Suspected sepsis: recognition, diagnosis and early management

Context

Sepsis is a clinical syndrome caused by the body's immune and coagulation systems being switched on by an infection. Sepsis with shock is a life-threatening condition that is characterised by low blood pressure despite adequate fluid replacement, and organ dysfunction or failure. Sepsis is an important cause of death in people of all ages. Both a UK Parliamentary and Health Service Ombudsman enquiry (2013) and a UK National Confidential Enquiry into Patient Outcome and Death (NCEPOD, 2015) highlighted sepsis as being a leading cause of avoidable death that kills more people than breast, bowel and prostate cancer combined.

Sepsis is difficult to diagnose with certainty. Although people with sepsis may have a history of infection, fever is not present in all cases. The signs and symptoms of sepsis can be very non-specific and can be missed if clinicians do not think 'could this be sepsis?'. In the same way that healthcare professionals consider 'could this pain be cardiac in origin?' when presented with someone of any age with chest pain this guideline aims to make 'could this be sepsis?' the first consideration for anyone presenting with a possible infection.

Detailed guidelines exist for the management of sepsis in adult and paediatric intensive care units, and by intensive care clinicians called to other settings. To reduce avoidable deaths, people with sepsis need to be recognised early and treatment initiated. This guideline aims to ensure healthcare systems in all clinical settings consider sepsis as an immediate life-threatening condition that should be recognised and treated as an emergency. The guideline outlines the immediate actions needed for those with suspicion of sepsis and who are at highest risk of morbidity and mortality from sepsis. It provides a framework for risk assessment, treatment and follow-up or 'safety netting' of people not needing immediate resuscitation. The intention of this guideline is to ensure that all people with sepsis due to any cause are recognised and initial treatment initiated before definitive treatment on other specific pathways is instituted.

Previous terminology included terms SIRS (systematic inflammatory response syndrome), severe sepsis and septic shock but more recent terminology suggests using terms sepsis and septic shock only. Sepsis is defined as a life-threatening organ dysfunction due to a dysregulated host response to infection and septic shock as persisting hypotension requiring vasopressors to maintain a mean arterial pressure (MAP) of 65 mmHg or more and having a serum lactate level of greater than 2 mmol/l despite adequate volume resuscitation. Neither of these definitions are useful in early identification of people at risk and the guideline recommends actions according to clinical parameters that stratify risk of severe illness or death from sepsis.

There is significant overlap between this guideline and other NICE guidance, in particular the care of acutely ill patients in hospital, the assessment and initial management of fever in under 5s, bacterial meningitis and meningococcal disease, neutropenic sepsis, antibiotics for prevention and treatment of neonatal infection, and pneumonia in adults.