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Sepsis: recognition, diagnosis and early management

Identifying people with suspected sepsis

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  • Think 'could this be sepsis?' if a person presents with signs or symptoms that indicate possible infection
  • Take into account that people with sepsis may have non-specific, non-localised presentations, for example feeling very unwell, and may not have a high temperature
  • Pay particular attention to concerns expressed by the person and their family or carers, for example changes from usual behaviour
  • Assess people who might have sepsis with extra care if they cannot give a good history (for example, people with English as a second language or people with communication problems)
  • Assess people with any suspected infection to identify:
    • possible source of infection
    • factors that increase risk of sepsis
    • any indications of clinical concern, such as new onset abnormalities of behaviour, circulation or respiration
  • Identify factors that increase risk of sepsis or indications of clinical concern such as new onset abnormalities of behavior, circulation or respiration when deciding during a remote assessment whether to offer a face-to-face-assessment and if so, on the urgency of face-to-face assessment
  • Use a structured set of observations to assess people in a face-to-face setting to stratify risk if sepsis is suspected
  • Suspect neutropenic sepsis in patients having anticancer treatment who become unwell
  • Refer patients with suspected neutropenic sepsis immediately for assessment in secondary or tertiary care

Risk factors for sepsis

  • Take into account that people in the groups below are at higher risk of developing sepsis:
    • the very young (under 1 year) and older people (over 75 years) or people who are very frail
    • people who have impaired immune systems because of illness or drugs, including:
      • people being treated for cancer with chemotherapy
      • people who have impaired immune function (for example, people with diabetes, people who have had a splenectomy, or people with sickle cell disease)
      • people taking long-term steroids
      • people taking immunosuppressant drugs to treat non-malignant disorders such as rheumatoid arthritis
    • people who have had surgery, or other invasive procedures, in the past 6weeks
    • people with any breach of skin integrity (for example, cuts, burns, blisters or skin infections)
    • people who misuse drugs intravenously
    • people with indwelling lines or catheters
  • Take into account that women who are pregnant, have given birth or had a termination of pregnancy or miscarriage in the past 6 weeks are in a high risk group for sepsis. In particular, women who:
    • have impaired immune systems because of illness or drugs
    • have gestational diabetes or diabetes or other comorbidities
    • needed invasive procedures (for example, caesarean section, forceps delivery, removal of retained products of conception)
    • had prolonged rupture of membranes
    • have or have been in close contact with people with group A streptococcal infection, for example, scarlet fever
    • have continued vaginal bleeding or an offensive vaginal discharge
  • Take into account the following risk factors for early-onset neonatal infection:
    • invasive group B streptococcal infection in a previous baby
    • maternal group B streptococcal colonisation, bacteriuria or infection in the current pregnancy
    • prelabour rupture of membranes
    • preterm birth following spontaneous labour (before 37 weeks' gestation)
    • suspected or confirmed rupture of membranes for more than 18 hours in a preterm birth
    • intrapartum fever higher than 38°C, or confirmed or suspected chorioamnionitis
    • parenteral antibiotic treatment given to the woman for confirmed or suspected invasive bacterial infection (such as septicaemia) at any time during labour, or in the 24-hour periods before and after the birth (this does not refer to intrapartum antibiotic prophylaxis)
    • suspected or confirmed infection in another baby in the case of a multiple pregnancy

Face-to-face assessment of people with suspected sepsis

  • Assess temperature, heart rate, respiratory rate, blood pressure, level of consciousness and oxygen saturation in young people and adults with suspected sepsis
  • Assess temperature, heart rate, respiratory rate, level of consciousness, oxygen saturation and capillary refill time in children under 12 years with suspected sepsis
  • Measure blood pressure of children under 5 years if heart rate or capillary refill time is abnormal and facilities to measure blood pressure, including a correctly-sized blood pressure cuff, are available
  • Measure blood pressure of children aged 5 to 11 years who might have sepsis if facilities to measure blood pressure, including a correctly-sized cuff, are available
  • Only measure blood pressure in children under 12 years in community settings if facilities to measure blood pressure, including a correctly-sized cuff, are available and taking a measurement does not cause a delay in assessment or treatment
  • Measure oxygen saturation in community settings if equipment is available and taking a measurement does not cause a delay in assessment or treatment
  • Examine people with suspected sepsis for mottled or ashen appearance, cyanosis of the skin, lips, or tongue, non-blanching rash of the skin, any breach of skin integrity (for example, cuts, burns or skin infections) or other rash indicating potential infection
  • Ask the person, parent or carer about frequency of urination in the past 18 hours

