Sepsis: recognition, diagnosis and early management

This guideline covers the recognition, diagnosis and early management of sepsis for all populations. The guideline committee identified that the key issues to be included were: recognition and early assessment, diagnostic and prognostic value of blood markers for sepsis, initial treatment, escalating care, identifying the source of infection, early monitoring, information and support for patients and carers, and training and education.

# Recommendations
People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

# Identifying people with suspected sepsis
This guidance should be used together with the algorithms organised by age group and treatment location and the risk stratification tools. There are algorithms for:
children under 5 out of hospital
children under 5 in hospital
children aged 5 to 11 years out of hospital
children aged 5 to 11 years in hospital
children and young people aged 12 to 17 out of hospital
children and young people aged 12 to 17 in hospital
adults aged 18 and over out of hospital
adults aged 18 and over in hospital
There are also risk stratification tools for:
children under 5
children aged 5 to 11 years
adults, children and young people aged 12 years and over
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 (see section 1.2 on risk factors for sepsis)
any indications of clinical concern, such as new onset abnormalities of behaviour, circulation or respiration.
Identify factors that increase risk of sepsis (see section 1.2 on risk factors for sepsis) or indications of clinical concern such as new onset abnormalities of behaviour, 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 (see section 1.3 on 1.3 face-to-face assessment on people with suspected sepsis) to assess people in a face-to-face setting to stratify risk (see section 1.4 on stratifying risk of severe illness or death from sepsis) 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 (see recommendation 1.1.9 in the section on identifying people with suspected sepsis)
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 (see recommendation 1.1.5 in the section on identifying people with suspected sepsis)
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 38C, 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
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 to 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 to 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 to 130 beats per minute (for pregnant women 100 to 130 beats per minute) or new onset arrhythmia
Not passed urine in the past 12 to 18 hours
For catheterised patients, passed 0.5  ml/kg to 1 ml/kg of urine per hour
No high risk or moderate to high risk criteria met
Temperature
Tympanic temperature less than 36C
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
A downloadable version of this table is also available.
Recognise that adults, children and young people aged 12 years and over with suspected sepsis and any of the symptoms or signs below are at high risk of severe illness or death from sepsis:
-bjective evidence of new altered mental state
respiratory rate of 25 breaths per minute or above, or new need for 40% oxygen or more to maintain oxygen saturation more than 92% (or more than 88% in known chronic obstructive pulmonary disease)
heart rate of more than 130 beats per minute
systolic blood pressure of 90 mmHg or less, or systolic blood pressure more than 40 mmHg below normal
not passed urine in previous 18 hours (for catheterised patients, passed less than 0.5 ml/kg/hour)
mottled or ashen appearance
cyanosis of the skin, lips or tongue
non-blanching rash of the skin.Be aware that some pulse oximeters can underestimate or overestimate oxygen saturation levels, especially if the saturation level is borderline. Overestimation has been reported in people with dark skin. See also the NHS England Patient Safety Alert on the risk of harm from inappropriate placement of pulse oximeter probes.
Recognise that adults, children and young people aged 12 years and over with suspected sepsis and any of the symptoms or signs below are at moderate to high risk of severe illness or death from sepsis:
history of new-onset changed behaviour or change in mental state, as reported by the person, a friend or relative
history of acute deterioration of functional ability
impaired immune system (illness or drugs, including oral steroids)
trauma, surgery or invasive procedure in the past 6 weeks
respiratory rate of 21 to 24 breaths per minute
heart rate of 91 to 130 beats per minute or new-onset arrhythmia, or if pregnant heart rate of 100 to 130 beats per minute
systolic blood pressure of 91 to 100 mmHg
not passed urine in the past 12 to 18 hours (for catheterised patients, passed 0.5 ml/kg/hour to 1 ml/kg/hour)
tympanic temperature less than 36C
signs of potential infection, including increased redness, swelling or discharge at a surgical site, or breakdown of a wound.
Consider adults, children and young people aged 12 years and over with suspected sepsis who do not meet any high or moderate to high risk criteria to be at low risk of severe illness or death from sepsis.

