Sepsis: recognition, diagnosis and early management

This Guidelines summary covers recognition, diagnosis, and early management of sepsis for all populations. It should be used together with NICE's algorithms organised by age group and treatment location and the risk stratification tools. Please refer to the full guideline for a complete list of recommendations.

 

Identifying people with suspected sepsis

• 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
• Consider using an early warning score (NEWS2 has been endorsed by NHS England) to assess people with suspected sepsis in acute hospital settings
• 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
• Treat people with neutropenic sepsis in line with NICE's guideline on neutropenic sepsis

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 (suspect neutropenic sepsis in patients having anticancer treatment who become unwell)
    • 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 6 weeks
  • 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

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

 

 

Category	High risk criteria	Moderate to high risk criteria	Low 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 6 weeks	Normal behaviour
Respiratory	Raised respiratory rate: 25 breaths per minute or more   New need for oxygen (40% FiO2 or more) 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 40 mmHg below normal	Systolic blood pressure 91–100 mmHg	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 5–11 years with suspected sepsis

Category	Age	High risk criteria	Moderate to high risk criteria	Low 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 5 years	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 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
	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

Category	Age	High risk criteria	Moderate to high risk criteria	Low 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

For information on oxygen useage for people with suspected sepsis, finding the source of infection, and information and support for people with sepsis and their families and carers, please refer to the full guideline.