Stratifying risk of severe illness or death from sepsis

  • Use the person's history and physical examination results to grade risk of severe illness or death from sepsis using criteria based on age (see tables 1, 2 and 3)

Adults, children and young people aged 12 years and over

Table 1: Risk stratification tool for adults, children and young people aged 12 years and over with suspected sepsis

CategoryHigh risk criteriaModerate to high risk criteriaLow risk criteria
History Objective evidence of new altered mental state

History from patient, friend or relative of new onset of altered behaviour or mental state

History of acute deterioration of functional ability

Impaired immune system (illness or drugs including oral steroids)

 

Trauma, surgery or invasive procedures in the last 6weeks
Normal behaviour
Respiratory

Raised respiratory rate: 25 breaths per minute or more

New need for oxygen (more than 40% FiO2) to maintain saturation more than 92% (or more than 88% in known chronic obstructive pulmonary disease)

Raised respiratory rate: 21–24 breaths per minute No high risk or moderate to high risk criteria met
Blood pressure Systolic blood pressure 90 mmHg or less or systolic blood pressure more than 40mmHg below normal Systolic blood pressure 91–100mmHg No high risk or moderate to high risk criteria met
Circulation and hydration Raised heart rate: more than 130 beats per minute
Not passed urine in previous 18 hours
For catheterised patients, passed less than 0.5 ml/kg of urine per hour
Raised heart rate: 91–130 beats per minute (for pregnant women 100–130 beats per minute) or new onset arrhythmia
Not passed urine in the past 12–18 hours
For catheterised patients, passed 0.5–1 ml/kg of urine per hour
No high risk or moderate to high risk criteria met
Temperature   Tympanic temperature less than 36°C  
Skin Mottled or ashen appearance
Cyanosis of skin, lips, or tongue
Non-blanching rash of skin
Signs of potential infection, including redness, swelling or discharge at surgical site or breakdown of wound No non-blanching rash

Children aged 5–11 years

Table 2: Risk stratification tool for children aged 5–11years with suspected sepsis

CategoryAgeHigh risk criteriaModerate to high risk criteriaLow risk criteria
Behaviour Any

Objective evidence of altered behaviour or mental state Appears ill to a healthcare professional

Does not wake or if roused does not stay awake

Not behaving normally
Decreased activity
Parent or carer concern that the child is behaving differently from usual
Behaving normally
Respiratory Any Oxygen saturation of less than 90% in air or increased oxygen requirement over baseline Oxygen saturation of less than 92% in air or increased oxygen requirement over baseline No high risk or moderate to high risk criteria met
Aged 5years Raised respiratory rate: 29 breaths per minute or more Raised respiratory rate: 24–28 breaths per minute
Aged 6–7years Raised respiratory rate: 27 breaths per minute or more Raised respiratory rate: 24–26 breaths per minute
Aged 8–11years Raised respiratory rate: 25 breaths per minute or more Raised respiratory rate: 22–24 breaths per minute
Circulation and hydration Any Heart rate less than 60 beats per minute Capillary refill time of 3seconds or more
Reduced urine output
For catheterised patients, passed less than 1 ml/kg of urine per hour
No high risk or moderate to high risk criteria met
Aged 5 years Raised heart rate: 130 beats per minute or more Raised heart rate: 120–129 beats per minute
Aged 6–7 years Raised heart rate: 120 beats per minute or more Raised heart rate: 110–119 beats per minute
Aged 8–11 years Raised heart rate: 115 beats per minute or more Raised heart rate: 105–114 beats per minute
Temperature Any   Tympanic temperature less than 36°C  
Skin Any Mottled or ashen appearance
Cyanosis of skin, lips, or tongue
Non-blanching rash of skin
   