## Children aged 5 to 11 years
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
Respiratory
Aged 5 years
Raised respiratory rate: 29 breaths per minute or more
Raised respiratory rate: 24 to 28 breaths per minute
No high risk or moderate to high risk criteria met
Respiratory
Aged 6 to 7 years
Raised respiratory rate: 27 breaths per minute or more
Raised respiratory rate: 24 to 26 breaths per minute
No high risk or moderate to high risk criteria met
Respiratory
Aged 8 to 11 years
Raised respiratory rate: 25 breaths per minute or more
Raised respiratory rate: 22 to 24 breaths per minute
No high risk or moderate to high risk criteria met
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
Circulation and hydration
Aged 5 years
Raised heart rate: 130 beats per minute or more
Raised heart rate: 120 to 129 beats per minute
No high risk or moderate to high risk criteria met
Circulation and hydration
Aged 6 to 7 years
Raised heart rate: 120 beats per minute or more
Raised heart rate: 110 to 119 beats per minute
No high risk or moderate to high risk criteria met
Circulation and hydration
Aged 8 to 11 years
Raised heart rate: 115 beats per minute or more
Raised heart rate: 105 to 114 beats per minute
No high risk or moderate to high risk criteria met
Temperature
Any
Tympanic temperature less than 36C
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
Be aware that some pulse oximeters can underestimate or overestimate oxygen saturation levels, especially if the saturation level is borderline. Overestimation has been reported in people with dark skin. See also the NHS England Patient Safety Alert on the risk of harm from inappropriate placement of pulse oximeter probes.
A downloadable version of this table is also available.
Recognise that children aged 5 to 11 years with suspected sepsis and any of the symptoms or signs below are at high risk of severe illness or death from sepsis:
has objective evidence of altered behaviour or mental state, or appears ill to a healthcare professional, or does not wake (or if roused, does not stay awake)
respiratory rate:
aged 5 years, 29 breaths per minute or more
aged 6 to 7 years, 27 breaths per minute or more
aged 8 to 11 years, 25 breaths per minute or more
-xygen saturation of less than 90% in air or increased oxygen requirement over baseline
heart rate:
aged 5 years, 130 beats per minute or more
aged 6 to 7 years, 120 beats per minute or more
aged 8 to 11 years, 115 beats per minute or more
-r heart rate less than 60 beats per minute at any age
mottled or ashen appearance
cyanosis of the skin, lips or tongue
non-blanching rash of the skin.
Recognise that children aged 5 to 11 years with suspected sepsis and any of the symptoms or signs below are at moderate to high risk of severe illness or death from sepsis:
not responding normally to social cues or decreased activity, or parent or carer concern that the child is behaving differently from usual
respiratory rate:
aged 5 years, 24 to 28 breaths per minute
aged 6 to 7 years, 24 to 26 breaths per minute
aged 8 to 11 years, 22 to 24 breaths per minute
-xygen saturation of less than 92% in air or increased oxygen requirement over baseline
heart rate:
aged 5 years, 120 to 129 beats per minute
aged 6 to 7 years, 110 to 119 beats per minute
aged 8 to 11 years, 105 to 114 beats per minute
-r capillary refill time of 3 seconds or more
reduced urine output, or for catheterised patients passed less than 1 ml/kg of urine per hour
tympanic temperature less than 36C
have leg pain or cold hands or feet.Be aware that some pulse oximeters can underestimate or overestimate oxygen saturation levels, especially if the saturation level is borderline. Overestimation has been reported in people with dark skin. See also the NHS England Patient Safety Alert on the risk of harm from inappropriate placement of pulse oximeter probes.
Consider children aged 5 to 11 years with suspected sepsis who do not meet any high or moderate to high risk criteria to be at low risk of severe illness or death from sepsis.

## Children aged under 5 years
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
Respiratory
Under 1 year
Raised respiratory rate: 60 breaths per minute or more
Raised respiratory rate: 50 to 59 breaths per minute
No high risk or moderate to high risk criteria met
Respiratory
to 2 years
Raised respiratory rate: 50 breaths per minute or more
Raised respiratory rate: 40 to 49 breaths per minute
No high risk or moderate to high risk criteria met
Respiratory
to 4 years
Raised respiratory rate: 40 breaths per minute or more
Raised respiratory rate: 35 to 39 breaths per minute
No high risk or moderate to high risk criteria met
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
Circulation and hydration
Under 1 year
Rapid heart rate: 160 beats per minute or more
Rapid heart rate: 150 to 159 beats per minute
No high risk or moderate to high risk criteria met
Circulation and hydration
to 2 years
Rapid heart rate: 150 beats per minute or more
Rapid heart rate: 140 to 149 beats per minute
No high risk or moderate to high risk criteria met
Circulation and hydration
to 4 years
Rapid heart rate: 140 beats per minute or more
Rapid heart rate: 130 to 139 beats per minute
No high risk or moderate to high risk criteria met
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 36oC
Temperature
Under 3 months
C or more
Temperature
to 6 months
C or more
Other
Any
Leg pain
Cold hands or feet
No high risk or high to moderate risk criteria met
Be aware that some pulse oximeters can underestimate or overestimate oxygen saturation levels, especially if the saturation level is borderline. Overestimation has been reported in people with dark skin. See also the NHS England Patient Safety Alert on the risk of harm from inappropriate placement of pulse oximeter probes.
This table is adapted from NICE's guideline on fever in under 5s. A downloadable version of this table is also available.
Recognise that children aged under 5 years with suspected sepsis and any of the symptoms or signs below are at high risk of severe illness or death from sepsis:
behaviour:
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
heart rate:
aged under 1 year, 160 beats per minute or more
aged 1 to 2 years, 150 beats per minute or more
aged 3 to 4 years, 140 beats per minute or more
heart rate less than 60 beats per minute at any age
respiratory rate:
aged under 1 year, 60 breaths per minute or more
aged 1 to 2 years, 50 breaths per minute or more
aged 3 to 4 years, 40 breaths per minute or more
grunting
apnoea
-xygen saturation of less than 90% in air or increased oxygen requirement over baseline
mottled or ashen appearance
cyanosis of the skin, lips or tongue
non-blanching rash of the skin
aged under 3 months and temperature 38C or more
temperature less than 36C.
Recognise that children aged under 5 years with suspected sepsis and any of the symptoms or signs below are at moderate to high risk of severe illness or death from sepsis:
behaviour:
not responding normally to social cues
no smile
wakes only with prolonged stimulation
decreased activity
parent or carer concern that the child is behaving differently from usual
respiratory rate:
aged under 1 year, 50 to 59 breaths per minute
aged 1 to 2 years, 40 to 49 breaths per minute
aged 3 to 4 years, 35 to 39 breaths per minute
-xygen saturation less than 92% in air or increased oxygen requirement over baseline
nasal flaring
heart rate:
aged under 1 year, 150 to 159 beats per minute
aged 1 to 2 years, 140 to 149 beats per minute
aged 3 to 4 years 130 to 139 beats per minute
capillary refill time of 3 seconds or more
reduced urine output, or for catheterised patients passed less than 1 ml/kg of urine per hour
pallor of skin, lips or tongue reported by parent or carer
aged 3 to 6 months and temperature 39C or over
have leg pain or cold hands or feet. Be aware that some pulse oximeters can underestimate or overestimate oxygen saturation levels, especially if the saturation level is borderline. Overestimation has been reported in people with dark skin. See also the NHS England Patient Safety Alert on the risk of harm from inappropriate placement of pulse oximeter probes.
Consider children aged under 5 years with suspected sepsis who do not meet any high or moderate to high risk criteria to be at low risk of severe illness or death from sepsis. 

