1]
• Sepsis has been redefined as life-threatening organ dysfunction caused by a dysregulated host response to an
infection.
• Owing to revisions to the definition of sepsis, the term 'severe sepsis' (as previously defined in the 1991/2001
international consensus definitions) should be made redundant.
• Septic shock has also been re-defined as a subset of sepsis in which particularly profound circulatory, cellular, and
metabolic abnormalities are associated with a greater risk of mortality than with sepsis alone. Septic shock can be
defined clinically as a patient diagnosed with sepsis, with persistent hypotension requiring vasopressors to maintain
a mean arterial pressure (MAP)≥ 65 mmHg, and a lactate level> 2 mmol/L (>18 mg/dL), despite adequate fluid
resuscitation.
7
First International Consensus Definitions for Sepsis and Septic Shock (1991)[5]
[8] [10]
• In the 1991 definitions (which were reviewed in 2001) sepsis is defined as a systemic inflammatory response to a
BASICS
new infection, and severe sepsis is defined as sepsis associated with organ dysfunction, hypoperfusion, or
hypotension.
• Sepsis with hypoperfusion is defined by the presence of acute circulatory failure, characterised by arterial hypotension
(systolic BP <90 mmHg, reduced by >40 mmHg from baseline or mean arterial pressure [MAP] of <65 mmHg), or
other evidence of hypoperfusion, such as serum lactate >2 mmol/L (>18 mg/dL).
• Septic shock is defined as being present when hypoperfusion persists for at least 1 hour despite adequate fluid
resuscitation and is unexplained by other causes. However, hypoperfusion is in itself a clinical emergency and
should be corrected as soon as is practicable. The distinction between hypoperfusion and shock in this context is
theoretical; in reality the urgency is identical.
Although the 1991 definitions have been superseded by the 2016 Sepsis-3 definitions, these changes have prompted
much debate and the 1991 definitions remain in widespread clinical use while the controversies are resolved.
Sepsis: recognition, diagnosis and early management (National Institute for

Health and Care Excellence, 2016)[9]
In 2016, the UK National Institute for Health and Care Excellence (NICE) published guidelines on sepsis recommending
that patients with suspected sepsis should be stratified according to risk of severe illness or death from sepsis (i.e., low
risk, moderate to high risk, and high risk).
Sepsis in adults Diagnosis
Case history
Case history #1
A 78-year-old woman presents to hospital for an elective right haemicolectomy. She has a past medical history of
hypertension, angina on exertion, and diabetes mellitus. She is independently mobile, does her own shopping, and
has a 30-pack-a-year history of smoking. The operation was uncomplicated. On day 5 post-surgery, she becomes
confused. On examination, she has a Glasgow Coma Scale score of 14/15. She has a temperature of 38.5°C (101.3°F),
a respiratory rate of 28 breaths/minute, and oxygen saturations of 92% on 2 L of oxygen. She is tachycardic at 118
bpm, and her BP is 110/65 mmHg. On chest auscultation, she has coarse crackles in the right lower zone. Her surgical
wound appears to be healing well and her abdomen is soft and not tender.
Other presentations
Sepsis may complicate benign primary infections found in any age group and requires a high suspicion for the clinical
signs of systemic inflammatory response (tachycardia, fever, tachypnoea, or respiratory compromise).
Altered mental status may also be a presenting feature, especially in older patients. Mild disorientation or confusion
is common with more severe presentations, including significant anxiety, agitation, and loss of consciousness.
Other features that may be present include reduced urine output; a mottled or ashen appearance; cyanosis of skin,
lips, or tongue; or presence of a non-blanching rash on the skin.[9]
Step-by-step diagnostic approach

Sepsis is a spectrum of disease, where there is a systemic and dysregulated host response to an infection.[1] Presentation
may range from non-specific or non-localised symptoms (e.g., feeling unwell with a normal temperature), to severe signs
with evidence of multi-organ dysfunction and septic shock. Risk of progression to fulminant disease is determined by
various factors, including:
DIAGNOSIS
• Magnitude and nature of the infective focus
• Timing and quality of interventions
• Genetic and acquired predisposition of the patient.
Early recognition and diagnosis is essential because early treatment is associated with significant short- and long-term
benefits in outcome.[59] [60] [61] [62] [63] [9]
Diagnostic criteria
There is ongoing debate about the most appropriate criteria for diagnosing sepsis in clinical practice, with several
different approaches suggested. These include use of the systemic inflammatory response syndrome (SIRS) criteria
in the presence of infection; the Sequential (or sepsis-related) Organ Failure Assessment (SOFA) score recommended
by the Sepsis-3 international consensus group; and use of a risk stratification system as recommended by guideline
groups in the US and UK.
In practice, sepsis is usually diagnosed by the clinical identification of an infection in a patient who meets the clinical
criteria for SIRS. According to the international consensus definition published in 1991 (and reviewed in 2001), SIRS
9
is defined by the presence of two or more criteria from a collection of clinical signs and laboratory investigations as
follows. (Hyperglycaemia and acutely altered mental status are not part of the original criteria for SIRS, but have since
been included by the Surviving Sepsis Campaign in their screening tool.)[5] [Surviving Sepsis Campaign: evaluation
for severe sepsis screening tool]
• Temperature> 38.3°C (101°F) or <36.0°C (96.8°F)
• Tachycardia> 90 bpm
• Tachypnoea> 20 breaths/minute or PaCO2 <4.3 kPa (32 mmHg)
• Leukocytosis (WBC count> 12x10^9/L [12,000/microlitre])
• Leukopenia (WBC count <4x10^9/L [4000/microlitre])
• Normal WBC count with> 10% immature forms.
• Hyperglycaemia (blood glucose> 7.7 mmol/L [>140 mg/dL]) in the absence of diabetes mellitus
• Acutely altered mental status.
In 2016, the definition of sepsis was updated by the Third International Consensus Group (Sepsis-3) to reflect greater
understanding of the disease. This step was taken because the SIRS criteria were found to be too non-specific to be
useful in defining sepsis: they defined sepsis as life-threatening organ dysfunction caused by a dysregulated host
response to an infection. Rather than using the SIRS criteria to identify these patients (upon which the previous
definition was based), the Sepsis-3 advised that sepsis should be defined using the SOFA criteria.[1] The SOFA score
is calculated based on the assessment of the following systems (with a score of ≥2 in a patient with a suspected
infection being suggestive of sepsis):[1]
DIAGNOSIS
Sequential (or Sepsis-related) Organ Failure Assessment (SOFA) criteria
Created by BMJ, adapted from Vincent JL, Moreno R, Takala J, et al. The SOFA (Sepsis-related Organ Failure Assessment) score
to describe organ dysfunction/failure. On behalf of the Working Group on Sepsis-Related Problems of the European Society
of Intensive Care Medicine. Intensive Care Med 1996;22:707-710.
As the SOFA score has primarily been validated on patients in an ICU setting and requires multiple laboratory test
results, the Third International Consensus Group suggested the use of the 'quick SOFA' (qSOFA) as a bedside assessment
to identify those at risk of deterioration due to sepsis. This is a simple clinical assessment that assesses for the presence
of at least 2 of the following:[1]
• Altered mental state
• Systolic blood pressure ≤100 mmHg
• Respiratory rate≥ 22 breaths/minute.
However, since the introduction of qSOFA, a large study in the US found that it had poor sensitivity (particularly when
compared with other bedside early warning scores and the SIRS criteria) and was a late indicator of deterioration.[64]
Further studies will be needed to determine the optimal screening methods for early recognition of sepsis.
The 2016 Sepsis-3 definitions also recommend that the term 'severe sepsis', as previously defined, should be made
redundant in light of revisions to the definition of sepsis.[1] Septic shock has also been redefined as a subset of sepsis
in which profound circulatory, cellular, and metabolic abnormalities are associated with a greater risk of mortality
than with sepsis alone.[1] According to the 2016 international consensus definition, septic shock should be defined
as sepsis with both of the following (despite adequate volume resuscitation):[1]
• Persistent hypotension requiring vasopressors to maintain mean MAP ≥65 mmHg, and
• Serum lactate> 2 mmol/L (>18 mg/dL).
DIAGNOSIS
Patients with septic shock (as defined by the Sepsis-3) are associated with hospital mortality rates greater than 40%.[1]
In 2016, the National Institute for Health and Care Excellence (NICE) published guidelines which focus on the early
recognition and identification of sepsis.[9] In a move away from the SIRS and SOFA criteria recommended by the
international consensus definitions, the NICE guidelines recommend a risk stratification approach to identify early
those patients at highest risk. The approach involves categorising a patient as being at low risk, moderate to high risk,
or high risk of severe illness or death from sepsis, based on the following criteria:
• History (altered behaviour; altered mental state; functional ability; impaired immunity; or recent trauma, surgery,
or invasive procedure)
• Respiratory (respiratory rate; new need for oxygen to maintain saturation)
• Systolic blood pressure
• Circulation and hydration (raised heart rate; urine output)
• Skin (signs of infection; mottled or ashen appearance; cyanosis of skin, lips, or tongue; non-blanching rash of
skin).
11
This focus on early identification of patients at risk of sepsis is shared with the American College of Emergency
Physicians (ACEP) Expert Panel on Sepsis in their tool DART (Detect, Act, Reassess, Titrate).[65] The NICE guidelines
also provide further recommendations for in-hospital clinical assessment and laboratory investigations (e.g., venous
blood test for blood gas, including glucose and lactate measurement; blood culture; FBC; CRP; urea and serum
electrolytes; creatinine; and coagulation) in patients with suspected sepsis based on their risk profile and symptoms.[9]
There are multiple scoring systems and definitions for sepsis and sepsis with organ dysfunction. None is perfect and
many seek to measure similar variables. Furthermore, the NICE sepsis guidelines published in the UK have highlighted
a limitation of the international consensus definitions in that they are unproven in the early identification of people
at risk of sepsis.[9] At present, SIRS and the earlier international consensus definitions of sepsis, severe sepsis, and
septic shock remain clinically established in most clinical settings.
Initial evaluation
Sepsis may present initially with non-specific, non-localised symptoms, such as feeling unwell with normal temperature.
Sepsis should be considered if a patient presents with signs or symptoms that indicate possible infection, regardless
of temperature.[9] This is because, although fever is frequently associated with sepsis, hypothermia is a common
presenting sign and carries a worse prognosis. [66] Initial assessment includes identifying the likely source of infection,
identifying risk factors for sepsis, determining the need for urgent source control (e.g., incision and drainage of an
abscess), and identifying abnormalities of behaviour, circulation, or respiration.
As for all acutely ill patients, initial evaluation should follow the ABCDE format, to include assessment of the airway,
respiratory, and circulatory sufficiency, and conscious level (Glasgow Coma Scale or AVPU [Alert, responds to Voice,
responds to Pain, Unresponsive]). Attention should be paid to seeking other signs of organ dysfunction (jaundice,
purpura fulminans,[Fig-2] cyanosis), and signs of circulatory insufficiency including oliguria, mottling of the skin, and
prolonged capillary refill times.[Fig-1] Oxygen saturation, respiratory rate, heart rate, BP, temperature, and accurate
hourly fluid balance (including urine output) should be monitored. It is important to seek clinical evidence for the
source of infection. This will aid diagnosis and provide vital information as to the patient's risk factors for sepsis. Risk
factors strongly associated with sepsis include: underlying malignancy, impaired immunity (e.g., due to illness or
drugs), recent surgery or other invasive procedures, breached skin integrity (e.g., wounds, skin infection), indwelling
catheter, intravenous drug misuse, age >65 years or frailness, pregnancy or recent pregnancy, haemodialysis, hx of
DIAGNOSIS
alcoholism, immunocompromise, and diabetes mellitus.
Sepsis is typically diagnosed when there are alterations in conscious level, hypotension, and organ failure, manifesting
as oliguria, hypoxaemia, jaundice, or petechial rash. However, delayed diagnosis and intervention are associated with
increased morbidity, and a high index of suspicion in all patients with abnormal signs and a possibility of infection
should be maintained.
Investigations
Initial investigations cover 4 purposes:
• To identify causative organisms
• To evaluate for organ dysfunction
• To identify the source of infection
• To prognosticate, to aid in the selection of an appropriate level of care.
Priority should be given to those investigations that will help to answer important clinical questions, such as the source
of infection and severity of illness. Cultures of blood and other fluids will take 48 to 72 hours to yield sensitivities of
causative organisms (if identified), but are far less sensitive if delayed until after antimicrobial administration.
Investigations to identify causative organisms:
• Blood cultures should be taken immediately, and preferably before antibiotics are started, provided their sampling
will not delay administration of antibiotics. Ideally, at least one set should be taken percutaneously, and one set
from any vascular access device that has been in situ for more than 24 hours.[67] [68] Other cultures (e.g.,
sputum, cerebrospinal fluid (CSF), pleural fluid, joint fluid, stool, and urine) should be taken as clinically indicated.
• If no localising signs are present, examination and culture of all potential sites of infection including wounds,
catheters, prosthetic implants, epidural sites, and pleural or peritoneal fluid, as indicated by the clinical
presentation and history, is required.
• If meningitis is suspected (e.g., headache, photophobia, neck stiffness, vomiting), a lumbar puncture (LP) for
CSF microscopy and culture should be performed. A CT scan prior to performing an LP to exclude raised
intracranial pressure is required if there is any clinical suspicion of this.
• If an enclosed collection such as an abscess or empyema is suspected, it is recommended that this be drained
and cultured early in the course of the illness (within 6 hours following identification).[69]
• Intubated patients in whom there is a suspicion of pneumonia should have tracheal aspirates, broncho-alveolar
lavage, or protected brush specimens taken.
Evaluation for organ dysfunction:
• Baseline assessment of liver function tests (notably bilirubin), an FBC (with differential), coagulation (INR, PTT),
serum creatinine, and blood urea.
• Serum electrolytes and glucose are frequently deranged, and should be measured at baseline and regularly
DIAGNOSIS
until the patient improves.
• Elevated serum lactate highlights tissue hypoperfusion, and is most reliably assessed using an arterial blood
gas (ABG) sample.[70] However, in practice, a venous blood gas (VBG) sample is generally used, as it is generally
easier and quicker to obtain compared with ABG. Most patients do not undergo ABG sampling unless there is
respiratory compromise.
• Markers of inflammation, including CRP and procalcitonin, are of use in determining clinical progress and
response to therapy. Serial measures of procalcitonin can be useful as a guide to the need to continue or stop
empiric antibiotics.[71] However, evidence for the prognostic value of procalcitonin is unclear,[72] and the use
of procalcitonin in the identification of sepsis is excluded from many guidelines.
Investigations to identify the source of the infection:
• The source of infection may be immediately evident; for example, with classical signs and symptoms of pneumonia
(purulent sputum, dyspnoea, tachypnoea, cyanosis) or peritonism (abdominal pain, guarding, distension,
tenderness, absent bowel sounds). However, in many patients the origin must be actively sought.
13
• Diagnostic studies may identify a source of infection that requires removal of a foreign body or drainage to
maximise the likelihood of a satisfactory response to therapy. Chest x-rays and ultrasound scans can be performed
at the bedside. Examinations such as CT scanning require transfer of potentially unstable patients and the
benefit should be weighed against the risk.
• In patients at risk of, or with symptoms compatible with, bacterial endocarditis, a transthoracic or
transoesophageal echocardiogram is useful. This is also helpful to differentiate between hypovolaemic, cardiac,
and septic shock, as well as alternative diagnoses such as valvular abnormalities, pulmonary embolus, myocardial
ischaemia (with segmental or global dysfunction), hypovolaemia, and pulmonary hypertension. If readily available,
an echocardiogram may also be appropriate in patients with sepsis of unknown origin.
• An ECG should be arranged to help exclude other differential diagnoses, including MI, pericarditis, and myocarditis.
Sepsis also predisposes to myocardial dysfunction (particularly in septic shock)[73] and arrhythmias (e.g., atrial
fibrillation).[9]
Certain investigations carry prognostic value and can help determine the need for critical care:
• Lactate measurement is a useful assessment of perfusion once a diagnosis of sepsis has been established.
Increasing levels of lactate are associated with increasing levels of anaerobic metabolism. Persistently elevated
lactate levels may parallel the degree of hypoperfusion or organ failure. High lactate carries adverse prognostic
value if elevated to >2 mmol/L (>18 mg/dL), and still worse outcomes are associated with levels >4 mmol/L
(>36 mg/dL).[9] Lactate clearance (the rate at which lactate is cleared over a period of 6 hours) has been
demonstrated to be as useful as more invasive tests, such as central venous oxygen saturation, in determining
a patient’s response to treatment.[74] [75]
• Studies with trauma patients have evaluated lactate levels against Acute Physiology and Chronic Health Evaluation
(APACHE) scores and lactate clearance rates and found lactate levels to be inferior in informing the prognosis.
However, an APACHE score takes 24 hours to calculate.[76]
• An alternative measure is serum procalcitonin levels. However, evidence for the prognostic value of procalcitonin
DIAGNOSIS
is unclear,[77] and the use of procalcitonin in the identification of sepsis is excluded from many guidelines.
Changes in procalcitonin levels may occur later than that of lactate, although changes in both markers combined
are highly predictive of outcome between 24 and 48 hours.[78] It may, therefore, have greater utility in permitting
early cessation of antimicrobial therapy.[72] [79]
• Some experts recommend the use of shock index (heart rate divided by systolic BP) as a predictor of requirement
for critical care, with one group finding an index of >0.9 to be predictive.[80]
• More recently, non-invasive impedance echocardiography has been shown, if a cardiac index of <2 is identified,
to predict poor outcome.[81]
Patients suffering from septic shock who have not responded to initial fluid resuscitation will require invasive monitoring
and treatment in high dependency units.
Emerging tests
The PhenoTest™ BC Kit can identify 14 species of bacteria and 2 species of yeast that commonly cause bloodstream
infections, while also providing guidance on antibiotic sensitivity. The test compares the organism's DNA to a database,
and then uses time-lapse images to analyse the organism’s response to antibiotics. It can identify a positive blood
culture in 1.5 hours and guide antibiotic treatment in 6.5 hours. However, the test has been associated with false
positive results.[82]
A number of other rapid detection methods for early pathogen detection and antimicrobial susceptibility testing are
in clinical testing at present. Such assays could be of significant value in the personalised care of septic patients in
the near future.
Risk factors
Strong
underlying malignancy
• Incidence rates of sepsis are up to 995 cases per 100,000 per year in patients with malignancy. Immunosuppression
(including both the severity and duration of neutropenia where present), recurrent infections, invasive
catheterisations, and treatment of resistant organisms contribute to the increased risk (odds ratio [OR] 9.77, 95%
confidence interval [CI] 9.67 to 9.88).[35]
age >65 years