Other Any   Leg pain
Cold hands or feet
No high or moderate to high risk criteria met

Children aged under 5 years

Table 3: Risk stratification tool for children aged under 5 years with suspected sepsis

CategoryAgeHigh risk criteriaModerate to high risk criteriaLow risk criteria
Behaviour Any No response to social cues
Appears ill to a healthcare professional
Does not wake, or if roused does not stay awake
Weak high-pitched or continuous cry
Not responding normally to social cues
No smile
Wakes only with prolonged stimulation
Decreased activity
Parent or carer concern that child is behaving differently from usual
Responds normally to social cues
Content or smiles
Stays awake or awakens quickly
Strong normal cry or not crying
Respiratory Any Grunting
Apnoea
Oxygen saturation of less than 90% in air or increased oxygen requirement over baseline
Oxygen saturation of less than 92% in air or increased oxygen requirement over baseline
Nasal flaring
No high risk or moderate to high risk criteria met
Under 1 year Raised respiratory rate: 60 breaths per minute or more Raised respiratory rate: 50–59 breaths per minute
1–2 years Raised respiratory rate: 50 breaths per minute or more Raised respiratory rate: 40–49 breaths per minute
3–4 years Raised respiratory rate: 40 breaths per minute or more Raised respiratory rate: 35–39 breaths per minute
Circulation and hydration Any Bradycardia: heart rate less than 60 beats per minute Capillary refill time of 3 seconds or more
Reduced urine output
For catheterised patients, passed less than 1 ml/kg of urine per hour
No high risk or moderate to high risk criteria met
Under 1 year Rapid heart rate: 160 beats per minute or more Rapid heart rate: 150–159 beats per minute
1–2 years Rapid heart rate: 150 beats per minute or more Rapid heart rate: 140–149 beats per minute
3–4 years Rapid heart rate: 140 beats per minute or more Rapid heart rate: 130–139 beats per minute
Skin Any Mottled or ashen appearance
Cyanosis of skin, lips, or tongue
Non-blanching rash of skin
Pallor of skin, lips or tongue  Normal colour
Temperature Any Less than 36°C    
Under 3 months 38°C or more    
3–6 months   39°C or more  
Other Any   Leg pain
Cold hands or feet
No high risk or high to moderate risk criteria met

Children, young people and adults with suspected sepsis

Temperature in suspected sepsis

  • Do not use a person's temperature as the sole predictor of sepsis
  • Do not rely on fever or hypothermia to rule sepsis either in or out
  • Ask the person with suspected sepsis and their family or carers about any recent fever or rigors
  • Take into account that some groups of people with sepsis may not develop a raised temperature. These include:
    • people who are older or very frail
    • people having treatment for cancer
    • people severely ill with sepsis
    • young infants or children
  • Take into account that a rise in temperature can be a physiological response, for example after surgery or trauma

Heart rate in suspected sepsis

  • Interpret the heart rate of a person with suspected sepsis in context, taking into account that:
    • baseline heart rate may be lower in young people and adults who are fit
    • baseline heart rate in pregnancy is 10–15 beats per minute more than normal
    • older people with an infection may not develop an increased heart rate
    • older people may develop a new arrhythmia in response to infection rather than an increased heart rate
    • heart rate response may be affected by medicines such as beta-blockers

Blood pressure in suspected sepsis

  • Interpret blood pressure in the context of a person's previous blood pressure, if known. Be aware that the presence of normal blood pressure does not exclude sepsis in children and young people

Confusion, mental state and cognitive state in suspected sepsis

  • Interpret a person's mental state in the context of their normal function and treat changes as being significant
  • Be aware that changes in cognitive function may be subtle and assessment should include history from patient and family or carers
  • Take into account that changes in cognitive function may present as changes in behaviour or irritability in both children and in adults with dementia
  • Take into account that changes in cognitive function in older people may present as acute changes in functional abilities

Oxygen saturation in suspected sepsis

  • Take into account that if peripheral oxygen saturation is difficult to measure in a person with suspected sepsis, this may indicate poor peripheral circulation because of shock