## 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 to 15 beats per minute more than normal
-lder people with an infection may not develop an increased heart rate
-lder 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.Be aware that some pulse oximeters can underestimate or overestimate oxygen saturation levels, especially if the saturation level is borderline. Overestimation has been reported in people with dark skin. See also the NHS England Patient Safety Alert on the risk of harm from inappropriate placement of pulse oximeter probes.

# 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.Emergency care requires facilities for resuscitation to be available and depending on local services may be emergency department, medical admissions unit and for children may be paediatric ambulatory unit or paediatric medical admissions unit.
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.

# Managing and treating suspected sepsis in acute hospital settings

## Adults, children and young people aged 12 years and over with suspected sepsis who meet 1 or more high risk criteria
For adults, children and young people aged 12 years and over who have suspected sepsis and 1 or more high risk criteria:
arrange for immediate review by the senior clinical decision maker to assess the person and think about alternative diagnoses to sepsis A 'senior clinical decision maker' for people aged 18 years or over should be someone who is authorised to prescribe antibiotics, such as a doctor of grade CT3/ST3 or above or equivalent, such as an advanced nurse practitioner with antibiotic prescribing responsibilities, depending on local arrangements. A 'senior decision maker' for people aged 12 to 17 years is a paediatric or emergency care qualified doctor of grade ST4 or above or equivalent.
carry out a venous blood test for the following:
blood gas including glucose and lactate measurement
blood culture
full blood count
C-reactive protein
urea and electrolytes
creatinine
a clotting screen
give a broad-spectrum antimicrobial at the maximum recommended dose without delay (within 1 hour of identifying that they meet any high risk criteria in an acute hospital setting) in line with recommendations in section 1.7 antibiotic treatment in people with suspected sepsis
discuss with a consultant.Appropriate consultant may be the consultant under whom the patient is admitted or a consultant covering acute medicine, anaesthetics.
For adults, children and young people aged 12 years and over with suspected sepsis and any high risk criteria and lactate over 4 mmol/litre, or systolic blood pressure less than 90 mmHg:
give intravenous fluid bolus without delay (within 1 hour of identifying that they meet any high risk criteria in an acute hospital setting) in line with recommendations in section 1.8 intravenous fluids in people with suspected sepsis and
refer to critical care for review of management including need for central venous access and initiation of inotropes or vasopressors.Referral may be a formal referral process or discussion with specialist in intensive care or intensive care outreach team.Critical care means an intensivist or intensive care outreach team, or specialist in intensive care or paediatric intensive care.
For adults, children and young people aged 12 years and over with suspected sepsis and any high risk criteria and lactate between 2 and 4 mmol/litre:
give intravenous fluid bolus without delay (within 1 hour of identifying that they meet any high risk criteria in an acute hospital setting) in line with recommendations in section 1.8 intravenous fluids in people with suspected sepsis.
For adults, children and young people aged 12 years and over with suspected sepsis and any high risk criteria and lactate below 2 mmol/litre:
consider giving intravenous fluid bolus (in line with recommendations in section 1.8 intravenous fluids in people with suspected sepsis).
Monitor people with suspected sepsis who meet any high risk criteria continuously, or a minimum of once every 30 minutes depending on setting. Physiological track and trigger systems should be used to monitor all adult patients in acute hospital settings. 
Monitor the mental state of adults, children and young people aged 12 years and over with suspected sepsis. Consider using a scale such as the Glasgow Coma Scale (GCS) or AVPU ('alert, voice, pain, unresponsive') scale.
Alert a consultant to attend in person if an adult, child or young person aged 12 years or over with suspected sepsis and any high risk criteria fails to respond within 1 hour of initial antibiotic and/or intravenous fluid resuscitation. Failure to respond is indicated by any of:
systolic blood pressure persistently below 90 mmHg
reduced level of consciousness despite resuscitation
respiratory rate over 25 breaths per minute or a new need for mechanical ventilation
lactate not reduced by more than 20% of initial value within 1 hour.

