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DRAFT FOR CONSULTATION

1 Sepsis: recognition, diagnosis and


2 management
3

4 NICE guideline: short version


5 Draft for consultation, January, 2016
6

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.

Who is it for?

 People with sepsis, their families and carers.


 Healthcare professionals working in primary, secondary and tertiary care.

This version of the guideline contains the recommendations, context and


recommendations for research. Information about how the guideline was
developed is on the guideline’s page on the NICE website. This includes the
guideline committee’s discussion and the evidence reviews (in the full
guideline), the scope, and details of the committee and any declarations of
interest.

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1 Contents
2 Algorithms ........................................................................................................ 1
3 Recommendations ........................................................................................... 1
4 1.1 Identifying sepsis and people at increased risk of sepsis.................... 1
5 1.2 Assessing people for suspected sepsis .............................................. 3
6 1.3 Stratifying risk ..................................................................................... 4
7 Adults and children and young people aged 12 years and over ................... 4
8 Children aged 5–11 years ............................................................................ 8
9 Children aged under 5 years ...................................................................... 10
10 Children, young people and adults with suspected sepsis ......................... 14
11 1.4 Managing people with suspected sepsis outside acute hospital
12 settings ....................................................................................................... 16
13 1.5 Managing and treating sepsis in hospital .......................................... 17
14 Children aged under 5 years ...................................................................... 25
15 1.6 Antibiotic treatment ........................................................................... 29
16 1.7 Fluids ................................................................................................ 31
17 1.8 Using oxygen .................................................................................... 32
18 1.9 Finding the source of infection .......................................................... 32
19 1.10 Information and support for people with sepsis and their families
20 and carers .................................................................................................. 34
21 1.11 Training and education .................................................................. 36
22 Context .......................................................................................................... 37
23 Recommendations for research ..................................................................... 38
24
25

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1 Algorithms

2 Managing adults and children and young people 12 years and over with suspected sepsis outside acute hospital settings
3

10

11

12

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1 Managing adults and children and young people 12 years and over with
2 suspected sepsis in acute hospital setting

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1 Managing children aged 5-11 years and over with suspected sepsis outside acute hospital settings
2

10

11

12

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1 Managing children aged 5-11 years and over with suspected sepsis in
2 acute hospital setting

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1 Managing children aged under 5 years with suspected sepsis outside acute hospital settings
2

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1 Managing children aged under 5 years with suspected sepsis in acute


2 hospital setting

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2 Recommendations
People have the right to be involved in discussions and make informed
decisions about their care, as described in 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.

3 1.1 Identifying sepsis and people at increased risk of


4 sepsis
5 1.1.1 Suspect sepsis if a person presents with signs or symptoms that
6 indicate possible infection, even if they do not have a high
7 temperature.

8 1.1.2 Take into account that people with sepsis may have non-specific,
9 non-localised presentations, for example feeling very unwell.

10 1.1.3 Pay particular attention to concerns expressed by the person and


11 their family or carers, for example changes from usual behaviour.

12 1.1.4 Assess people who might have sepsis with extra care if they cannot
13 give a good history (for example, people with English as a second
14 language or people with communication problems).

15 1.1.5 Take into account that people in the groups below are at higher risk
16 of developing sepsis:

17  the very young (under 1 year) and older people (over 75 years)
18 or very frail people
19  people who have impaired immune systems because of illness
20 or drugs, including:

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1  people being treated for cancer with chemotherapy


2  people who have impaired immune function (for example,
3 people with diabetes, people who have had a splenectomy, or
4 people with sickle cell disease)
5  people taking long-term steroids
6  people taking immunosuppressant drugs to treat non-
7 malignant disorders such as rheumatoid arthritis
8  people who have had surgery, or other invasive procedures, in
9 the past 6 weeks
10  people with any breach of skin integrity (for example, cuts,
11 burns, blisters or skin infections)
12  people who misuse drugs intravenously
13  people with indwelling lines or catheters.

