SPECIFIC CONDITIONS

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

DEFINITIONS

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)

SCREENING

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

Sepsis Proforma tool

Next Question Here

IMMEDIATE MANAGEMENT

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

Administer Oxygen

see Oxygen therapy in acutely hypoxaemic patients guideline

Take blood cultures. Consider cultures from potential sources of infection & Chest X-ray
Give IV antimicrobials
Give IV fluids

see Adult fluid management guideline

Check serial lactates

corroborate high VBG lactate with arterial sample
If lactate >4mmol/L, call critical care

Measure urine output

may require urinary catheter
start fluid balance chart & complete hrly

Record observations at least every 30 min

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

Only accept penicillin allergy as genuine hypersensitivity if convincing history of either rash within 72 hr of dose or anaphylactic reaction

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:

First line: Meropenem 1 g IV 8-hrly plus vancomycin IV by infusion – see Vancomycin calculator and guideline
Alternative (true penicillin allergy): Meropenem 1 g IV 8-hrly plus vancomycin IV by infusion – see Vancomycin calculator and guideline. If anaphylaxis to penicillin, discuss with consultant in infectious diseases or microbiologist

First line: Piperacillin/tazobactam 4.5 g IV 8-hrly plus vancomycin IV by infusion – see Vancomycin calculator and guideline
Alternative (true penicillin allergy): Aztreonam 1 g IV 8-hrly plus vancomycin IV by infusion – see Vancomycin calculator and guideline

First line: Meropenem 1 g IV 8-hrly alone
Alternative (true penicillin allergy): Meropenem 1 g IV 8-hrly alone. If anaphylaxis to penicillin, discuss with consultant in infectious diseases or microbiologist

First line: Piperacillin/tazobactam 4.5 g IV 8-hrly
Alternative (true penicillin allergy): Aztreonam 1 g IV 8-hrly plus vancomycin IV by infusion - see Vancomycin calculator and guideline

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

patient’s systolic blood pressure ≤90 mmHg or
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

CODING FOR DIAGNOSIS OF SEPSIS

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'

SEPSIS MANAGEMENT