## Adults, children and young people aged 12 years and over with suspected sepsis who meet 2 or more moderate to high risk criteria
For adults, children and young people aged 12 years and over with suspected sepsis and 2 or more moderate to high risk criteria, or systolic blood pressure 91 to 100 mmHg, carry out a venous blood test for the following:
blood gas, including glucose and lactate measurement
blood culture
full blood count
C-reactive protein
urea and electrolytes
creatinineand arrange for a clinician to review the person's condition and venous lactate results within 1 hour of meeting criteria in an acute hospital setting.A 'clinician' should be a medically qualified practitioner or equivalent who has antibiotic prescribing responsibilities.
For adults, children and young people aged 12 years and over with suspected sepsis who meet 2 or more moderate to high risk criteria and have lactate over 2 mmol/litre or evidence of acute kidney injury, treat as high risk and follow recommendations 1.6.1 to 1.6.7.For definition of acute kidney injury, see NICE's guideline on acute kidney injury.
For adults, children and young people aged 12 years and over with suspected sepsis who meet 2 or more moderate to high risk criteria, have lactate of less than 2 mmol/litre, no evidence of acute kidney injury and in whom a definitive condition cannot be identified:
repeat structured assessment at least hourly
ensure review by a senior clinical decision maker within 3 hours of meeting 2 or more moderate to high risk criteria in an acute hospital setting for consideration of antibiotics.A 'senior clinical decision maker' for people aged 18 years or over should be someone who is authorised to prescribe antibiotics, such as a doctor of grade CT3/ST3 or above or equivalent, such as an advanced nurse practitioner with antibiotic prescribing responsibilities, depending on local arrangements. A 'senior decision maker' for people aged 12 to 17 years is a paediatric or emergency care qualified doctor of grade ST4 or above or equivalent. For definition of acute kidney injury, see NICE's guideline on acute kidney injury.
For adults, children and young people aged 12 years and over with suspected sepsis who meet 2 or more moderate to high risk criteria, have lactate of less than 2 mmol/litre, no evidence of acute kidney injuryand in whom a definitive condition or infection can be identified and treated:
manage the definitive condition
if appropriate, discharge with information depending on the setting (see recommendations 1.11.5 and 1.11.6). For definition of acute kidney injury, see NICE's guideline on acute kidney injury.

## Adults, children and young people aged 12 years and over with suspected sepsis who meet only 1 moderate to high risk criterion
For adults, children and young people aged 12 years and over with suspected sepsis who meet only 1 moderate to high risk criterion:
arrange clinician review within 1 hour of meeting criterion for clinical assessment in an acute hospital settingA 'clinician' should be a medically qualified practitioner or equivalent who has antibiotic prescribing responsibilities.
perform blood tests if indicated.
For adults, children and young people aged 12 years and over with suspected sepsis who meet only 1 moderate to high risk criterion and in whom a definitive condition can be identified and treated:
manage the definitive condition
if appropriate, discharge with information depending on setting (see recommendations 1.11.5 and 1.11.6).
For adults, children and young people aged 12 years and over with suspected sepsis who meet only 1 moderate to high risk criterion, have lactate of less than 2 mmol/litre, no evidence of acute kidney injury and in whom a definitive condition cannot be identified:
repeat structured assessment at least hourly
ensure review by a senior clinical decision maker within 3 hours of meeting moderate to high criterion in an acute hospital setting for consideration of antibiotics.A 'senior clinical decision maker' for people aged 18 years or over should be someone who is authorised to prescribe antibiotics, such as a doctor of grade CT3/ST3 or above or equivalent, such as an advanced nurse practitioner with antibiotic prescribing responsibilities, depending on local arrangements. A 'senior decision maker' for people aged 12 to 17 years is a paediatric or emergency care qualified doctor of grade ST4 or above or equivalent. For definition of acute kidney injury, see NICE's guideline on acute kidney injury.

## Adults, children and young people aged 12 years and over with suspected sepsis and no high risk or moderate to high risk criteria
Arrange clinical assessment of adults, children and young people aged 12 years and over who have suspected sepsis and no high risk or moderate to high risk criteria and manage according to clinical judgement.Clinical assessment should be carried out by a medically qualified practitioner or equivalent who has antibiotic prescribing responsibilities.