14 1.1.6 Take into account that women who are pregnant, have given birth
15 or had a termination of pregnancy or miscarriage in the past
16 6 weeks are in a high risk group for sepsis. In particular, women
17 who:

18  have gestational diabetes or diabetes


19  needed invasive procedures (for example, caesarean section,
20 forceps delivery, removal of retained products of conception)
21  had prolonged spontaneous rupture of membranes
22  have been in close contact with people with group A
23 streptococcal infection
24  have continued bleeding or an offensive vaginal discharge.

25 1.1.7 Take into account the following risk factors for early-onset neonatal
26 infection:

27  invasive group B streptococcal infection in a previous baby


28  maternal group B streptococcal colonisation, bacteriuria or
29 infection in the current pregnancy
30  prelabour rupture of membranes

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1  preterm birth following spontaneous labour (before 37 weeks’


2 gestation)
3  suspected or confirmed rupture of membranes for more than
4 18 hours in a preterm birth
5  intrapartum fever higher than 38°C, or confirmed or suspected
6 chorioamnionitis
7  parenteral antibiotic treatment given to the woman for confirmed
8 or suspected invasive bacterial infection (such as septicaemia)
9 at any time during labour, or in the 24-hour periods before and
10 after the birth (this does not refer to intrapartum antibiotic
11 prophylaxis).
12  suspected or confirmed infection in another baby in the case of a
13 multiple pregnancy.

14 [This recommendation is from NICE’s guideline on neonatal


15 infection.]

16 1.2 Assessing people for suspected sepsis


17 1.2.1 Use a structured set of observations (see recommendations 1.2.2
18 and 1.2.3) when assessing people who might have sepsis.
19 Consider using an early warning score in hospital settings .

20 1.2.2 Assess temperature, heart rate, respiratory rate, systolic blood


21 pressure, level of consciousness and oxygen saturation in young
22 people and adults with suspected sepsis.

23 1.2.3 Assess temperature, heart rate, respiratory rate, level of


24 consciousness, oxygen saturation and capillary refill time in
25 children under 12 years with suspected sepsis. [This
26 recommendation is adapted from NICE’s guideline on fever in
27 under 5s.]

28 1.2.4 Measure blood pressure of children under 5 years if heart rate or


29 capillary refill time is abnormal and facilities to measure blood
30 pressure, including correct blood pressure cuff, are available. .

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1 [This recommendation is adapted from NICE’s guideline on fever in


2 under 5s.]

3 1.2.5 Measure blood pressure of children aged 5 to 11 years who might


4 have sepsis if facilities to measure blood pressure, including correct
5 cuff, are available.

6 1.2.6 Only measure blood pressure in children under 12 years in


7 community settings if facilities to measure blood pressure, including
8 correct cuff, are available and taking a measurement does not
9 cause a delay in assessment or treatment.

10 1.2.7 Only measure oxygen saturation in community settings if


11 equipment is available and taking a measurement does not cause a
12 delay in assessment or treatment.

13 1.2.8 Examine skin of people with suspected sepsis for mottled or ashen
14 complexion, cyanosis, non-blanching rash, any breach of skin
15 integrity (for example, cuts, burns or skin infections) or other rash
16 indicating potential infection.

17 1.2.9 Ask the person, parent or carer about frequency of urination in the
18 past 18 hours.

19 1.3 Stratifying risk


20 1.3.1 Use the person’s history and physical examination results to grade
21 risk of severe illness or death from sepsis using criteria based on
22 age (see tables 1, 2 and 3).