• Associated with an increased risk of sepsis (relative risk [RR] 7.0, 95% CI 5.6 to 8.7).[19]
• Risk of sepsis is particularly high in people aged >75 years or those who are frail.[9]
immunocompromise
• Associated with an increased risk of sepsis.
• Immunocompromise may arise from treatment (e.g., chemotherapy, corticosteroids, or other immunosuppressants),
underlying disease (e.g., diabetes, sickle cell), or surgery (e.g., splenectomy).[9] [56]
haemodialysis
• Associated with an increased risk of sepsis (RR 208.7, 95% CI 142.9 to 296.3).[19]
alcoholism
DIAGNOSIS
• Associated with an increased risk of sepsis (RR 5.6, 95% CI 3.8 to 8.0).[19]
diabetes mellitus
• Decreased resistance to infections, complications of diabetes, and increased surgical complications play a role (RR
5.9, 95% CI 4.4 to 7.8).[19]
recent surgery or other invasive procedures

• Risk of sepsis is high in people who have had surgery or other invasive procedures in the past 6 weeks.[9]
• Risk of sepsis is particularly high following oesophageal, pancreatic, or elective gastric surgery.[57]
breached skin integrity

• Risk of sepsis is high in people with any breach of skin integrity (e.g., cuts, burns, blisters, or skin infection).[9]
indwelling lines or catheters

• Risk of sepsis is high in people with indwelling lines or catheters.[9]
intravenous drug misuse

• Risk of sepsis is high in people who misuse drugs intravenously.[9]
15
pregnancy
• Pregnancy or recent pregnancy is a risk factor for the development of sepsis.[9] In the UK, the estimated incidence
of sepsis in pregnancy has been reported to be 47 cases per 100,000 maternities per year,[58] whereas the estimated
annual incidence among people aged 18 to 19 years in a general population has been reported to be around 29.6
cases per 100,000.[13]
• Risk of sepsis among women may be higher if they have impaired immunity, gestational diabetes, diabetes (or
other comorbid condition), needed invasive procedures during pregnancy (e.g., caesarean section, forceps delivery,
removal of retained products of conception), had prolonged rupture of membranes during pregnancy, have or
have been in close contact with people with group A streptococcal infection (e.g., scarlet fever), or have continued
vaginal bleeding or an abnormal vaginal discharge with odour.[9]
Weak
urban residence
• May predispose to increased exposure to infections and drug-resistant pathogens (RR 2.4, 95% CI 1.2 to 5.6).[19]
lung disease
• Weakly associated with sepsis (RR 3.8, 95% CI 2.6 to 5.4).[19]
male sex
• May be at greater risk (OR 1.28, 95% CI 1.24 to 1.32).[14]
non-white ancestry
• May be at increased risk (OR 1.90, 95% CI 1.80 to 2.00).[14]
winter season
• Seasonal infections (e.g., respiratory infections in winter) are weakly associated with sepsis.
• Sepsis is 1.4 times more likely to occur in the winter than in the autumn.[28]
DIAGNOSIS
History & examination factors

Key diagnostic factors
presence of risk factors (common)

• Key risk factors include: underlying malignancy, age older than 65 years, immunocompromise, haemodialysis,
alcoholism, and diabetes mellitus.
high (>38°C) or low (<36°C) temperature (common)

• Temperature should not be used as the sole predictor of sepsis and should not be used to rule sepsis either in or
out.
• Fever may not be apparent in the following groups of people with sepsis: older people or those who are very frail,
people undergoing treatment for cancer, immunocompromised people, and severely ill people with sepsis.
• Temperature rise can result from a physiological response (e.g., after surgery or trauma).
tachycardia (common)
• Heart rate >90 bpm (>100 bpm in pregnant women).
tachypnoea (common)
• Respiratory rate >20 breaths/minute.
acutely altered mental status (common)

• Due to impaired cerebral perfusion and inflammatory cytokines.
poor capillary refill, mottling of the skin, or ashen appearance (common)

• Signs of circulatory insufficiency.[Fig-1]
signs associated with specific source of infection (common)

• The source of infection may be immediately evident; for example, with classical signs and symptoms of pneumonia
(purulent sputum, dyspnoea, tachypnoea, cyanosis) or peritonism (abdominal pain, guarding, distension, tenderness,
absent bowel sounds). However, in many patients the origin must be actively sought.
low oxygen saturation (common)

• Sign of circulatory insufficiency.
arterial hypotension (common)

• Systolic BP <90 mmHg, mean arterial pressure (MAP) <65 mmHg, or reduction in systolic BP >40 mmHg from
baseline.
• May be present when sepsis leads to organ dysfunction.
• The use of vasopressor agents to correct hypotension does not exclude shock.
decreased urine output (common)

• Urine output <0.5 mL/kg/hour for at least 2 hours, or no urine passed in the last 18 hours.
cyanosis (common)
• Sign of circulatory insufficiency.
DIAGNOSIS
Other diagnostic factors
purpura fulminans (common)
• Sign of organ dysfunction.[Fig-2]
jaundice (uncommon)
• Sign of organ dysfunction.
ileus (uncommon)
17
Diagnostic tests
1st test to order
Test Result
FBC with differential WBC count >12×10^9/L
(12,000/microlitre)
• WBC count is sensitive but not specific for the diagnosis of sepsis.
• Non-infectious injury (e.g., crush injury), cancer, and immunosuppressive agents (leukocytosis); WBC count
<4×10^9/L (4000/microlitre)
can also cause either increased or decreased WBC counts.
• Thrombocytopenia of non-haemorrhagic origin may occur in patients who are (leukopenia); or a normal WBC
count with >10% immature
severely ill with sepsis.
forms; low platelets
blood urea and serum electrolytes serum electrolytes frequently

• Blood urea is performed with serum creatinine to evaluate for renal dysfunction. deranged; blood urea may be
elevated
• Serum electrolytes should be measured at baseline and regularly until the
patient improves.
serum creatinine may be elevated
• Elevated creatinine may occur in sepsis associated with renal dysfunction.
LFT elevated bilirubin, ALT, AST,
alkaline phosphatase, and
• Baseline test.
gamma-GT
• Sepsis can originate from hepatic or peri-hepatic infections.
• Comorbidity of underlying hepatic disease can affect drug metabolism and
outcome in sepsis.
• Septic shock can compromise hepatic blood flow and metabolism, including
lactate.
coagulation studies (INR, aPTT) may be prolonged
• Baseline test, especially before central line placement.
serum glucose may be elevated or, more
• May be elevated, with or without known history of diabetes, due to the stress rarely, low
DIAGNOSIS
response and to altered glucose metabolism.