## Children aged 5 to 11 years

## Children aged 5 to 11 years with suspected sepsis who meet 1 or more high risk criteria
For children aged 5 to 11 years who have suspected sepsis and 1 or more high risk criteria:
arrange for immediate review by the senior clinical decision maker to assess the child and think about alternative diagnoses to sepsisA 'senior clinical decision maker' for children aged 5 to 11 years is a paediatric or emergency care doctor of grade ST4 or above or equivalent.
carry out a venous blood test for the following:
blood gas, including glucose and lactate measurement
blood culture
full blood count
C-reactive protein
urea and electrolytes
creatinine
a clotting screen
give a broad-spectrum antimicrobial (see section 1.7) at the maximum recommended dose without delay (within 1 hour of identifying that they meet any high risk criteria in an acute hospital setting)
discuss with a consultant.
For children aged 5 to 11 years with suspected sepsis and any high risk criteria and lactate over 4 mmol/litre:
give intravenous fluid bolus without delay (within 1 hour of identifying that they meet any high risk criteria in an acute hospital setting) in line with recommendations in section 1.8 intravenous fluids in people with suspected sepsis and
refer to critical care for review of central access and initiation of inotropes or vasopressors.Referral may be a formal referral process or discussion with specialist in intensive care or intensive care outreach team.Critical care means an intensivist or intensive care outreach team, or specialist in intensive care or paediatric intensive care.
For children aged 5 to 11 years with suspected sepsis and any high risk criteria and lactate between 2 and 4 mmol/litre:
give intravenous fluid bolus as soon as possible (within 1 hour of identifying that they meet any high risk criteria in an acute hospital setting) in line with recommendations in section 1.8 intravenous fluids in people with suspected sepsis.
For children aged 5 to 11 years with suspected sepsis and any high risk criteria and lactate below 2 mmol/litre:
consider giving intravenous fluid bolus in line with recommendations in section 1.8 intravenous fluids in people with suspected sepsis.
Monitor children with suspected sepsis who meet any high risk criteria continuously, or a minimum of once every 30 minutes depending on setting. Physiological track and trigger systems should be used to monitor all children in acute hospital settings. 
Monitor the mental state of children aged 5 to 11 years with suspected sepsis. Consider using the Glasgow Coma Scale (GCS) or AVPU ('alert, voice, pain, unresponsive') scale.
Alert a consultant to attend in person if a child aged 5 to 11 years with suspected sepsis and any high risk criteria fails to respond within 1 hour of initial antibiotic and/or intravenous fluid resuscitation. Failure to respond is indicated by any of:
reduced level of consciousness despite resuscitation
heart rate or respiratory rate fulfil high risk criteria
lactate remains over 2 mmol/litre after 1 hour.

## Children aged 5 to 11 years with suspected sepsis who meet 2 or more moderate to high risk criteria
For children aged 5 to 11 years with suspected sepsis and 2 or more moderate to high risk criteria:
carry out a venous blood test for the following:
blood gas, including glucose and lactate measurement
blood culture
full blood count
C-reactive protein
urea and electrolytes
creatinine
arrange for a clinician to review the person's condition and venous lactate results within 1 hour of meeting criteria in an acute hospital setting.
For children aged 5 to 11 years with suspected sepsis who meet 2 or more moderate to high risk criteria and have lactate over 2 mmol/litre, treat as high risk and follow recommendations 1.6.16 to 1.6.22.
For children aged 5 to 11 years with suspected sepsis who meet 2 or more moderate to high risk criteria, have lactate of less than 2 mmol/litre, and in whom a definitive condition cannot be identified:
repeat structured assessment at least hourly
ensure review by a senior clinical decision maker within 3 hours of meeting 2 or more moderate to high risk criteria in an acute hospital setting for consideration of antibiotics.A 'senior clinical decision maker' for children aged 511 years is a paediatric or emergency care doctor of grade ST4 or above or equivalent.
For children aged 5 to 11 years with suspected sepsis who meet 2 or more moderate to high risk criteria, have lactate of less than 2 mmol/litre, and in whom a definitive condition or infection can be identified and treated:
manage the definitive condition, and
if appropriate, discharge with information depending on setting (see recommendations 1.11.5 and 1.11.6).

## Children aged 5 to 11 years with suspected sepsis who meet only 1 moderate to high risk criterion
For children aged 5 to 11 years with suspected sepsis who meet only 1 moderate to high risk criterion:
arrange clinician review within 1 hour of meeting 1 moderate to high risk criterion in an acute hospital setting for clinical assessment andA 'clinician' should be a medically qualified practitioner or equivalent who has antibiotic prescribing responsibilities.
perform blood tests if indicated.
For children aged 5 to 11 years with suspected sepsis who meet only 1 moderate to high risk criterion and in whom a definitive condition can be identified and treated:
manage the definitive condition
if appropriate, discharge with information depending on setting (see recommendations 1.11.5 and 1.11.6).
For children aged 5 to 11 years with suspected sepsis who meet only 1 moderate to high risk criterion, and in whom a definitive condition cannot be identified:
repeat structured assessment at least hourly
ensure review by a senior clinical decision maker within 3 hours of meeting a moderate to high risk criterion in an acute hospital setting for consideration of antibiotics.A 'senior clinical decision maker' for children aged 5 to 11 years is a paediatric or emergency care doctor of grade ST4 or above or equivalent.

## Children aged 5 to 11 years with suspected sepsis and no high risk or moderate to high risk criteria
Arrange clinical assessment of children aged 5 to 11 years who have suspected sepsis and no high risk or moderate to high risk criteria and manage according to clinical judgement.This should be by a medically qualified practitioner or equivalent with prescribing responsibilities.

