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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.

 

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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

 

 

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 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

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 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

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

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

© 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 published: July 2016.

Last updated: September 2017.