• Hyperglycaemia is associated with increased morbidity and mortality.
• Spontaneous or iatrogenic hypoglycaemia also poses significant dangers.[83]
[84]
• The Surviving Sepsis Campaign recommends the maintenance of
normoglycaemia (above lower limit of normal, but <10 mmol/L [180 mg/dL]),
preferably with the use of an insulin infusion protocol.[79]
• Rarely, glucose may be low, suggesting acute liver failure.
lactate levels may be elevated; levels >2
• Elevated serum lactate highlights tissue hypoperfusion, and is most reliably mmol/L (>18 mg/dL)
associated with adverse
assessed using an ABG sample.[70]
• Increasing levels of lactate are associated with increasing levels of anaerobic prognosis; even worse
prognosis with levels >4
metabolism. Persistently elevated lactate levels may parallel the degree of
mmol/L (>36 mg/dL)
malperfusion or organ failure.
• High lactate carries adverse prognostic value if elevated to >2 mmol/L (>18
mg/dL), and still worse outcomes are associated with levels >4 mmol/L (>36
mg/dL).
• Lactate clearance (the rate at which lactate is cleared over a period of 6 hours)
has been demonstrated to be as useful as more invasive tests, such as central
venous oxygen saturation, in determining a patient’s response to treatment.[74]
[75]
Test Result
CRP elevated
• Baseline test. A marker for inflammation.
blood culture may be positive for organism
• Blood cultures should be taken immediately, and preferably before antibiotics
are started, provided their sampling will not delay administration of antibiotics.
• Ideally, at least one set should be taken percutaneously, and one set from any
vascular access device that has been in situ for more than 24 hours.[67] [68]
other cultures (e.g., of sputum, stool, urine, wounds, catheters, prosthetic may be positive for organism
implants, epidural sites, pleural or peritoneal fluid)
• Other cultures (for example, of sputum, stool, and urine) should be taken as
clinically indicated.
• If meningitis is suspected, a lumbar puncture (LP) for CSF microscopy and
culture should be performed. A CT scan prior to performing a LP to exclude
raised intracranial pressure is required if there is any clinical suspicion of this.
• If an enclosed collection such as an abscess or empyema is suspected, it is
recommended that this be drained and cultured early in the course of the
illness (within 6 hours following identification).[69]
• Intubated patients, in whom there is a suspicion of pneumonia, should have
tracheal aspirates, broncho-alveolar lavage, or protected brush specimens
taken.
• If no localising signs are present, examination and culture of all potential sites
of infection, including wounds, catheters, prosthetic implants, epidural sites,
and pleural or peritoneal fluid, as indicated by the clinical presentation and
history, is required.
arterial blood gas (ABG) or venous blood gas (VBG) PaCO2 <4.3 kPa (32 mmHg) is
one of the diagnostic criteria
• ABG evaluation facilitates optimisation of oxygenation, and is indicative of
for systemic inflammatory
metabolic status (acid-base balance).
response syndrome (SIRS); may
• In ventilated patients, it helps to determine optimal positive end-expiratory
be hypoxaemia, hypercapnia
pressure (PEEP), while minimising adverse levels of inspiratory pressure and
unnecessarily high FiO2.
• Differentiation of respiratory from metabolic acidosis allows metabolic demands
DIAGNOSIS
to be identified and treated.
• Lactate levels are most reliably assessed using an ABG sample. However, in
practice, a venous blood gas (VBG) sample is often used, as it is generally easier
and quicker to obtain compared with ABG. Most patients do not undergo ABG
sampling unless there is a respiratory component.
• Repeat blood gases are indicated depending on the clinical state of the patient.
chest x-ray may show evidence of
• Required to look for cause of sepsis. infection, such as consolidation
• A chest x-ray is always indicated after central venous pressure and endotracheal or pleural effusion, cardiac
abnormalities, or a
tube placement to rule out malposition and complications.
pneumothorax
ECG may show evidence of

ischaemia, atrial fibrillation, or
• An ECG should be arranged to help exclude other differential diagnoses,
other arrhythmia; may be
including myocardial infarction, pericarditis, and myocarditis. Sepsis also
normal
predisposes to myocardial dysfunction (particularly in septic shock)[73] and
arrhythmias (e.g., atrial fibrillation).[9]
19
Other tests to consider
Test Result
lumbar puncture elevated WBC count, presence
• Performed if meningitis suspected, provided no suspicion of raised intracranial of organism on microscopy,
and positive culture
pressure. A CT scan is required prior to performing an LP to exclude raised
intracranial pressure if there is any clinical suspicion of this.
• Bacterial meningitis: WBC count >1×10^9/L (1000/microlitre); protein is
elevated; glucose is normal or reduced; cell differential is predominantly
neutrophils.
• Viral meningitis may be associated with lower WBC counts and predominant
lymphocytes.
echocardiogram (transthoracic or transoesophageal) inadequate left ventricular
• A transthoracic or transoesophageal echocardiogram is useful in patients at filling suggests hypovolaemia;
vegetations, if endocarditis is
risk of, or with symptoms compatible with, bacterial endocarditis.
• If readily available, may also be appropriate in patients with sepsis of unknown cause of sepsis
origin.
• Also helpful to differentiate between hypovolaemic, cardiac, and septic shock.
• May determine alternative diagnoses, such as valvular abnormalities, pulmonary
embolus, myocardial ischaemia, segmental or global dysfunction, hypovolaemia,
and pulmonary hypertension.
ultrasound scan may demonstrate abscess, fluid
collection, pneumoperitoneum
• Including but not limited to abdominal ultrasound scan.
from perforated viscus,
• May indicate source of infection (e.g., dilated common bile duct indicating
obstruction of GI/renal/biliary
biliary obstruction).
tracts
CT chest or abdomen abscess, effusion may be

demonstrated
• If clinically indicated to establish source of infection.
• Requires transfer of potentially unstable patients and the benefit should be
weighed against the risk.
serum procalcitonin elevated
DIAGNOSIS
• Evidence for the prognostic value of procalcitonin is unclear,[77] and its use
in the identification of sepsis is excluded from many guidelines.
• Changes in procalcitonin levels may occur later than that of lactate, although
changes in both markers combined are highly predictive of outcome between
24 and 48 hours.[78] It may, therefore, have greater utility in permitting early
cessation of antimicrobial therapy.[72]
• Seldom used in practice.
Emerging tests
Test Result
PhenoTest™ BC Kit may be positive for organism
• Can identify 14 species of bacteria and 2 species of yeast that commonly cause and guide antimicrobial therapy
bloodstream infections, while also providing guidance on antibiotic sensitivity.
• Compares the organism's DNA to a database, and then uses time-lapse images
to analyse the organism’s response to antibiotics.
• Can identify a positive blood culture in 1.5 hours and guide antibiotic treatment
in 6.5 hours.
• Has been associated with false positive results.[82]
Differential diagnosis
Condition Differentiating signs / Differentiating tests

symptoms
Non-infectious causes of • SIRS can result as a non-specific • Specific tests are directed by
systemic inflammatory finding from a host of other clinical suspicion of underlying
response syndrome (SIRS) disease states, including cause.
postoperative recovery, trauma, • Associated medical interventions
burns, transplant rejection, (e.g., catheterisation, surgical
hyperthyroidism, Addisonian procedures, ventilation) can
crisis, blood product transfusion subsequently lead to
reactions, serum sickness, superimposed infections to make
immunisations, and CNS sepsis a continual threat and
infarction or haemorrhages. possibility.
Myocardial infarction (MI) • Symptoms suggesting MI are • Ischaemic changes on ECG.

central, squeezing chest pain • Elevated CK-MB and troponin.
radiating down the left arm or into
the jaw. Pain may be felt in the
epigastric region.
• Patients may present in
cardiogenic shock.
Pericarditis • Patients present with sharp, • ECG may have upward concave
stabbing, pleuritic chest pain ST-segment elevation globally and
(typically better on sitting up and PR-segment depression.
leaning forward, and worse with • Echo may demonstrate a
lying down). pericardial effusion; absence of
LV wall motion abnormalities.
Myocarditis • Patients typically present with a • ECG may show non-specific

viral prodrome, dyspnoea, or ST-segment and T-wave
underlying autoimmune abnormalities.
condition, such as SLE. • Inflammatory markers may be
DIAGNOSIS
• Medications such as antibiotics, elevated.
thiazide diuretics, antiepileptics, • Two-dimensional echo
digoxin, lithium, amitriptyline, and demonstrates global and regional
dobutamine may be suggestive LV motion abnormalities and
of drug aetiology. dilatation.
Acute pancreatitis • May present with abdominal pain • Elevated serum amylase, lipase,
and hypovolaemia. glucose; low calcium.
• There may be a history of
gallstones, alcohol use, or viral
infections (e.g., mumps).
Massive pulmonary embolism • Presents with acute dyspnoea, • CT pulmonary angiogram shows
pleuritic chest pain, and a filling defect in the pulmonary
hypotension. arteries.
21
Condition Differentiating signs / Differentiating tests

symptoms
Leukaemia • May present with fever, • Biopsies of blood smear, bone
leukocytosis, anaemia, marrow, tumour, or lymph nodes
tachycardia, multi-organ may identify neoplastic cells.
dysfunction, and dyspnoea and • Identification of a specific
thus meet diagnostic criteria for infectious agent is definitive in
(suspected) sepsis. differentiating sepsis from SIRS.
• The immunocompromise may
additionally facilitate
development of infections or the
increased clinical suspicion of
undiagnosed infection.
Malignant hyperthermia • This is a rare condition • The caffeine-halothane

characterised by severe contracture test (CHCT) is most
hyperthermia (>41.1°C [106°F]) commonly used to screen for
and muscle rigidity following susceptibility, as ryanodine
administration of anaesthetic receptor gene (RYR1)
agents (e.g., succinylcholine for identification is gaining in clinical
intubation). Lactic acidosis, importance.[86]
hyperkalaemia, rhabdomyolysis, • The CHCT requires muscle biopsy
hypoxia, and arrhythmias may also and testing in select regional
occur.[85] laboratories after resolution of the
• Malignant hyperthermia is an episode.
inherited disorder (autosomal • Neither test is clinically useful to
dominant) and a high index of direct therapy in the acute
suspicion is necessary if there is situation.
a positive family history.[85]
Drug-induced fever and coma • This includes neuroleptic • Clinical diagnosis. Specific tests
malignant syndrome, are not readily available.
serotonergic syndrome, delirium
tremens, and metformin lactic
acidosis.
DIAGNOSIS
• History of causative drug use.
Diagnostic criteria
There are multiple scoring systems and definitions for sepsis and sepsis with organ dysfunction. None is perfect and
many seek to measure similar variables. The systemic inflammatory response syndrome (SIRS) criteria and the 1991/2001
international consensus definitions of sepsis, severe sepsis, and septic shock remain clinically established in most clinical
settings. The Sequential (Sepsis-related) Organ Failure Assessment (SOFA) score is recommended in the 2016 international
consensus definitions, and may replace SIRS, but it is important to recognise that the clinical utility of any score relies
on individual practitioner clinical assessment and decision-making.
Third International Consensus definitions for sepsis and septic shock (Sepsis-3)
(2016)[1]
1. Sepsis: the third international consensus definition of sepsis published in 2016 redefines sepsis as life-threatening
organ dysfunction caused by a dysregulated host response to infection. According to the 2016 consensus definitions,
an increase in SOFA score of 2 or more constitutes organ dysfunction. The SOFA score is calculated based on the
assessment of the following systems in the ICU setting:
• Respiratory (PaO2/FiO2 ratio)
• Neurological (as assessed by the Glasgow coma scale)
• Cardiovascular (mean arterial pressure [MAP] or administration of vasopressors)
• Coagulation (platelet count)
• Renal (creatinine level and urine output)
• Hepatic (bilirubin level).
The 2016 consensus definitions recommend that the SOFA criteria should replace the previously recommended SIRS
criteria. Furthermore, the 'quick' (q)SOFA criteria are recommended for use outside of the ICU setting to promptly identify
patients with suspected infection who are likely to have a poor outcome. According to the 2016 consensus definitions,
patients with 2 or more of the following qSOFA criteria are likely to have poor outcomes typical of sepsis:
• Alteration in mental status
• Systolic blood pressure ≤100 mmHg
• Respiratory rate ≥22 per minute.
2. Severe sepsis: in light of the revisions to the definition of sepsis, the 2016 consensus definitions recommend that the
term 'severe sepsis' (as defined in the 1991/2001 consensus definitions) should be made redundant.
3. Septic shock: the definition of septic shock has been redefined as a subset of sepsis in which particularly profound
circulatory, cellular, and metabolic abnormalities are associated with a greater risk of mortality than with sepsis alone.[1]
According to the 2016 consensus definitions, septic shock is defined as sepsis with both:
DIAGNOSIS
• Persistent hypotension requiring vasopressors to maintain MAP ≥65 mmHg, and
• Serum lactate level >2 mmol/L (>18 mg/dL) despite adequate volume resuscitation.
Revised International Consensus definitions for sepsis and septic shock: SIRS
in the presence of infection (2001)[5]
These criteria have in principle been superseded by the Sepsis-3 definitions. However, they remain in widespread use in
clinical practice.
1. Definitive diagnosis requires clinical identification of infection in a patient who also meets the clinical criteria for SIRS.
According to the revised consensus conference definition published in 2001, SIRS is defined by the presence of 2 or
more criteria from a collection of clinical signs and laboratory investigations as follows: [Surviving Sepsis Campaign:
evaluation for severe sepsis screening tool]
• Temperature >38.3°C (101°F) or <36.0°C (96.8°F)
• Tachycardia >90 bpm
23
• Tachypnoea >20 breaths/minute or PaCO2 <4.3 kPa (32 mmHg)
• Hyperglycaemia (blood glucose >7.7 mmol/L [>140 mg/dL]) in the absence of diabetes mellitus
• Acutely altered mental status
• Leukocytosis (WBC count >12×10^9/L [12,000/microlitre])
• Leukopenia (WBC count <4×10^9/L [4000/microlitre])
• Normal WBC count with >10% immature forms.
2. Sepsis: when SIRS is present in an individual patient and the cause is thought likely to be an infection, sepsis is present.
3. Severe sepsis: present when sepsis leads to dysfunction of 1 or more organ systems, and includes the subset septic
shock. Organ dysfunction variables are:
• Arterial hypoxaemia (PaO2/FiO2 ratio <300) with new pulmonary infiltrates
• A new or increased oxygen requirement to maintain SpO2 >90%
• Acute oliguria (urine output <0.5 mL/kg/hour for at least 2 hours)
• Serum creatinine >176.8 micromol/L (2.0 mg/dL)
• Coagulation abnormalities (INR >1.5 or aPTT >60 seconds)
• Thrombocytopenia (platelets <100 × 10^9/L [100,000/microlitre])
• Hyperbilirubinaemia (total bilirubin >68.42 micromol/L [4 mg/dL])
• Arterial hypotension (systolic BP <90 mmHg, mean BP <65 mmHg, or reduction in systolic BP >40 mmHg from
baseline)
DIAGNOSIS
• Serum lactate >2 mmol/L (>18 mg/dL).
4. Septic shock is defined as:
• Arterial hypotension (systolic BP <90 mmHg, mean BP <65 mmHg, or reduction in systolic BP >40 mmHg from
baseline) persisting for at least 1 hour, despite adequate fluid resuscitation, or
• Serum lactate >4 mmol/L (>36 mg/dL) after adequate fluid resuscitation.
The use of vasopressor agents to correct hypotension does not exclude shock.
Sepsis: recognition, diagnosis and early management (National Institute for