## Children aged under 5 years

## Children aged under 5 years with suspected sepsis who meet 1 or more high risk criteria
For children aged under 5 years who have suspected sepsis and 1 or more high risk criteria:
arrange for immediate review by the senior clinical decision maker to assess the child and think about alternative diagnoses to sepsis (for example bronchiolitis)A 'senior clinical decision maker' for children aged under 5 years is a paediatric qualified doctor of grade ST4 or above.
carry out a venous blood test for the following:
blood gas, including glucose and lactate measurement
blood culture
full blood count
C-reactive protein
urea and electrolytes
creatinine
a clotting screen
give a broad-spectrum antimicrobial at the maximum recommended dose without delay (within 1 hour of identifying that they meet any high risk criteria in an acute hospital setting; see section 1.7).
discuss with a consultant.
For children aged under 5 years with suspected sepsis and any high risk criteria and lactate over 4 mmol/litre:
give intravenous fluid bolus without delay (in line with recommendations in section 1.8 intravenous fluids in people with suspected sepsis) and
refer to critical care for review of central access and initiation of inotropes or vasopressors.Referral may be a formal referral process or discussion with specialist in intensive care or intensive care outreach team.Critical care means an intensivist or intensive care outreach team, or specialist in intensive care or paediatric intensive care.
For children aged under 5 years with suspected sepsis and any high risk criteria and lactate between 2 and 4 mmol/litre:
give intravenous fluid bolus without delay (within 1 hour of identifying that they meet any high risk criteria in an acute hospital setting) in line with recommendations in section 1.8 intravenous fluids in people with suspected sepsis .
For children aged under 5 years with suspected sepsis and any high risk criteria and lactate below 2 mmol/litre, consider giving intravenous fluid bolus in line with recommendations in section 1.8 intravenous fluids in people with suspected sepsis .
Monitor children aged under 5 years with suspected sepsis who meet any high risk criteria continuously, or a minimum of once every 30 minutes depending on setting. Physiological track and trigger systems should be used to monitor all children in acute hospital settings. 
Monitor the mental state of children under 5 years with suspected sepsis. Consider using the Glasgow Coma Scale (GCS) or AVPU ('alert, voice, pain, unresponsive') scale.
Alert a consultant to attend in person if a child aged under 5 years with suspected sepsis and any high risk criteria fails to respond within 1 hour of initial antibiotic and/or intravenous fluid resuscitation. Failure to respond is indicated by any of:
reduced level of consciousness despite resuscitation
heart rate or respiratory rate fulfil high risk criteria
lactate over 2 mmol/litre after 1 hour.
Give parenteral antibiotics to infants aged under 3 months as follows:
infants younger than 1 month with fever
all infants aged 1 to 3 months with fever who appear unwell
infants aged 1 to 3 months with white blood cell count less than 5109/litre or greater than 15109/litre.

## Children aged under 5 years with suspected sepsis who meet 2 or more moderate to high risk criteria
For children aged under 5 years with suspected sepsis and 2 or more moderate to high risk criteria:
carry out a venous blood test for the following:
blood gas, including glucose and lactate measurement
blood culture
full blood count
C-reactive protein
urea and electrolytes
creatinine
arrange for a clinician to review the person's condition and venous lactate results within 1 hour of meeting 2 or more moderate to high risk criteria in an acute hospital setting.A 'clinician' should be a medically qualified practitioner or equivalent who has antibiotic prescribing responsibilities.
For children aged under 5 years with suspected sepsis who meet 2 or more moderate to high risk criteria and have lactate over 2 mmol/litre, treat as high risk and follow recommendations 1.6.31 to 1.6.37.
For children aged under 5 years with suspected sepsis who meet 2 or more moderate to high risk criteria, have lactate of less than 2 mmol/litre, and in whom a definitive condition cannot be identified:
repeat structured assessment at least hourly
ensure review by a senior clinical decision maker within 3 hours of meeting 2 or more moderate to high risk criteria in an acute hospital setting for consideration of antibiotics.A 'senior clinical decision maker' for children aged under 5 years is a paediatric qualified doctor of grade ST4 or above.
For children aged under 5 years with suspected sepsis who meet 2 or more moderate to high risk criteria, have lactate of less than 2 mmol/litre, and in whom a definitive condition or infection can be identified and treated:
manage the definitive condition and
if appropriate, discharge with information depending on the setting (see recommendations 1.11.5 and 1.11.6).

## Children aged under 5 years with suspected sepsis who meet only 1 moderate to high risk criterion
For children aged under 5 years with suspected sepsis who meet only 1 moderate to high risk criterion:
arrange clinician review within 1 hour of meeting a moderate to high risk criterion for clinical assessment and
perform blood tests if indicated.
For children aged under 5 years with suspected sepsis who meet only 1 moderate to high risk criterion and in whom a definitive condition can be identified and treated:
manage the definitive condition
if appropriate, discharge with information depending on setting (see recommendations 1.11.5 and 1.11.6).
For children aged under 5 years with suspected sepsis who meet only 1 moderate to high risk criterion and in whom a definitive condition cannot be identified:
repeat structured assessment at least hourly
ensure review by a senior clinical decision maker within 3 hours of meeting a moderate to high risk criterion in an acute hospital setting for consideration of antibiotics.A 'senior clinical decision maker' for children aged under 5 years is a paediatric qualified doctor of grade ST4 or above.

## Children aged under 5 years with suspected sepsis and no high risk or moderate to high risk criteria
Arrange clinical assessment of children aged under 5 years who have suspected sepsis and no high risk or moderate to high risk criteria and manage according to clinical judgement.Clinical assessment should be carried out by a medically qualified practitioner or equivalent who has antibiotic prescribing responsibilities.