Managing suspected sepsis outside acute hospital settings

  • Refer all people with suspected sepsis outside acute hospital settings for emergency medical care by the most appropriate means of transport (usually 999 ambulance) if:
    • they meet any high risk criteria (see tables 1, 2 and 3) or
    • they are aged under 17 years and their immunity is impaired by drugs or illness and they have any moderate to high risk criteria
  • Assess all people with suspected sepsis outside acute hospital settings with any moderate to high risk criteria to:
    • make a definitive diagnosis of their condition
    • decide whether they can be treated safely outside hospital
  • If a definitive diagnosis is not reached or the person cannot be treated safely outside an acute hospital setting, refer them urgently for emergency care
  • Provide people with suspected sepsis, who do not have any high or moderate to high risk criteria information about symptoms to monitor and how to access medical care if they are concerned

Antibiotic treatment in people with suspected sepsis

  • Pre-alert secondary care (through GP or ambulance service) when any high risk criteria are met in a person with suspected sepsis outside of an acute hospital, and transfer them immediately
  • Ensure GPs and ambulance services have mechanisms in place to give antibiotics for people with high risk criteria in pre-hospital settings in locations where transfer time is more than 1 hour
  • If meningococcal disease is specifically suspected (fever and purpuric rash) give appropriate doses of parenteral benzyl penicillin in community settings and intravenous ceftriaxone in hospital settings
  • For all people with suspected sepsis where the source of infection is clear use existing local antimicrobial guidance

Using oxygen in people with suspected sepsis

  • Give oxygen to achieve a target saturation of 94–98% for adult patients or 88–92% for those at risk of hypercapnic respiratory failure
  • Oxygen should be given to children with suspected sepsis who have signs of shock or oxygen saturation (SpO2) of less than 92% when breathing air. Treatment with oxygen should also be considered for children with an SpO2 of greater than 92%, as clinically indicated

Finding the source of infection in people with suspected sepsis

  • Carry out a thorough clinical examination to look for sources of infection, including sources that might need surgical drainage, as part of the initial assessment
  • Tailor investigations of the sources of infection to the person's clinical history and findings on examination

Information and support for people with sepsis and their families and carers

People who have sepsis and their families and carers

  • Ensure a care team member is nominated to give information to families and carers, particularly in emergency situations such as in the emergency department. This should include:
    • an explanation that the person has sepsis, and what this means
    • an explanation of any investigations and the management plan
    • regular and timely updates on treatment, care and progress
  • Ensure information is given without using medical jargon. Check regularly that people understand the information and explanations they are given
  • Give people with sepsis and their family members and carers opportunities to ask questions about diagnosis, treatment options, prognosis and complications. Be willing to repeat any information as needed
  • Give people with sepsis and their families and carers information about national charities and support groups that provide information about sepsis and the causes of sepsis

Information at discharge for people assessed for suspected sepsis, but not diagnosed with sepsis

  • Give people who have been assessed for sepsis but have been discharged without a diagnosis of sepsis (and their family or carers, if appropriate) verbal and written information about:
    • what sepsis is, and why it was suspected
    • what tests and investigations have been done
    • instructions about which symptoms to monitor
    • when to get medical attention if their illness continues
    • how to get medical attention if they need to seek help urgently
  • Confirm that people understand the information they have been given, and what actions they should take to get help if they need it

Information at discharge for people who have had sepsis

  • Ensure discharge notifications to GPs include the diagnosis of sepsis

Training and education

  • Ensure all healthcare staff and students involved in assessing people's clinical condition are given regular, appropriate training in identifying people who might have sepsis. This includes primary, community care and hospital staff including those working in care homes
  • Ensure all healthcare professionals involved in triage or early management are given regular appropriate training in identifying, assessing and managing sepsis. This should include:
    • risk stratification strategies
    • local protocols for early treatments, including antibiotics and intravenous fluids
    • criteria and pathways for escalation, in line with their health care setting 

Now Test and Reflect: view our multiple choice questions

© NICE 2016. Sepsis: recognition, diagnosis and early management. Available from: www.nice.org.uk/guidance/NG51. All rights reserved. Subject to Notice of rights.

NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication. 

First included: July 2016.