Health and Care Excellence, 2016)[9]
In the UK, the National Institute for Health and Care Excellence (NICE) has published guidance on the recognition,
diagnosis, and early management of sepsis, which includes specific criteria for risk stratification of adults with suspected
sepsis. The criteria are as follows:
Low risk of severe illness or death from sepsis:
• Normal behaviour
• No history of acute deterioration of functional ability, impaired immunity, or trauma/surgery in the past 6 weeks
• Normal respiratory rate (i.e., <21 breaths per minute) and no oxygen requirement to maintain saturation
• Normal blood pressure (i.e., systolic blood pressure >100 mmHg)
• Normal heart rate (i.e., ≤90 beats per minute; <100 beats per minute in pregnant women) and no new onset
arrhythmias
• Normal urine output in the past 18 hours
• Normal temperature
• No non-blanching rash.
Moderate to high risk of severe illness or death from sepsis:
• History of new onset of altered behaviour or mental state (reported by patient, friend, or relative)
• History of acute deterioration of functional ability
• Impaired immunity (e.g., from illness or drugs)
• Trauma, surgery, or invasive procedures in the past 6 weeks
• Respiratory rate 21-24 breaths per minute
• Systolic blood pressure 91-100 mmHg
• Heart rate 91-130 beats per minute (100-130 beats per minute in pregnant women), or new onset arrhythmia
• No urine passed in previous 12-18 hours (for catheterised patients, 0.5-1.0 mL/kg of urine passed per hour)
DIAGNOSIS
• Tympanic temperature <36°C
• Signs of potential infection (e.g., redness, swelling or discharge at surgical site, or breakdown of wound).
High risk of severe illness or death from sepsis:
• Objective evidence of new altered mental state
• Respiratory rate ≥25 breaths per minute
• New need for oxygen (>40% FiO2) to maintain saturation >92% (or >88% in known chronic obstructive pulmonary
disease)
• Systolic blood pressure ≤90 mmHg, or systolic blood pressure >40 mmHg below normal
• Heart rate >130 beats per minute
• No urine passed in previous 18 hours (for catheterised patients, <0.5 mL/kg of urine passed per hour)
25
• Mottled or ashen appearance; cyanosis of skin, lips, or tongue; non-blanching rash of skin.
Acute Physiology and Chronic Health Evaluation II score (APACHE II)[87]

The APACHE score is commonly used to establish illness severity in the ICU and predict the risk of death. [APACHE II
calculator] There is a high risk of death if the score is ≥25.
Other sepsis risk-scoring models

Several other models have been developed for use in the ICU, including APACHE III, the Simplified Acute Physiology
Score, and Mortality Probability Model II.[34] [88] [89]
Patient group-specific scoring systems have also been developed. For example, the Predisposition Insult Response and
Organ failure (PIRO) and Mortality in Emergency Department Sepsis (MEDS) scores have been developed to risk-stratify
patients with sepsis or septic shock who are admitted to the accident and emergency department;[90] the Sepsis in
Obstetrics Score (SOS) has been developed to risk-stratify pregnant or postnatal women with sepsis.[91] These scoring
systems can assist in the identification and management of sepsis in specific patient groups.[92]
There are numerous ongoing studies investigating techniques for 'staging' the severity of sepsis using a variety of
blood-borne markers.[77] [93] Although some techniques have shown initial promise, the evidence base remains weak,
and they have an unclear role in future clinical practice.
DIAGNOSIS
Sepsis in adults Treatment
Step-by-step treatment approach

Early recognition and treatment of sepsis is key to improving outcomes. Treatment guidelines have been produced by
the Surviving Sepsis Campaign and remain the most widely accepted standards.[79] Current best practice is based upon
evidence for care bundles in sepsis.[79] [94] [95] They include:
• Obtain blood cultures prior to administration of antibiotics
• Administer broad-spectrum antibiotics that target the suspected pathogen(s)
• Administer 30 mL/kg crystalloid for hypotension or lactate ≥4 mmol/L (≥36 mg/dL)
• Obtain serial measurement of blood lactate
• Use vasopressors to maintain a mean arterial pressure (MAP) ≥65 mmHg in patients refractory to fluid therapy
• In patients with an initial lactate ≥4 mmol/L (≥36 mg/dL), or who are persistently hypotensive (i.e., MAP <65 mmHg),
assess volume status and perfusion using either a repeat focused examination (including vital signs and
cardiopulmonary, capillary refill, pulse, and skin findings), or 2 of the following methods:
• Measurement of central venous pressure (CVP)
• Measurement of central venous oxygen saturation (ScvO2)
• Bedside cardiovascular ultrasound
• Dynamic assessment of fluid responsiveness with passive leg raise or fluid challenge.
In the UK, the National Institute for Health and Care Excellence (NICE) guidelines recommend administering crystalloid
if the patient has a lactate ≥2 mmol/L (≥18 mg/dL) and at least one high risk criterion.[9] Crystalloids are also recommended
if the patient has a lactate >2 mmol/L (>18 mg/dL) and at least two moderate to high risk criteria, or evidence of acute
kidney injury. Crystalloid can be considered in patients with a lactate <2 mmol/L (<18 mg/dL) if they have at least one
high risk criterion.[9]
The Sepsis Six

One bundle dealing with basic therapies, the ‘Sepsis Six’, has been shown to improve outcomes in septic patients. If
the 6 factors are completed within the first hour following recognition of sepsis, the associated mortality has been
reported to reduce by as much as 50%.[63] The 6 factors are as follows:
• Administer high-flow oxygen to maintain target oxygen saturations greater than 94% (or 88%-92% in people
at risk of hypercapnic respiratory failure)
• Take blood cultures
• Give intravenous antibiotics

TREATMENT
• Start intravenous fluid resuscitation
• Check lactate level
• Monitor hourly urine output.
27
Patients who are refractory to initial treatments, in particular those with septic shock, may require invasive monitoring
and consideration for organ support (e.g., central venous catheter and vasopressors), so management on a high
dependency unit or ICU may well be required.
One aspect of basic intervention, the delivery of appropriate rapid fluid challenges, is intended to restore the imbalance
between oxygen supply and demand to the tissues. Patients who fail to respond to the rapid delivery of adequate
volumes of intravenous fluids are in septic shock. The immediate priority in this group of patients is the restoration
of the circulation and oxygen delivery.
Early goal-directed fluid therapy has previously been the gold standard of care,[6] [59] [62] [83] [79] [96] [97] but
several randomised, prospective studies have found no discernible benefit with this therapy over usual care.[98] [99]
[100] [101] [102] However, the central tenets of early goal-directed therapy (e.g., restoration of circulating volume,
correction of hypotension, and assessing cardiac output) remain important to the management of sepsis and have
now become standard practice in many emergency departments.
Monitoring of vital signs and response to fluid therapy is essential. Assessment of oxygenation via pulse oximetry and
serial lactate measurements should be performed, along with monitoring of urinary output. A failure of lactate to
improve with therapy is indicative of a poor outcome. Lactate clearance has been shown to correlate positively with
survival.[74] All patients receiving vasopressors should have an arterial catheter inserted as soon as it is practical to
do so to aid more accurate monitoring of arterial blood pressure.[79]
Antibiotic therapy
Broad-spectrum intravenous antibiotics should be given before a pathogen is identified.[79] [103] [104] They are
recommended within the first hour once sepsis is diagnosed, preferably after cultures have been taken.[79] [9] The
delivery of appropriate antibiotics within the first hour is of critical importance in maximising chances of survival.[63]
[105] [106] [107]
Knowledge of locally prevalent pathogens and their antibiotic resistance patterns are important when deciding
empirical therapy.[103] [12] Empirical antibiotic recommendations will be necessarily individualised at the institutional
level, based on local antibiotic protocols. Once culture and sensitivity results are available, antibiotics can be tailored
to the known pathogens. Cultures should be repeated (e.g., at 6-hour to 8-hour intervals) if there are persistent or
repeated fever spikes, or there is the identification of a new site of infection. Antibiotics should be given targeted to
the presumed site of infection. If there is no clinical evidence to suggest a site of infection, empirical broad-spectrum
antibiotics should still be given.
Empirical antibiotics should be narrowed as soon as a pathogen has been identified and sensitivities are available.[79]
Respiratory source
Respiratory infections account for approximately 30% to 50% of cases. Monotherapy appears as effective as combination
therapy in community-acquired pneumonia, although some units prefer combination therapy in patients with severe
pneumonia requiring critical care admission.[108] Treatment regimens should cover common respiratory pathogens
and atypical organisms such as Legionella pneumophilia.
Antibiotics listed are suggested as guidance only. Local or national policy, which may take into account specialist
TREATMENT
knowledge of sensitivity patterns, should be sought and adhered to when possible. Combination therapy should
include a beta-lactam (such as benzyl penicillin, cefotaxime, or amoxicillin/clavulanate), with a macrolide (such as
azithromycin). A suitable monotherapy treatment regimen is to use a respiratory quinolone, such as moxifloxacin or
levofloxacin, or alternatively, doxcycline. These monotherapy regimens are suitable for patients with penicillin allergy.
Risk factors for the presence of multiple drug-resistant pathogens (MDRPs) for Pseudomonas aeruginosa and for
methicillin-resistant Staphylococcus aureus (MRSA) will affect choice of antimicrobial agents and should be evaluated.
These include hospitalisation (for >48 hours, including residence in nursing home) or systemic antibiotic use within
the previous 90 days. A history of MRSA infection or colonisation should be sought. Recently, increasing numbers of
cases of community-acquired MRSA pneumonia have been reported, particularly in association with influenza virus
infection. Mortality rates appear somewhat higher than for non-MRSA severe pneumonia at 33%.[109]
MRSA should be considered in patients presenting with particularly severe community-acquired pneumonia, especially
in the presence of haemoptysis, shock, and an influenza-like prodromal illness.[110] [111] [112]
In high-risk patients, a broader spectrum of cover can be achieved using a carbapenem such as imipenem/cilastatin,
or an antipseudomonal penicillin such as piperacillin/tazobactam in combination with an aminoglycoside such as
gentamicin. Tigecycline is an alternative for patients with penicillin allergy; however, monotherapy with this drug
should be used with caution as it may be associated with an increased risk of mortality. Expert advice should be sought
before using tigecycline.[113] In patients at risk of MRSA, or with unusual severity of pneumonia with haemoptysis,
vancomycin or linezolid should be added to one of the above regimens. In patients with significant risk factors for
Pseudomonas infection (bronchiectasis, systemic corticosteroid use, malnourishment) consideration should be given
to the addition of ciprofloxacin to one of the above regimens.
Urinary tract source