# 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 urgent assessment mechanisms are in place to deliver antibiotics when any high risk criteria are met in secondary care (within 1 hour of meeting a high risk criterion in an acute hospital setting).
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.
For patients in hospital who have suspected infections, take microbiological samples before prescribing an antimicrobial and review the prescription when the results are available. For people with suspected sepsis take blood cultures before antibiotics are given. 
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 people aged 18 years and over who need an empirical intravenous antimicrobial for a suspected infection but who have no confirmed diagnosis, use an intravenous antimicrobial from the agreed local formulary and in line with local (where available) or national guidelines. 
For people aged up to 17 years (for neonates see recommendation 1.7.12) with suspected community acquired sepsis of any cause give ceftriaxone 80 mg/kg once a day with a maximum dose of 4 g daily at any age. 
For people aged up to 17 years with suspected sepsis who are already in hospital, or who are known to have previously been infected with or colonised with ceftriaxone-resistant bacteria, consult local guidelines for choice of antibiotic.
For children younger than 3 months, give an additional antibiotic active against listeria (for example, ampicillin or amoxicillin). 
Treat neonates presenting in hospital with suspected sepsis in their first 72 hours with intravenous benzylpenicillin and gentamicin. 
Treat neonates who are more than 40 weeks corrected gestational age who present with community acquired sepsis with ceftriaxone 50 mg/kg unless already receiving an intravenous calcium infusion at the time. If 40 weeks corrected gestational age or below or receiving an intravenous calcium infusion use cefotaxime 50 mg/kg every 6 to 12 hours, depending on the age of the neonate.
Follow the recommendations in NICE's guideline on antimicrobial stewardship: systems and processes for effective antimicrobial medicine when prescribing and using antibiotics to treat people with suspected or confirmed sepsis.

# Intravenous fluids in people with suspected sepsis
If patients over 16 years need intravenous fluid resuscitation, use crystalloids that contain sodium in the range 130  mmol/litre to 154 mmol/litre with a bolus of 500 ml over less than 15 minutes. 
If children and young people up to 16 years need intravenous fluid resuscitation, use glucose-free crystalloids that contain sodium in the range 130 to 154 mmol/litre, with a bolus of 10 ml/kg over less than 10 minutes. Take into account pre-existing conditions (for example, cardiac disease or kidney disease), because smaller fluid volumes may be needed. 
If neonates need intravenous fluid resuscitation, use glucose-free crystalloids that contain sodium in the range 130 to 154 mmol/litre, with a bolus of 10 ml/kg to 20 ml/kg over less than 10 minutes. 
Reassess the patient after completion of the intravenous fluid bolus, and if no improvement give a second bolus. If there is no improvement after a second bolus alert a consultant to attend (in line with recommendations 1.6.7, 1.6.22 and 1.6.37).
Use a pump, or syringe if no pump is available, to deliver intravenous fluids for resuscitation to children under 12 years with suspected sepsis who need fluids in bolus form.
If using a pump or flow controller to deliver intravenous fluids for resuscitation to people over 12 years with suspected sepsis who need fluids in bolus form ensure device is capable of delivering fluid at required rate for example at least 2000 ml/hour in adults.
Do not use starch based solutions or hydroxyethyl starches for fluid resuscitation for people with sepsis. 
Consider human albumin solution 4 to 5% for fluid resuscitation only in patients with sepsis and shock. 

# Using oxygen in people with suspected sepsis
Give oxygen to achieve a target saturation of 94% to 98% for adult patients or 88% to 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. Be aware that some pulse oximeters can underestimate or overestimate oxygen saturation levels, especially if the saturation level is borderline. Overestimation has been reported in people with dark skin. See also the NHS England Patient Safety Alert on the risk of harm from inappropriate placement of pulse oximeter probes.

# 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.
Consider urine analysis and chest X-ray to identify the source of infection in all people with suspected sepsis.
Consider imaging of the abdomen and pelvis if no likely source of infection is identified after clinical examination and initial tests.
Involve the adult or paediatric surgical and gynaecological teams early on if intra-abdominal or pelvic infection is suspected in case surgical treatment is needed.
Do not perform a lumbar puncture without consultant instruction if any of the following contraindications are present:
signs suggesting raised intracranial pressure or reduced or fluctuating level of consciousness (Glasgow Coma Scale score less than 9 or a drop of 3 points or more)
relative bradycardia and hypertension
focal neurological signs
abnormal posture or posturing
unequal, dilated or poorly responsive pupils
papilloedema
abnormal 'doll's eye' movements
shock
extensive or spreading purpura
after convulsions until stabilised
coagulation abnormalities or coagulation results outside the normal range or platelet count below 100x109/litre or receiving anticoagulant therapy
local superficial infection at the lumbar puncture site
respiratory insufficiency in children.
Perform lumbar puncture in the following children with suspected sepsis (unless contraindicated, see contraindications in recommendation 1.10.6):
infants younger than 1 month
all infants aged 1 to 3 months who appear unwell
infants aged 1 to 3 months with a white blood cell count less than 5109/litre or greater than 15109/litre. 

# 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 at increased risk of sepsis
Ensure people who are at increased risk of sepsis (for example after surgery) are told before discharge about symptoms that should prompt them to get medical attention and how to get it.See NICE's guideline on neutropenic sepsis for information for people with neutropenic sepsis (recommendation 1.1.1.1).

