If patient has any of the following conditions, follow appropriate condition-specific guideline

• For neutropenic sepsis in cancer patients – see Neutropenic sepsis guideline
• For sepsis management in children – see Paediatric guidelines
• For peri-natal sepsis – see Obstetric and Neonatal guidelines

• Sepsis – a life-threatening organ dysfunction due to dysregulated host response caused by an infection. It is a medical emergency
• Septic shock is associated with a higher risk of mortality (>40%) and refers to patients with sepsis who:
  • remain hypotensive despite adequate fluid resuscitation and require vasopressors to maintain a mean arterial pressure (MAP) ≥65 mmHg
  • have persistently elevated serum lactate (≥2 mmol/L)

• All patients who have a NEWS ≥5 (or) any individual NEWS element ≥3, screen for sepsis by completing Sepsis Proforma Looking for red flags and moderate risk factors

• Start Sepsis Six if the patient satisfies 1 of the following:
• presence of 1 red flag sign or
• presence of 2 moderate risk factors along with AKI and/or lactate ≥2

Sepsis Six

• Complete all actions in one hour
• Ensure senior clinician attends
• Administer Oxygen
  • see Oxygen therapy in acutely hypoxaemic patients guideline
• Obtain IV access
• Take blood cultures, glucose, lactate, FBC, U&Es, CRP and clotting
• Consider cultures from potential sources of infection & Chest X-ray
  • if probable CNS infection, perform lumbar puncture. See Lumbar puncture
• Give IV antimicrobials
• Give IV fluids
  • see Adult fluid management guideline

Monitor

• NEWS2. See NEWS
• Measure urine output
  • may require urinary catheter
  • start fluid balance chart & complete hrly
• Check serial lactates
  • corroborate high VBG lactate with arterial sample
  • If lactate >4mmol/L, call critical care
• Record observations at least every hour
  • if initial lactate raised or if clinical condition deteriorates, at least every 30 minutes

Antimicrobials

Penicillin Allergy

• True penicillin allergy is rare
• Ask the patient and record what happened when they were given penicillin
• If any doubt about whether patient is truly allergic to penicillin, seek advice from a microbiologist or consultant in infectious diseases

Infection Control alerts

• Check for IC alert
• if IC alert not available, check previous 12 months of microbiology reports
• If MRSA present, treat as tagged for MRSA. See MRSA management
• high risk of MRSA: recent history of MRSA, patient in other hospital/nursing home in last 12 months, sepsis likely to be hospital-acquired, or line infection suspected
• If ESBL, MGNB, CARB present, treat as tagged for ESBL. See ESBL/MGNB/CARB management
• ESBL or MGNB tag: history of ESBL-producing or multi-resistant Gram-negative Bacilli

Choice of anti-microbials

Select type of patient from list:

Septic shock

• Consider patient in septic shock if any of the following are present despite 30 mL/kg of fluid resuscitation within first 3 hr
  • mean arterial blood pressure ≤65 mmHg or
  • serum lactate persistently elevated ≥2 mmol/L on repeated measurements
• Consider immediate escalation to senior clinician (registrar and above) and/or to critical care team
• Once decision is made, admit patients requiring critical care to the ICU within 6 hours

• Correct coding of sepsis enables local and national data to accurately reflect the incidence of sepsis
• Current consensus definition is 'organ dysfunction' and dysregulated host response secondary to an infectious source
• Do not document localised infections (non-septic infections) in medical record as sepsis (e.g. terms like urosepsis, biliary sepsis, chest sepsis etc., may be inaccurately coded as systemic sepsis)
• good practice is for a responsible consultant to confirm that initial diagnosis of sepsis is a 'true sepsis' or indicate only a localised infection present (rather than generalised sepsis), code as a localised infection only or a 'non-septic infection'