Urinary tract infections account for approximately 10% to 20% of cases. Ensuring patency of the urinary tract is vital.
Cover should include gram-negative coliforms and Pseudomonas. Antibiotics listed are suggested as guidance only.
Local or national policy, which may take into account specialist knowledge of sensitivity patterns, should be sought
and adhered to when possible. A suitable treatment regimen is to use a combination of either ampicillin or a
cephalosporin, such as cefotaxime with gentamicin. Ciprofloxacin is a suitable alternative in patients with penicillin
allergy.
Abdominal source
Infection arising from abdominal sources accounts for approximately 20% to 25% of cases. Gram-positive and
gram-negative organisms including anaerobes should be covered. Peritonitis or intra-peritoneal abscesses require
urgent surgical drainage or (where appropriate) percutaneous drainage.
knowledge of sensitivity patterns, should be sought and adhered to when possible. Treatment with ampicillin or
cefotaxime with metronidazole and gentamicin is a suitable regimen, or alternatively piperacillin/tazobactam with
gentamicin. A regimen of tigecycline and gentamicin is a suitable choice in patients with penicillin allergy.
Patients with recurrent perforation of the large intestine are at increased risk of invasive fungaemia. An azole, such
as fluconazole, or an echinocandin, such as micafungin, should be added to the antibacterial cover. Non-albicans
species of Candida are increasingly resistant to azoles.[42] [43] [114]
Soft-tissue and joint source

This heterogeneous group of infections includes septic arthritis, wound infections, cellulitis, and acute super-infections
TREATMENT
arising from chronic ulceration, and accounts for approximately 5% to 10% of cases. A high index of suspicion should
also be held for necrotising fasciitis, which requires immediate surgical intervention (as does septic arthritis). Most
infections are polymicrobial, and broad-spectrum cover against gram-positive and gram-negative organisms including
anaerobes should be used.
29
knowledge of sensitivity patterns, should be sought and adhered to when possible. A suitable regimen is to use
flucloxacillin (or tigecycline in penicillin-allergic patients) together with metronidazole. Alternatively, clindamycin may
be used. If the patient has risk factors for MRSA, vancomycin (or alternatively linezolid) should be added.
If necrotising fasciitis is suspected, clindamycin together with flucloxacillin or tigecycline would be a sensible choice.
CNS source
CNS infections are a relatively uncommon but potentially devastating cause of sepsis, accounting for under 5% of
cases. Meningococcal septicaemia can be extremely rapidly fatal, and if survived, can lead to greater morbidity than
other forms. Immediate antibiotic therapy in suspected cases is essential.
knowledge of sensitivity patterns, should be sought and adhered to when possible. Suspected meningitis or
meningococcal septicaemia should be treated immediately using a third-generation cephalosporin, such as ceftriaxone
or cefotaxime. For patients with penicillin allergy, vancomycin with chloramphenicol is a suitable alternative. Some
suggest the addition of rifampicin to either regimen to aid penetration.
For patients over 50 years, and those with a history of alcoholism or other debilitating illness, or at increased risk of
infection with Listeria, cephalosporins alone provide inadequate cover. Ampicillin should be added to the regimen,
provided the patient is not allergic to penicillin. For those allergic to penicillin, erythromycin or
trimethoprim/sulfamethoxazole can be substituted.
Patients with a more insidious onset of CNS symptoms should be suspected as having viral encephalitis. Viruses cause
sepsis extremely rarely, but early use of antiviral agents such as acyclovir may improve outcome.
Corticosteroids for bacterial meningitis can improve neurological outcomes.[115]
Sepsis of unknown origin

Intensive efforts, including imaging, should be undertaken to attempt to evaluate the source of infection. Urgent
broad-spectrum coverage to include all common pathogens should be administered.
knowledge of sensitivity patterns, should be sought and adhered to when possible. Carbapenems give appropriately
broad cover, with imipenem or meropenem being suitable choices. Piperacillin/tazobactam with gentamicin is an
alternative. If the patient has risk factors for MRSA, vancomycin should be added.
Fluid resuscitation
Early, vigorous fluid resuscitation in sepsis-induced hypoperfusion is needed with at least 30 mL/kg body weight of
crystalloid given within the first 3 hours.[79] Additional fluid may be required, but this should be guided by thorough
clinical assessment of the patient's haemodynamic status.[79]
Repeated fluid boluses of crystalloid (typical volume 500 mL) given over 5 to 30 minutes may be effective in correcting
hypotension secondary to hypovolaemia. Boluses of a colloid solution (typical volume 250-300 mL) may be used as
TREATMENT
an alternative, but no evidence supports the use of colloids over other fluids such as crystalloids or albumin
solution.[116] [117] [118] [119] [120] [121] [122] [123] [124] Solutions containing starch may be harmful and should
be avoided.[79] Evidence has shown that solutions containing hydroxyethyl starch are associated with a greater risk
of renal dysfunction and adverse outcome.[125] [126] [127] [128] [129] [130] [131] In some countries hydroxyethyl
starch solutions are no longer available. sepsis is defined as a systemic inflammatory response to a new infection; and
Normal saline and albumin should be given according to local protocols. Current evidence suggests that resuscitation
using albumin-containing solutions is safe, but evidence of its efficacy is insufficient to recommend its use over
crystalloids.[124] [132] [133] Red cell or plasma transfusion may be considered to target specific deficiencies but
should not be used for volume augmentation. Aggressive red cell transfusion has not been shown to improve
outcomes.[134]
Patients should be monitored closely for signs of fluid overload (e.g., pulmonary or systemic oedema).[135] Changes
in inferior vena cava (IVC) diameter during respiration (visualised using bedside ultrasound) have been shown to be
an accurate means of judging fluid responsiveness, and requirement for further intravenous fluids. In the spontaneously
breathing patient, a collapsed or collapsing IVC suggest that cardiac output will improve with additional fluid
resuscitation. In the mechanically ventilated patient, an increase in IVC size >18% (or visible to the naked eye) with
positive pressure ventilation, fluid responsiveness is expected.[136] [137] One systematic review has shown passive
leg raising to be an accurate predictor of fluid responsiveness in ventilated patients, regardless of ventilator mode or
technique, and with flow variables (e.g., cardiac output) having greater accuracy compared with pulse pressure.[138]
Glycaemic control in the critically ill

There has been a shift of opinion and practice regarding glycaemic control in the critically ill. Since 2001, the use of
tight glycaemic control in septic patients has been advocated. However, more recent evidence suggests an increase
in adverse events (e.g., severe hypoglycaemia) in patients managed with tight glycaemic control (target blood glucose
6.1 mmol/L).[127] [139] An international randomised controlled trial demonstrated an increase in the absolute risk
of death at 90 days by 2.6 percentage points in the patient group managed with intensive glycaemic control compared
with the group managed with conventional glycaemic control (blood glucose target of 10 mmol/L [180 mg/dL]).[140]
The American Diabetes Association recommends a general glucose goal of 7.8 to 10.0 mmol/L (140-180 mg/dL) in
critically ill diabetic patients, preferably with use of an insulin infusion protocol.[141] The Surviving Sepsis Campaign
recommends the use of validated insulin infusion protocols targeting a blood glucose level of <10 mmol/L (180
mg/dL).[79]
Persistent haemodynamic instability

If hypotension persists, with a MAP of <65 mmHg, a vasopressor should be started.[79] [142] Noradrenaline
(norepinephrine) administered via a central venous catheter is the drug of choice as it increases MAP. Vasopressin or
adrenaline can be added to noradrenaline to achieve the target MAP (≥65 mmHg), or vasopressin can be added to
wean noradrenaline.[79] Dopamine is an option, but should only be given to highly selected patients as it has been
associated with higher mortality than noradrenaline.[79] [143] [144] All infusions of vasoactive medications to correct
shock should be given via a secure catheter in a central vein with high flow, such as via a central venous catheter,
unless resources do not permit this and the situation is urgent. The use of low-dose dopamine for renal protection is
not recommended.[79]
Adjunctive therapies
In patients with low cardiac output despite adequate fluid resuscitation, inotropes (e.g., dobutamine) can be added.
Low cardiac output suspected through clinical examination (prolonged capillary refill times, low urine output, poor
peripheral perfusion) can be confirmed through the use of cardiac output monitoring or by sampling central venous
or pulmonary arterial blood to measure oxygen saturations. Heart rate should be kept <100 bpm to minimise myocardial
TREATMENT
oxygen demand.[142]
According to a landmark study published in 2002,[145] corticosteroids may be beneficial in patients with septic shock
that is refractory to fluids and vasopressor agents. However, current evidence for giving corticosteroids to patients
with sepsis or septic shock appears to be mixed.[146] [147] [148] [149] [150] [151] [152] Current guidelines
31
recommend that low-dose corticosteroids are given only to patients whose BP is poorly responsive to both fluid
resuscitation and vasopressor therapy.[79] The use of the ACTH stimulation test to guide corticosteroid therapy is
no longer recommended, as it may be unreliable in critically ill patients and response does not predict efficacy of
corticosteroids.
Other more novel therapies include bathing patients with chlorhexidine washes, which may decrease the rate of
hospital-acquired infections,[153] and antioxidants such as acetylcysteine. These agents have been used as an
adjuvant therapy in sepsis with the aim of decreasing the levels of reactive oxygen species. However, they have been
found to be ineffective and their use is not currently recommended.[154]
Standard ICU supportive care

All patients with sepsis should be considered for admission to the high dependency unit or ICU.[59] [135]
General intensive care measures include stress ulcer prophylaxis with histamine H2 receptor antagonists or proton
pump inhibitors (in patients at risk of GI bleeding), DVT prophylaxis (with heparin and compression stockings), enteral
or parenteral nutrition, and glycaemic control.[79] [96] [155]
Transfusion of packed cells may be required. Despite studies of early goal-directed therapy transfusing to a target
haemoglobin concentration of >100 g/L (10 g/dL), it is recommended that a lower threshold of 70 g/L (7 g/dL) be
used.[79] Reasons for this include resource usage and a number of studies in the general critical care population
showing no improvement with a higher haemoglobin threshold compared with a lower haemoglobin threshold,[134]
and potential harm associated with liberal transfusion.[156] A higher haemoglobin level may be necessary in certain
circumstances (myocardial ischaemia, severe hypoxaemia, acute haemorrhage, cyanotic heart disease, or lactic
acidosis).[79] In the initial resuscitative phase, particularly with the application of early goal-directed therapy, a higher
haematocrit of ≥30% may be appropriate.[59]
Patients requiring prolonged ventilatory support should receive lung-protective ventilation using minimal peak
inspiratory pressures (<30 cmH2O) and permissive hypercapnia to specifically limit pulmonary compromise.[157]
FiO2 should be titrated to lowest effective levels to prevent oxygen toxicity and maintain central venous oxygen
tension. Patients should be placed in a semi-recumbent position with the head elevated to 30° to 45°.[79]
Treatment details overview

Consult your local pharmaceutical database for comprehensive drug information including contraindications, drug
interactions, and alternative dosing. ( see Disclaimer )
Acute ( summary )
Patient group Tx line Treatment
presumed or confirmed sepsis 1st antibiotics
plus fluid resuscitation
adjunct standard supportive ICU care

TREATMENT
adjunct vasopressors
adjunct dobutamine
adjunct corticosteroids
Acute ( summary )
likely source of infection: plus broad-spectrum respiratory pathogen cover to
pneumonia, without risk factors include atypicals
for multiple drug-resistant
pathogens or MRSA
likely source of infection: plus broad-spectrum cover of respiratory pathogens to

pneumonia, with risk factors for include multiple drug-resistant pathogens (MDRPs)
multiple drug-resistant pathogens
adjunct antibiotic coverage for MRSA
adjunct antipseudomonal quinolone
likely source of infection: UTI plus broad-spectrum cover for predominant

gram-negative coliforms and Pseudomonas
likely source of infection: plus broad-spectrum cover for gram-positive and

intra-abdominal gram-negative organisms, including anaerobes
adjunct azole or echinocandin
likely source of infection: plus broad-spectrum gram-positive and gram-negative

soft-tissue or joint infection (not cover, including anaerobes
necrotising fasciitis), MRSA not
suspected
likely source of infection: plus broad-spectrum cover to include MRSA

soft-tissue or joint infection (not
necrotising fasciitis), MRSA
suspected
likely source of infection: plus broad-spectrum cover to include group A

necrotising fasciitis suspected Streptococci and gram-negative organisms
likely source of infection: CNS plus broad-spectrum cover to include Neisseria

meningitidis, Streptococcus pneumoniae, and
other common gram-positive causative agents
adjunct rifampicin
adjunct antibiotic cover for Listeria
adjunct antiviral cover for HSV
sepsis of unknown source or plus broad-spectrum gram-positive and gram-negative

where source is unclear, MRSA cover
not suspected
sepsis of unknown source or plus broad-spectrum cover to include MRSA

where source is unclear, MRSA
suspected
TREATMENT
33
Treatment options
Acute
presumed or confirmed sepsis 1st antibiotics
» Broad-spectrum intravenous antibiotics should be
given before a pathogen is identified.[79] [103] [104]
They are recommended within the first hour once
sepsis is diagnosed, preferably after cultures have been
taken.[79] [9] The delivery of appropriate antibiotics
within the first hour is of critical importance in
maximising chances of survival.[63] [105] [107] [106]
» Appropriate antibiotic administration typically

precedes identification of specific pathogen.
» Once culture and sensitivity results are known,

antibiotics should be narrowed if it is possible to do
so.[79]
» When choosing empirical therapy, the suspected

source of infection or causative organism, local
resistance patterns, and the patient's immune status
need to be considered.[54] [103]
plus fluid resuscitation