## Information at discharge for people who have had sepsis
Ensure people and their families and carers if appropriate have been informed that they have had sepsis.
Ensure discharge notifications to GPs include the diagnosis of sepsis.
Give people who have had sepsis (and their families and carers, when appropriate) opportunities to discuss their concerns. These may include:
why they developed sepsis
whether they are likely to develop sepsis again
if more investigations are necessary
details of any community care needed, for example, related to peripherally inserted central venous catheters (PICC) lines or other intravenous catheters
what they should expect during recovery
arrangements for follow-up, including specific critical care follow up if relevant
possible short-term and long-term problems.
Give people who have had sepsis and their families and carers information about national charities and support groups that provide information about sepsis and causes of sepsis.
Advise carers they have a legal right to have a carer's assessment of their needs, and give them information on how they can get this.See NICE's guideline on rehabilitation after critical illness in adults for recommendations on rehabilitation and follow up after critical illness.See NICE's guideline on meningitis (bacterial) and meningococcal septicaemia in under 16s for follow up of people who have had meningococcal septicaemia.

# 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.

# Terms used in this guideline

## Sepsis
Sepsis is a life-threatening organ dysfunction due to a dysregulated host response to infection.

## Suspected sepsis
Suspected sepsis is used to indicate people who might have sepsis and require face-to-face assessment and consideration of urgent intervention.# Recommendations for research
The guideline committee has made the following recommendations for research.

# Epidemiological study on presentation and management of sepsis in England
What is the incidence, presentation and management of sepsis in the United Kingdom?

## Why this is important
The lack of robust UK based epidemiological studies on the incidence and outcomes from sepsis have been clear throughout the guideline development process. A large epidemiological study to collect information about where sepsis is being treated, patient interventions and patient outcomes would provide population based statistics on epidemiology of sepsis which are necessary to support evaluation of interventions, planning of services and service redesign. The mortality and morbidity and service complexity associated with severe infection and sepsis, and the need to use broad spectrum antimicrobials to treat sepsis, justifies the cost required to set up such a study.

# A complex service evaluation of implementation of NICE Sepsis guideline
What effect will the NICE sepsis guideline have on patient care processes and outcomes in the UK over the next 5 years?

## Why this is important
Implementation of NICE's guideline on sepsis will be a challenge to the NHS. A robust evaluation of how NHS service providers adhere to the recommended care processes needs to be carried out over the next 5 years.
A complex evaluation is needed to understand the effect of guidelines on services and on patient outcomes. Evaluation should include assessment of costs and cost effectiveness, the use of a universal audit tool for sepsis patient care that includes evaluation of pre-hospital and secondary care and monitoring of broad spectrum antibiotic use, development of multi-resistant organisms and incidence of antibiotic-related infection such as C. difficile.

# Use of biomarkers to diagnose and initiate treatment
What is the clinical and cost effectiveness of procalcitonin (PCT) point-of-care tests at initial triage for diagnosis of serious infection and the initiation of appropriate antibiotic therapy?

## Why this is important
There is an urgent clinical need for accurate biomarkers of serious bacterial infection (SBI) which provide early diagnosis of SBI, and prompt clinical interventions to improve outcomes. The current tests used in the NHS (white cell count and C-reactive protein) are non-specific and not sensitive enough. Biomarker-guided initiation and termination of antibiotic therapy might be an effective strategy to reduce unnecessary antibiotic use and help prevent further multidrug resistance. The NICE diagnostics guidance on procalcitonin for diagnosing and monitoring sepsis has shown there is not enough evidence in this area.

# Validation of clinical early warning scores in pre-hospital and emergency care settings
Can early warning scores, for example NEWS (national early warning scores for adults) and PEWS (paediatric early warning score), be used to improve the detection of sepsis and facilitate prompt and appropriate clinical response in pre-hospital settings and in emergency departments?

## Why this is important
Delay in detecting and treating sepsis increases mortality. Early detection and appropriate management will reduce morbidity and mortality and will reduce NHS costs by reducing critical care admissions, inappropriate antimicrobial use and length of hospital stay. No high quality data exist on the validation or use of early warning scores in pre-hospital settings or in the emergency department settings. The use of scores might improve communication between pre-hospital settings and hospital settings and allow recognition of people who need more urgent assessment.

# Derivation of clinical decision rules in suspected sepsis
Is it possible to derive and validate a set of clinical decision rules or a predictive tool to rule out sepsis which can be applied to patients presenting to hospital; with suspected sepsis?

## Why this is important
In primary care and emergency departments people with suspected sepsis are often seen by relatively inexperienced doctors. Many of these people will be in low and medium risk groups but evidence is lacking as to who can be sent home safely and who needs intravenous or oral antibiotics. The consequences of getting the decision making wrong can be catastrophic and therefore many patients are potentially over-investigated and admitted inappropriately. Current guidance is dependent on use of individual variables informed by low quality evidence.# 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.
At the time of writing, the terminology around sepsis is changing and new international consensus definitions have been published. Previous terminology included terms SIRS (systematic inflammatory response syndrome), severe sepsis and septic shock but new 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 for the care of acutely ill patients in hospital (see NICE's guideline on acutely ill adults in hospital), the assessment and initial management of fever in under 5s (see NICE's guideline on fever in under 5s), bacterial meningitis and meningococcal septicaemia (see NICE's guideline on meningitis (bacterial) and meningococcal septicaemia in under 16s), NICE's guideline on neutropenic sepsis, antibiotics for prevention and treatment of neonatal infection (see NICE's guideline on neonatal infection), and NICE's guideline on pneumonia in adults.