Summary
Definition
History and exam
Key diagnostic factors
- risk factors
- signs associated with specific source of infection
- high early warning score (e.g., NEWS2 5 or more)
- tachypnoea (NEWS2)
- high or low temperature, sometimes with rigors (NEWS2)
- tachycardia (NEWS2)
- acutely altered mental status (NEWS2)
- low oxygen saturation (NEWS2)
- hypotension (NEWS2)
- oliguria
- poor capillary refill, mottling of the skin, or ashen appearance
- cyanosis
Other diagnostic factors
- malaise/lethargy
- nausea/vomiting/diarrhoea
- purpura fulminans
- ileus
- jaundice
Risk factors
- age >65 years
- immunocompromise
- indwelling lines or catheters
- recent surgery or other invasive procedures
- haemodialysis
- diabetes mellitus
- intravenous drug misuse
- alcohol dependency
- pregnancy
- breached skin integrity
- urban residence
- lung disease
- male sex
- non-white ancestry
- winter season
Diagnostic investigations
1st investigations to order
- blood cultures
- serum lactate
- hourly urine output
- full blood count
- urea and electrolytes (including creatinine)
- serum glucose
- C-reactive protein
- serum procalcitonin
- clotting screen
- liver function tests
- blood gas
- ECG
Investigations to consider
- urine analysis
- chest x-ray
- cultures from multiple sources
- lumbar puncture
- computed tomography
- ultrasound
- urine antigen testing
- viral swabs
- HIV screen
- echocardiogram
Treatment algorithm
in hospital: sepsis highly suspected and unknown or unclear source of bacterial infection
in the community: sepsis highly suspected and bacterial infection confirmed or highly suspected
in hospital: sepsis highly suspected and clear source of bacterial infection identified
Contributors
Expert advisers
Alexander Alexiou, MB, BS, BSc, DCH, FRCEM, Dip IMC RCSEd
Emergency Medicine Consultant
Physician Response Unit Consultant
Barts Health NHS Trust
London’s Air Ambulance
Royal London Hospital
London
UK
Disclosures
AA declares that he has no competing interests.
Clovis Rau, MBBS, BSc, FRCEM, DipIMC
Specialty Registrar Emergency Medicine (ST6)
Barnet Hospital
Royal Free NHS Foundation Trust
London
UK
Disclosures
CR declares that he has no competing interests.
Acknowledgements
BMJ Best Practice would like to gratefully acknowledge the previous team of expert contributors, whose work has been retained in parts of the content:
Ron Daniels MBChB, FRCA
Chief Executive
United Kingdom Sepsis Trust
Chief Executive
Global Sepsis Alliance
Programme Director
Survive Sepsis
Consultant in Critical Care and Anaesthesia
Heart of England NHS Foundation Trust
Birmingham
UK
Matt Inada-Kim MBBS, FRCP
Consultant Acute Physician & Sepsis Lead
Department of Acute Medicine
Royal Hampshire County Hospital
Hampshire Hospitals NHS Foundation Trust
Winchester
UK
Aamir Saifuddin BMBCh, BA, MRCP, AFFMLM
Specialty Registrar in Gastroenterology and General Medicine
Maidstone and Tunbridge Wells NHS Trust
UK
Tim Nutbeam MSc, Dip IMC FRCEM
Consultant in Emergency Medicine
Clinical Academic
University of Plymouth
Lead Doctor
Devon Air Ambulance Trust
Derriford Hospital
Plymouth
UK
Edward Berry MBChB, MCEM
Specialty Registrar in Emergency Medicine
Derriford Hospital
Plymouth
UK
Disclosures
RD has received payment for consultancy on sepsis from Kimal Plc, manufacturers of vascular access devices, from the Northumbria Partnership, a patient safety collaborative, and, where annual leave or other income was compromised in fulfilling his charity duties, from the UK Sepsis Trust. RD has received sponsorship to attend and speak at one meeting from Abbott Diagnostics. He is CEO of the UK Sepsis Trust and Global Sepsis Alliance, and advises HM Government, the World Health Organization, and NHS England on sepsis. Each of these positions demands that he express opinion on strategies around the recognition and management of sepsis. MIK is a national clinical advisor on sepsis to NHS England and a national clinical advisor on deterioration to NHS Improvement. He was reimbursed for a slide set by Relias Learning. AS is the clinical fellow to the National Medical Director at NHS Improvement. AS has been sponsored on two occasions by Dr Falk Pharma UK to attend specialist gastroenterology conferences abroad; there was no contractual obligation to disseminate product information. TN is a clinical adviser to the UK Sepsis Trust. EB declares that he has no competing interests.
Peer reviewers
Matt Inada-Kim, MBBS, FRCP
Consultant Acute Physician & Sepsis Lead
Department of Acute Medicine
Royal Hampshire County Hospital
Hampshire Hospitals NHS Foundation Trust
Winchester
UK
Disclosures
MIK is a national clinical advisor on sepsis to NHS England and a national clinical advisor on deterioration to NHS Improvement. He was reimbursed for a slide set by Relias Learning.
Editors
Tannaz Aliabadi-Oglesby
Lead Section Editor, BMJ Best Practice
Disclosures
TAO declares that she has no competing interests.
Jo Haynes
Head of Editorial, BMJ Knowledge Centre
Disclosures
JH declares that she has no competing interests.
Rachel Wheeler
Lead Section Editor, BMJ Best Practice
Disclosures
RW declares that she has no competing interests.
Julie Costello
Comorbidities Editor, BMJ Best Practice
Disclosures
JC declares that she has no competing interests.
Adam Mitchell
Drug Editor, BMJ Best Practice
Disclosures
AM declares that he has no competing interests.
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