» Early, vigorous fluid resuscitation in sepsis-induced
hypoperfusion is needed and admission to the high
dependency unit or ICU should be considered.[59]
[135] At least 30 mL/kg body weight of crystalloid
should be given within the first 3 hours.[79] Additional
fluid may be required, but this should be guided by
thorough clinical assessment of the patient's
haemodynamic status.[79] Repeated fluid boluses of
crystalloid (typical volume 500 mL) given over 5 to 30
minutes may be effective in correcting hypotension
secondary to hypovolaemia. Boluses of a colloid
solution (typical volume 250-300 mL) may be used as
an alternative, but no evidence supports the use of
colloids over other fluids such as crystalloids or albumin
solution.[116] [117] [118] [119] [120] [121] [122] [123]
[124] Resuscitation with crystalloids requires more
volume than colloids.
» In the UK, the National Institute for Health and Care

Excellence (NICE) guidelines recommend administering
crystalloid if the patient has a lactate ≥2 mmol/L (≥18
mg/dL) and at least one high risk criterion.[9]
Crystalloids are also recommended if the patient has
TREATMENT
a lactate >2 mmol/L (>18 mg/dL) and at least two

moderate to high risk criteria, or evidence of acute
kidney injury. Crystalloid can be considered in patients
with a lactate <2 mmol/L (<18 mg/dL) if they have
least one high risk criterion.
Acute
» Solutions containing starch may be harmful and
should be avoided.[79] Evidence has shown that
solutions containing hydroxyethyl starch are associated
with a greater risk of renal dysfunction and adverse
outcome.[128] [129] [130] [131] In some countries
hydroxyethyl starch solutions are no longer available.
» Red cell or plasma transfusion may be considered to

target specific deficiencies but should not be used for
volume augmentation. Aggressive red cell transfusion
has not been shown to improve outcomes.[134]
» Normal saline and albumin should be given according

to local protocols. Current evidence suggests that
resuscitation using albumin-containing solutions is
safe, but evidence of its efficacy is insufficient to
recommend its use over crystalloids.[124] [132] [133]
» Patients should be monitored closely for signs of fluid

overload (e.g., pulmonary or systemic oedema).[135]
[138]
adjunct standard supportive ICU care

» All patients with sepsis should be considered for
admission to the high dependency unit or ICU.[59]
[135]
» General intensive care measures include stress ulcer

prophylaxis with histamine H2 receptor antagonists or
proton pump inhibitors (in patients at risk of GI
bleeding), DVT prophylaxis (with heparin and
compression stockings), enteral or parenteral nutrition,
and glycaemic control.[155] [96] [79] The American
Diabetes Association recommends a general glucose
goal of 7.8 to 10.0 mmol/L (140-180 mg/dL) in critically
ill diabetic patients, preferably with use of an insulin
infusion protocol.[141] The Surviving Sepsis Campaign
recommends the use of validated insulin infusion
protocols targeting a blood glucose level of <10
mmol/L (180 mg/dL).[79]
» Transfusion of packed cells may be required. Despite

studies of early goal-directed therapy transfusing to a
target haemoglobin concentration of >100 g/L (>10
g/dL), it is recommended that a lower threshold of 70
g/L (7 g/dL) be used.[79] Reasons for this include
resource usage and a number of studies in the general
critical care population showing no improvement with
a higher haemoglobin threshold compared with a lower
TREATMENT
haemoglobin threshold,[134] and potential harm

associated with liberal transfusion.[156] A higher
haemoglobin level may be necessary in certain
circumstances (myocardial ischaemia, severe
hypoxaemia, acute haemorrhage, cyanotic heart
disease, or lactic acidosis).[79] In the initial resuscitative
35
Acute
phase, particularly with the application of early
goal-directed therapy, a higher haematocrit of ≥30%
may be appropriate. [59]
» Patients requiring prolonged ventilatory support

should receive lung protective ventilation using
minimal peak inspiratory pressures (<30 cmH2O) to
specifically limit pulmonary compromise.[157] FiO2
should be titrated to lowest effective levels to prevent
oxygen toxicity and maintain central venous oxygen
tension. Patients should be placed in a semi-recumbent
position with the head elevated to 30° to 45°.[79]
adjunct vasopressors
» Patients unresponsive to fluid resuscitation may be
treated with vasopressors. Patients requiring vasoactive
support (those with septic shock) are identified by a
systolic BP <90 mmHg, mean arterial pressure (MAP)
<65 mmHg, or lactate ≥4 mmol/L (≥36 mg/dL),
persisting after adequate fluid resuscitation.[79]
» MAP should be maintained between 65 and 90

mmHg.
» Noradrenaline (norepinephrine) administered via a

central venous catheter is the drug of choice as it
increases MAP. Vasopressin or adrenaline can be added
to noradrenaline to achieve the target MAP (≥65
mmHg).[79]
» Dopamine is an option, but should only be given to

highly selected patients as it has been associated with
higher mortality than noradrenaline.[79] [143] [144]
» The use of low-dose dopamine for renal protection

is not recommended.[79]
Primary options
» noradrenaline (norepinephrine): 0.02 to 0.5

micrograms/kg/minute intravenously initially,
titrate to effect, maximum 30 micrograms/minute
OR
» noradrenaline (norepinephrine): 0.02 to 0.5
titrate to effect, maximum 30 micrograms/minute
--AND--
TREATMENT
» vasopressin: 0.01 to 0.03 units/minute

intravenously initially, titrate to effect
-or-
» adrenaline (epinephrine): 0.05 to 2
titrate to effect
Acute
Secondary options
» dopamine: 5-20 micrograms/kg/minute

intravenously, titrate to effect
adjunct dobutamine
» Dobutamine is the first choice inotrope for patients
with low cardiac output and adequate left ventricular
filling pressure (or adequate fluid administration) and
adequate mean arterial pressure (MAP).[79] [135]
Primary options
» dobutamine: 0.5 to 1 microgram/kg/minute

intravenously initially, followed by 2-20
micrograms/kg/minute
adjunct corticosteroids
» According to a landmark study published in
2002,[145] corticosteroids may be beneficial in patients
with septic shock that is refractory to fluids and
vasopressor agents. In this study, 7-day treatment with
low doses of hydrocortisone and fludrocortisone was
shown to significantly reduce the risk of death in septic
shock without increasing adverse events.[145]
However, current evidence for giving corticosteroids
to patients with sepsis or septic shock appears to be
mixed.[146] [147] [148] [149] [150] [151] [152]
» Current guidelines recommend that low-dose

corticosteroids are given only to patients whose BP is
poorly responsive to both fluid resuscitation and
vasopressor therapy.[79] Fludrocortisone may or may
not be added to hydrocortisone therapy.
» Although the proposed mechanism of action of

corticosteroids in septic shock is in the correction of
relative adrenal insufficiency, the use of the ACTH
stimulation test to guide corticosteroid therapy is no
longer recommended as it may be unreliable in critically
ill patients and response does not predict efficacy of
corticosteroids.[79] [148]
Primary options
» hydrocortisone: 50 mg intravenously every 6

TREATMENT
hours
OR
» hydrocortisone: 50 mg intravenously every 6
hours
-and-
37
Acute
» fludrocortisone: 0.05 mg orally daily
likely source of infection: plus broad-spectrum respiratory pathogen cover to

pneumonia, without risk factors include atypicals
for multiple drug-resistant » Monotherapy appears as effective as combination
pathogens or MRSA therapy in community-acquired pneumonia, although
some units prefer combination therapy in patients with
severe pneumonia requiring critical care
admission.[108]
» For patients with suspected pneumonia, risk factors

for the presence of multiple drug-resistant pathogens
(MDRPs) and for methicillin-resistant Staphylococcus
aureus (MRSA) will affect choice of antimicrobial agents,
and should be evaluated. Risk factors include
hospitalisation for >48 hours (including residence in
nursing home), or systemic antibiotic use within the
previous 90 days.

need to be considered.[54] Antibiotics listed are
suggested as guidance only. Local or national policy,
which may take into account specialist knowledge of
sensitivity patterns, should be sought and adhered to
when possible.
Primary options
no penicillin allergy
» cefotaxime: 1-2 g intravenously every 8 hours
-or-
» amoxicillin/clavulanate: 1.2 g intravenously every
8 hours
Dose consists of 1 g amoxicillin plus 0.2 mg
clavulanate.
--AND--
» azithromycin: 500 mg intravenously every 24
hours
-or-
» clarithromycin: 500 mg intravenously every 12
hours
Secondary options
TREATMENT
penicillin allergy
» moxifloxacin: 400 mg intravenously every 24
hours
OR
penicillin allergy
Acute
» levofloxacin: 500 mg intravenously every 12 hours
OR
penicillin allergy
» doxycycline: 100 mg intravenously every 12 hours
likely source of infection: plus broad-spectrum cover of respiratory pathogens to

pneumonia, with risk factors for include multiple drug-resistant pathogens (MDRPs)
multiple drug-resistant pathogens » For patients with suspected pneumonia, risk factors
for the presence of MDRPs will affect choice of
antimicrobial agents, and should be evaluated. Risk
factors include hospitalisation for >48 hours (including
residence in nursing home), or systemic antibiotic use
within the previous 90 days.

when possible.
» Tigecycline is an alternative for patients with penicillin

allergy; however, monotherapy with this drug should
be used with caution as it may be associated with an
increased risk of mortality. Expert advice should be
sought before using tigecycline.[113]
Primary options
» imipenem/cilastatin: 1 g intravenously every 8
hours
Dose refers to imipenem component.
-or-
» piperacillin/ tazobactam: 4.5 g intravenously every
8 hours
Dose consists of 4 g piperacillin plus 0.5 g
tazobactam.
--AND--
» gentamicin: 5 mg/kg intravenously every 24 hours
Secondary options
TREATMENT
penicillin allergy
» tigecycline: 100 mg intravenously initially,
followed by 50 mg every 12 hours
adjunct antibiotic coverage for MRSA
39
Acute
» Patients presenting with particularly severe
community-acquired pneumonia, especially if there is
a history of haemoptysis, and patients with recent
hospitalisation or history of MRSA infection should
receive additional coverage for MRSA.[111]
» Vancomycin levels need to be monitored.
Primary options
» vancomycin: 1 g intravenously every 12 hours
OR
» linezolid: 600 mg intravenously every 12 hours
adjunct antipseudomonal quinolone

» Patients with bronchiectasis, those who take systemic
corticosteroids, or those who are malnourished are at
risk of infection with Pseudomonas aeruginosa and
should be additionally treated with an antipseudomonal
quinolone.[158]
Primary options
» ciprofloxacin: 400 mg intravenously every 8-12

hours
likely source of infection: UTI plus broad-spectrum cover for predominant

gram-negative coliforms and Pseudomonas
» If urinary stasis is present, drainage is of immediate
importance.

when possible.
Primary options
» ampicillin: 1-2 g intravenously every 6 hours
-or-
TREATMENT

-or-
» amoxicillin/clavulanate: 1.2 g intravenously every
8 hours
Dose consists of 1 g amoxicillin plus 0.2 mg
clavulanate.
Acute
--AND--
Secondary options
penicillin allergy
» ciprofloxacin: 500 mg intravenously every 12
hours
likely source of infection: plus broad-spectrum cover for gram-positive and

intra-abdominal gram-negative organisms, including anaerobes
» Control and drainage of an intra-abdominal source
of infection is of immediate importance.

when possible.
Primary options
» amoxicillin: 1 g intravenously every 6 hours
-or-
--AND--
» metronidazole: 500 mg intravenously every 8
hours
--AND--
OR
» piperacillin/tazobactam: 4.5 g intravenously every
8 hours
tazobactam.
-and-
TREATMENT
Secondary options
penicillin allergy
41
Acute
-and-
adjunct azole or echinocandin

» Patients with recurrent perforation of the large
intestine are at increased risk of invasive fungaemia.
An azole, such as fluconazole, or an echinocandin, such
as micafungin, should be added to the antibacterial
cover. Non-albicans species of Candida are increasingly
resistant to azoles.[42] [43] [114]
Primary options
» fluconazole: consult specialist for guidance on

dose
OR
» micafungin: consult specialist for guidance on
dose
likely source of infection: plus broad-spectrum gram-positive and gram-negative

soft-tissue or joint infection (not cover, including anaerobes
necrotising fasciitis), MRSA not » When choosing empirical therapy, the suspected
suspected source of infection or causative organism, local
when possible. Metronidazole should be considered
as empirical therapy if anaerobic infection is suspected.
Primary options
» flucloxacillin: 2 g intravenously every 6 hours
-or-
» nafcillin: 1-2 g intravenously every 4-6 hours
--AND--
hours
Secondary options
penicillin allergy
TREATMENT
» clindamycin: 300-600 mg intravenously every 6

hours
OR
penicillin allergy
Acute
-and-
hours
likely source of infection: plus broad-spectrum cover to include MRSA

soft-tissue or joint infection (not » When choosing empirical therapy, the suspected
necrotising fasciitis), MRSA source of infection or causative organism, local
suspected resistance patterns, and the patient's immune status
when possible.
» In cases of suspected MRSA-associated soft-tissue

or joint infections, vancomycin or linezolid is typically
added to the antibiotic therapy.
Primary options
OR
» linezolid: 600 mg intravenously every 12 hours
likely source of infection: plus broad-spectrum cover to include group A

necrotising fasciitis suspected Streptococci and gram-negative organisms
» If necrotising fasciitis is suspected, surgical control
and debridement is of immediate importance.
» Once culture and sensitivity results are known,

antibiotics should be adjusted if required; 90% of cases
are polymicrobial.

when possible.
Primary options
TREATMENT
» flucloxacillin: 2 g intravenously every 6 hours
-or-
» nafcillin: 1-2 g intravenously every 6 hours
--AND--
43
Acute
hours
Secondary options
penicillin allergy
-and-
hours
likely source of infection: CNS plus broad-spectrum cover to include Neisseria

meningitidis, Streptococcus pneumoniae, and
other common gram-positive causative agents
» Suspected meningitis or meningococcal septicaemia
should be treated immediately using a third-generation
cephalosporin, such as ceftriaxone or cefotaxime. For
patients with penicillin allergy, vancomycin with
chloramphenicol is a suitable alternative. Some suggest
the addition of rifampicin to either regimen to aid
penetration.

when possible.
Primary options
» ceftriaxone: 2 g intravenously every 12 hours
OR
» cefotaxime: 2 g intravenously every 6 hours
Secondary options
penicillin allergy
TREATMENT
-and-
» chloramphenicol: 1 g intravenously every 6 hours
adjunct rifampicin
Acute
» Some experts suggest the addition of rifampicin to
the standard antibiotic regimen to aid penetration.
Primary options
» rifampicin: 600 mg intravenously every 24 hours
adjunct antibiotic cover for Listeria

» For patients over 50 year,s and those with history of
alcoholism or other debilitating illness, or at increased
risk of infection with Listeria, cephalosporins alone
provide inadequate cover. Ampicillin should be added
to the regimen, provided the patient is not allergic to
penicillin. For those allergic to penicillin, erythromycin
or trimethoprim/sulfamethoxazole can be substituted.
Primary options
» ampicillin: 2 g intravenously every 6 hours
Secondary options
penicillin allergy
» erythromycin: 1 g intravenously every 6 hours
OR
penicillin allergy
» trimethoprim/sulfamethoxazole: 20 mg/kg/day
intravenously given in divided doses every 6 hours
Dose refers to trimethoprim component.
adjunct antiviral cover for HSV

» For patients in whom HSV encephalitis is suspected
(symptoms of confusion, seizure or with CSF findings
consistent with viral meningitis), empirical coverage
with acyclovir is recommended.
Primary options
» aciclovir: 5-10 mg/kg intravenously every 8 hours
sepsis of unknown source or plus broad-spectrum gram-positive and gram-negative

where source is unclear, MRSA cover
TREATMENT
not suspected » Intensive efforts, including imaging, should be

undertaken to attempt to evaluate the source of
infection. Urgent broad-spectrum coverage to include
all common pathogens should be administered.
45
Acute
when possible.
Primary options

hours
OR
» meropenem: 1 g intravenously every 8 hours
OR
» piperacillin/tazobactam: 4.5 g intravenously every
8 hours
tazobactam.
-and-
sepsis of unknown source or plus broad-spectrum cover to include MRSA

where source is unclear, MRSA » Intensive efforts, including imaging, should be
suspected undertaken to attempt to evaluate the source of
infection. Urgent broad-spectrum coverage to include
all common pathogens should be administered.
» When choosing empiric therapy, the suspected

when possible. Vancomycin is used if MRSA is
suspected.
Primary options

--AND--
TREATMENT

hours
-or-
» meropenem: 1 g intravenously every 8 hours
Sepsis in adults Follow up
Recommendations
Monitoring
FOLLOW UP
Standard monitoring of vital signs, pulse oximetry, ECG, regular laboratory tests, and urinary output by catheterisation
are routinely performed. All patients receiving vasopressors should have an arterial catheter inserted as soon as it is
practical to do so, to aid more accurate monitoring of arterial blood pressure.[79]
Patients with evidence of circulatory dysfunction or shock should be managed in a critical care or higher dependency
area. Central venous catheters will be required to ensure reliable delivery of vasoactive medication. The principles of
Early Goal-Directed Therapy[59] remain relevant in ongoing care for patients with shock.
Central venous pressure (CVP) may be used in combination with clinical assessment and other monitoring modalities
to guide ongoing fluid resuscitation. Additional monitoring techniques include the use of stroke volume variability
(an index of change in stroke volume with each contraction), cardiac ejection time (corrected for heart rate) and
changes in inferior vena cava (IVC) diameter during respiration (visualised using bedside ultrasound).[136] [137]
Mechanical ventilation can alter cardiac filling pressures and affect measurement. CVP values must be corrected with
increasing levels of positive end-expiratory pressure (PEEP) or haemodynamic parameters.[59] [169] In the
spontaneously breathing patient, a collapsed or collapsing IVC suggest that cardiac output will improve with additional
fluid resuscitation. In the mechanically ventilated patient, if IVC size increases by >18% (or visible to the naked eye)
with positive pressure ventilation, fluid responsiveness is expected. One systematic review has shown passive leg
raising to be an accurate predictor of fluid responsiveness in ventilated patients, regardless of ventilator mode or
technique, and with flow variables (e.g., cardiac output) having greater accuracy compared with pulse pressure.[138]
Central venous catheters may also be used to sample central venous oxygen saturation (ScvO2), which gives a global
indication of the balance between tissue oxygen demand and supply. If ScvO2 is low (<70%), it is likely that oxygen
delivery is inadequate and the need for blood transfusion (to increase oxygen carrying capacity) or inotropes (to
increase cardiac output) should be assessed. Other measures of the adequacy of oxygen delivery are increasingly
used, including the use of lactate clearance rate over the first 6 hours. Lactate clearance has been shown to correlate
positively with survival.[74]
The use of pulmonary artery catheters may be an advantage in selected patients with suspected cardiac compromise
or complicated presentations. It is not considered to be essential as a first-line routine monitor, and its use in clinical
practice has been largely superseded by less invasive cardiac output monitoring modalities, including oesophageal
Doppler, arterial pulse contour analysis, and thermodilution/indicator dilution techniques.
Patient instructions
Complications
Complications Timeframe Likelihood

renal dysfunction short term high
Transient oliguria is common and is related to hypotension. Rarely, anuria occurs.[163] Acute kidney injury is relatively
common but is rarely associated with histological change or with any need for long-term renal replacement therapy.
Correction of volume depletion and hypotension generally reverses oliguria.[163]
hypotension short term high
47

Volume depletion is caused by reduced oral intake, increased venous capacitance, increased fluid losses due to pyrexia,
FOLLOW UP
capillary leakage leading to oedema, tachypnoea, diarrhoea, and possibly bleeding. Persistent hypotension is often
due to a combination of low systemic vascular resistance, hypovolaemia and reductions in cardiac output from
myocardial failure, excessive PEEP, or acidosis.
Fluid resuscitation is given with either colloids or crystalloids, and early central venous pressure (CVP) monitoring is
indicated if rapid response is not achieved. Vasopressors can be started for persistent hypotension or inotropes for
myocardial failure. Caution is required to prevent tachyarrhythmia.
ARDS short term medium
Respiratory failure often progresses quickly and is indicated by a respiratory rate >30/minute, even though arterial
oxygen levels may be normal.
ARDS may resolve completely or can progress to fibrosing alveolitis with persistent hypoxaemia.[162]
Intubation and ventilation reduce respiratory muscle oxygen demand and the risk of aspiration and cerebral anoxia.[163]
Lung protective ventilation (low tidal volumes) should be used.[4] Tidal volumes should be reduced over 1 to 2 hours
to a target of 6 mL/kg of predicted body weight. Minimum positive end-expiratory pressure (PEEP) is recommended
to prevent lung collapse at end expiration.[79]
myocardial dysfunction and failure short term medium
Myocardial dysfunction with biventricular dilatation is a recognised complication of sepsis, but is usually transient and
not commonly severe. Death from myocardial failure is rare.[135] Circulating myocardial depressant factors are thought
responsible.
After adequate filling pressures have been achieved, inotropic agents should be considered to maintain an adequate
cardiac index, mean arterial pressure (MAP), mixed venous oxygen saturation, and urine output.
Clinicians should define specific goals and desired endpoints of inotropic therapy in patients with sepsis and titrate
therapy to those end points. These end points should be refined at frequent intervals as patient's clinical status
changes.[135]
multiple organ system failure short term medium
The inflammatory response in sepsis causes widespread tissue injury. Multi-organ dysfunction may be partly caused
by apoptosis of immune, epithelial, and endothelial cells and a shift to an anti-inflammatory phenotype, compounded
by impaired organ perfusion due to hypotension, low cardiac output states, circulatory microthrombi, a disordered
microcirculation, and tissue oedema.[4]
Failure of each additional organ increases the average risk of death by 15% to 20%. Lung dysfunction tends to occur
early and persists. Serious CNS dysfunction or liver function often occur hours to days after sepsis onset and persists
for variable periods of time. Most organ failures resolve within a month in surviving patients.[163]
Treatment of multi-organ failure in sepsis is primarily supportive. It includes effective antibiotic therapy, goal-directed
therapy (to reverse hypotension, anaemia, coagulopathy, bleeding, and shock), and standard supportive ICU care. This
may include dialysis, ventilatory support, and sedation.
hepatic encephalopathy short term low

Rarely, liver dysfunction may lead to hepatic encephalopathy.[161] Hepatic encephalopathy results primarily from
FOLLOW UP
nitrogen absorption from the gut bypassing effective hepatic clearance, resulting in electrolyte abnormalities.
The mainstay of therapy includes laxatives to empty the bowel, prevention of GI bleeding, and avoidance of nitrogen
intake and sedative drugs, which further suppress consciousness.
DIC short term low
Occurs in sepsis when leukocytes and endothelial cells are activated or injured by toxic substances released during
infection or shock. The injured cells generate tissue factor on the cell surface, activating the coagulation cascade. In
acute DIC, an explosive generation of thrombin depletes clotting factors and platelets. This activates the fibrinolytic
system.
DIC leads to bleeding into the subcutaneous tissues, skin, and mucous membranes occurs, along with occlusion of
blood vessels caused by fibrin in the microcirculation.
Treatment of the underlying disease is the mainstay of management of either acute or chronic DIC, with blood products
to control bleeding.[164]
neurological sequelae long term medium
The incidence and severity of complications from sepsis depend on the pathogen, duration of disease, age, and
presence of comorbidities.
Focal neurological deficits and hearing loss occur in up to 30% of patients with bacterial meningitis. The mortality and
morbidity is higher for pneumococcal meningitis than for meningococcal meningitis.
Polyneuropathy occurs in 70% of patients with sepsis and multi-organ failure. The use of neuromuscular blocking
agents may increase the severity of polyneuropathy.[165] [166]
death variable high
The exact cause of death in sepsis is multi-factorial, exhibiting great individual variability.[161] Death from septic shock
typically occurs due to multi-organ failure, unresponsiveness to treatments, or secondary infection.[54]
Predictors of death include vasopressor use, development of ARDS, failure to improve with early critical care therapy,
and severity of underlying illness.[167]
Patients with sepsis have an increased mortality risk for at least 1 year after the septic episode.[168]
Administration of early effective antibiotic therapy and fluid challenges are paramount to reduce mortality.[59]
Prognosis
The prognosis in patients with sepsis and septic shock is guarded at best. The mortality rate from sepsis has been estimated
in a number of studies to be between 28% and 50%.[159] [160] More recently, the SOAP study in Europe observed an
overall hospital mortality of 36%,[36] and the Surviving Sepsis Campaign reported mortality by the end of an improvement
project to be 31%.[10]
49
ICU-specific mortality has been shown to be 27% to 32% in patients with sepsis, and 50% to 70% in patients with septic
shock, compared with 14% in ICU patients without sepsis.[4] [12]
Multi-organ compromise is common in advanced sepsis with variable residual morbidity.[4] [8]
FOLLOW UP
Sepsis in adults Guidelines
Diagnostic guidelines
Europe
Sepsis: recognition, diagnosis and early management

Published by: National Institute for Health and Care Excellence Last published: 2016
Summary: This guideline covers the recognition and diagnosis of sepsis for all populations. The guideline committee
identified that the key issues to be included were: recognition and early assessment as well as diagnostic and prognostic
value of blood markers for sepsis.
Sepsis - a clinical toolkit for emergency departments

Published by: College of Emergency Medicine Last published: 2014
Summary: Aims to provide operational solutions to the complexities that challenge the reliable identification and
management of sepsis, and to complement clinical toolkits designed for other clinical areas.
GUIDELINES
Latin America
Guidelines for the treatment of severe sepsis and septic shock: management of the infectious
agent - diagnosis
Published by: Brazilian Medical Association Last published: 2010
Summary: This guideline provides a comprehensive overview of the diagnosis of sepsis.
Oceania
Sepsis toolkit
Published by: Clinical Excellence Commission Last published: 2014
Summary: Sepsis pack produced in Australia to achieve system-wide improvements in early sepsis recognition and
management.
Treatment guidelines
Europe
Sepsis: recognition, diagnosis and early management

Published by: National Institute for Health and Care Excellence Last published: 2016
Summary: This guideline covers the early management of sepsis for all populations. The guideline committee identified
that the key issues to be included were initial treatment, escalating care, identifying the source of infection, early
monitoring, information and support for patients and carers, and training and education.
51
Europe
Sepsis - a clinical toolkit for emergency departments

Published by: College of Emergency Medicine Last published: 2014
Summary: Aims to provide operational solutions to the complexities that challenge the reliable identification and
management of sepsis, and to complement clinical toolkits designed for other clinical areas.
British consensus guidelines on intravenous fluid therapy for adult surgical patients
Published by: British Association for Parenteral and Enteral Nutrition; Association Last published: 2011
for Clinical Biochemistry; Association of Surgeons of Great Britain and Ireland; Society
of Academic and Research Surgery; Renal Association; Intensive Care Society
Summary: These guidelines provide evidence-based recommendations for good perioperative fluid prescribing
practices in patients undergoing various surgical procedures.
GUIDELINES
Haemodynamic management of severe sepsis: recommendations of the French Intensive

Care Societies (SFAR/SRLF) Consensus Conference, 13 October 2005, Paris, France
Published by: French Intensive Care Societies Last published: 2006
Summary: Evidence-based consensus guideline focusing on haemodynamic management of severe sepsis in adults
and children.
International
Surviving sepsis campaign guidelines for management of sepsis and septic shock - 2016
Published by: International Surviving Sepsis Campaign Guidelines Committee Last published: 2016
Summary: These evidence-based guidelines provide the following recommendations for the treatment of sepsis and
septic shock. Initial fluid resuscitation should be done with crystalloid, with at least 30 mL/kg in the first 3 hours in
patients with sepsis-induced hypoperfusion. In patients who continue to require substantial amounts of crystalloid to
maintain adequate mean arterial pressure, addition of albumin should be considered. It is recommended to avoid
hydroxyethyl starch formulations. It is recommended that intravenous antibiotics are started within the first hour of
recognising severe sepsis (preferably after cultures have been taken). Vasopressors are recommended if fluid challenge
fails to restore adequate BP. Dobutamine can be used to increase cardiac output if cardiac output is low despite fluid
resuscitation and vasopressors. Intravenous hydrocortisone should be given only to patients whose BP is poorly
responsive to both fluid resuscitation and vasopressor therapy.
North America
Standards of medical care in diabetes - 2017

Published by: American Diabetes Association Last published: 2017
Summary: This guideline provides a comprehensive overview of the management of this condition.
North America
Management of patients with infections caused by methicillin-resistant Staphylococcus

aureus
Published by: Infectious Diseases Society of America Last published: 2011
Summary: Evidence-based consensus guideline for the management of patients with methicillin-resistant S aureus
(MRSA) infections, prepared by an expert panel of the Infectious Diseases Society of America. The guidelines are
intended for use by health care providers who care for adult and paediatric patients with MRSA infections. The guidelines
discuss the management of a variety of clinical syndromes associated with MRSA disease, including skin and soft-tissue
infections, bacteraemia and endocarditis, pneumonia, bone and joint infections, and CNS infections. Recommendations
are provided regarding antimicrobial selection and dosing, suggested level of care and location, and ongoing
management.
Severe sepsis and septic shock: review of the literature and emergency department
management guidelines
GUIDELINES
Published by: Emergency Department Sepsis Education Program and Strategies Last published: 2006
to Improve Survival (ED-SEPSIS) Working Group
Summary: Early recognition and management of severe sepsis or septic shock optimises outcome. Continuous
monitoring of vital signs and laboratory examination is needed to facilitate early recognition. Rigorous clinical evaluation
and appropriate cultures (including blood, urine, and site-specific) should be obtained before giving antibiotics. Empirical
antibiotics should be started as soon as possible. Ideally, site-specific regimens should be given if possible. Early
goal-directed therapy should be started as soon as possible, with monitoring of central venous pressure (CVP) and
mixed venous oxygen saturation (SVO2). After achievement of the target haemodynamic goals (CVP 8-12 mmHg; MAP
65-90 mmHg; SVO2 >70%) serial lactate levels should be obtained to evaluate response to therapy. Depending on the
site of infection, source control (drainage) should be aggressively performed. Patients requiring mechanical ventilation
should be treated with low tidal volume to maintain end-inspiratory plateau pressure <30 cmH2O. Vasopressors are
required for refractory shock or organ dysfunction.
53
Sepsis in adults Online resources
Online resources
1. Surviving Sepsis Campaign: evaluation for severe sepsis screening tool (external link)
2. APACHE II calculator (external link)

ONLINE RESOURCES
Sepsis in adults References
Key articles
REFERENCES
• Russell JA. Management of sepsis. N Engl J Med. 2006;355:1699-1713. Abstract
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https://www.nice.org.uk (last accessed 17 May 2017). Full text
• Diament D, Salomão R, Rigatto O, et al. Guidelines for the treatment of severe sepsis and septic shock: management
of the infectious agent - diagnosis. December 2010. http://www.scielo.br (last accessed 17 May 2017). Full text
• Ware LB, Matthay MA. The acute respiratory distress syndrome. N Engl J Med. 2000;342:1334-1349. Abstract
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65
Sepsis in adults Images
Images
IMAGES
Figure 1: Capillary refill time. Top image: normal skin tone; middle image: pressure applied for 5 seconds; bottom image:
time to hyperaemia measured
From the collection of Ron Daniels, MB, ChB, FRCA; used with permission
Figure 2: Severe purpura fulminans, most commonly associated with pneumococcal septicaemia
From the collection of Ron Daniels, MB, ChB, FRCA; used with permission
Sepsis in adults Images
IMAGES
Figure 3: Sequential (or Sepsis-related) Organ Failure Assessment (SOFA) criteria
Created by BMJ, adapted from Vincent JL, Moreno R, Takala J, et al. The SOFA (Sepsis-related Organ Failure Assessment)
score to describe organ dysfunction/failure. On behalf of the Working Group on Sepsis-Related Problems of the European
Society of Intensive Care Medicine. Intensive Care Med 1996;22:707-710.
67
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DISCLAIMER
Contributors:
// Authors:
Ron Daniels, MBChB, FRCA

Chief Executive
United Kingdom Sepsis Trust, Chief Executive, Global Sepsis Alliance , Programme Director , Survive Sepsis , Consultant in Critical
Care and Anaesthesia, Heart of England NHS Foundation Trust, Birmingham, UK
DISCLOSURES: RD has received payment for consultancy on sepsis from Kimal Plc, manufacturers of vascular access devices,
from the Northumbria Partnership, a patient safety collaborative, and, where annual leave or other income was compromised in
fulfilling his charity duties, from the UK Sepsis Trust. RD has received sponsorship to attend and speak at one meeting from Abbott
Diagnostics. He is CEO of the UK Sepsis Trust and Global Sepsis Alliance, and advises HM Government, the World Health Organisation
and NHS England on sepsis. Each of these positions demands that he express opinion on strategies around the recognition and
management of sepsis.
Tim Nutbeam, MSc, Dip IMC FRCEM

Consultant in Emergency Medicine
Clinical Academic, University of Plymouth, Lead Doctor, Devon Air Ambulance Trust, Derriford Hospital, Plymouth , UK
DISCLOSURES: TN is a clinical advisor to the UK Sepsis Trust.
Edward Berry, MBChB, MCEM

Specialty Registrar in Emergency Medicine
Derriford Hospital , Plymouth , UK
DISCLOSURES: EC declares that he has no competing interests.
// Acknowledgements:
Dr Ron Daniels, Dr Tim Nutbeam, and Dr Edward Berry would like to gratefully acknowledge Dr Lewys Richmond and Dr Paul
Kempen, the previous contributors to this monograph.
DISCLOSURES: LR and PK declare that they have no competing interests.
// Peer Reviewers:
Steven M. Opal, MD, FIDSA

Professor of Medicine
Infectious Disease Division, Rhode Island Hospital, Alpert Medical School of Brown University, Providence, RI
DISCLOSURES: SMO declares that he has no competing interests.
Laura Evans, MD, MSc, FCCP, FCCM

Associate Professor
NYU School of Medicine, Medical Director of Critical Care, Bellevue Hospital Center, New York, NY
DISCLOSURES: LE serves as the guidelines co-chair and on the steering committee of the Surviving Sepsis Campaign.

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Sepsis in adults

The right clinical information, right where it's needed

Last updated: Jun 06, 2017

Step-by-step treatment approach 27

Sepsis is a syndrome comprising an immune system-mediated collection of physiological responses to an infectious

The endothelium and coagulation system:

Sepsis: recognition, diagnosis and early management (National Institute for

Step-by-step diagnostic approach

• Timing and quality of interventions

• Genetic and acquired predisposition of the patient.

• Temperature> 38.3°C (101°F) or <36.0°C (96.8°F)

• Tachypnoea> 20 breaths/minute or PaCO2 <4.3 kPa (32 mmHg)

• Leukocytosis (WBC count> 12x10^9/L [12,000/microlitre])

• Leukopenia (WBC count <4x10^9/L [4000/microlitre])

• Normal WBC count with> 10% immature forms.

• Acutely altered mental status.

• Altered mental state

• Systolic blood pressure ≤100 mmHg

• Respiratory rate≥ 22 breaths/minute.

• Serum lactate> 2 mmol/L (>18 mg/dL).

• Respiratory (respiratory rate; new need for oxygen to maintain saturation)

• Systolic blood pressure

• Circulation and hydration (raised heart rate; urine output)

alcoholism, immunocompromise, and diabetes mellitus.

• To identify causative organisms

• To evaluate for organ dysfunction

• To identify the source of infection

• To prognosticate, to aid in the selection of an appropriate level of care.

Investigations to identify causative organisms:

Evaluation for organ dysfunction:

Investigations to identify the source of the infection:

age >65 years

recent surgery or other invasive procedures

breached skin integrity

indwelling lines or catheters

intravenous drug misuse

History & examination factors

presence of risk factors (common)

high (>38°C) or low (<36°C) temperature (common)

acutely altered mental status (common)

poor capillary refill, mottling of the skin, or ashen appearance (common)

signs associated with specific source of infection (common)

low oxygen saturation (common)

arterial hypotension (common)

decreased urine output (common)

blood urea and serum electrolytes serum electrolytes frequently

response and to altered glucose metabolism.

ECG may show evidence of

Other tests to consider

CT chest or abdomen abscess, effusion may be

Condition Differentiating signs / Differentiating tests

Myocardial infarction (MI) • Symptoms suggesting MI are • Ischaemic changes on ECG.

Myocarditis • Patients typically present with a • ECG may show non-specific

Condition Differentiating signs / Differentiating tests

Malignant hyperthermia • This is a rare condition • The caffeine-halothane

• History of causative drug use.

• Respiratory (PaO2/FiO2 ratio)

• Neurological (as assessed by the Glasgow coma scale)

• Cardiovascular (mean arterial pressure [MAP] or administration of vasopressors)

• Coagulation (platelet count)

• Renal (creatinine level and urine output)

• Hepatic (bilirubin level).

• Alteration in mental status

• Systolic blood pressure ≤100 mmHg

BMJ Best Practice 'Sepsis in Adult'

BMJ Best Practice 'Sepsis in Adult'