23 Adults and children and young people aged 12 years and over

24 Table 1 Risk stratification tool for adults and children and young people
25 aged 12 years and over with suspected sepsis
High risk criteria Moderate to Low risk criteria
high risk
criteria

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History Objective History from Normal behaviour


evidence of new patient, friend or
altered mental relative of new
state onset of altered
behaviour or
mental state
History of acute
deterioration of
functional ability
History of rigors
Impaired immune
system (illness or
drugs including
oral steroids)
Trauma, surgery
or invasive
procedures in the
past 6 weeks
Respiratory Raised Raised No high risk or
respiratory rate: respiratory rate: moderate to high risk
25 breaths per 21–24 breaths criteria met
minute or more per minute or
New need for increased work
oxygen (more of breathing
than 40% FiO2) to
maintain
saturation more
than 92% (or
more than 88% in
known chronic
obstructive
pulmonary
disease)
Blood pressure Systolic blood Systolic blood No high risk or
pressure pressure 91– moderate to high risk
90 mmHg or less 100 mmHg criteria met
or systolic blood
pressure more
than 40 mmHg
below normal
Circulation and Raised heart rate: Raised heart rate No high risk or
hydration more 91–130 beats moderate to high risk
than130 beats per per minute (for criteria met
minute pregnant women * typical heart rate in
Not passed urine 100 -130 beats pregnancy is 10-15
in previous per minute) or beats per minute more
18 hours. new onset than normal
arrhythmia
For catheterised
patients, passed Not passed urine
less than in the last 12–
0.5 ml/kg of urine 18 hours
per hour For catheterised

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patients, passed
0.5–1 ml/kg of
urine per hour
Temperature - Tympanic -
temperature less
than 36°C
Skin Mottled or ashen, Signs of potential No non-blanching rash
with cyanosis of infection,
skin, lips or including
tongue redness, swelling
Non-blanching or discharge at
rash of skin surgical site or
breakdown of
wound
1

2 1.3.2 Recognise that adults and children and young people aged
3 12 years and over with any of the symptoms or signs below are at
4 high risk of severe illness or death from sepsis:

5  objective evidence of new altered mental state


6  respiratory rate of 25 breaths per minute or above, or new need
7 for 40% oxygen to maintain oxygen saturation more than 92%
8 (or more than 88% in known chronic obstructive pulmonary
9 disease)
10  heart rate of 130 beats per minute or above
11  systolic blood pressure of 90 mmHg or less, or systolic blood
12 pressure more than 40 mmHg below normal
13  not passed urine in previous 18 hours (for catheterised patients,
14 passed less than 0.5 ml/kg/hour)
15  mottled or ashen complexion, with cyanosis of the skin, lips or
16 tongue
17  non-blanching rash of the skin, lips or tongue.

18 1.3.3 Recognise that adults and children and young people aged
19 12 years and over with any of the symptoms or signs below are at
20 moderate to high risk of severe illness or death from sepsis:

21  history of new-onset changed behaviour or change in mental


22 state, as reported by the person, a friend or relative

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1  history of acute deterioration of functional ability


2  history of rigors
3  impaired immune system (illness or drugs, including oral
4 steroids)
5  trauma, surgery or invasive procedure in the last 6 weeks
6  respiratory rate of 21–24 breaths per minute, or increased work
7 of breathing
8  heart rate of 91–130 beats per minute or new-onset arrhythmia
9 or if pregnant heart rate of 100-130 beats per minute
10  systolic blood pressure of 91–100 mmHg
11  not passed urine in the past 12–18 hours (for catheterised
12 patients, passed 0.5–1 ml/kg/hour)
13  tympanic temperature less than 36°C
14  signs of potential infection, including increased redness, swelling
15 or discharge at a surgical site, or breakdown of a wound.

16 1.3.4 Consider adults and children and young people aged 12 years and
17 over who do not meet any high or moderate to high risk criteria to
18 be at low risk of severe illness or death from sepsis.

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1 Children aged 5–11 years

2 Table 2 Risk stratification tool for children aged 5–11 years with
3 suspected sepsis
High risk criteria Moderate to high Low risk
risk criteria criteria
Behaviour Objective evidence of Not behaving Behaving
altered behaviour or normally or normally,
mental state wanting to play wanting to play
Appears ill to a healthcare Decreased Responds
professional activity normally to
Does not wake or if Parent or carer social cues
roused does not stay concern that the
awake child is behaving
differently from
usual
Respiratory Raised respiratory rate: Raised No high risk or
Aged 5 years, 29 breaths respiratory rate: moderate to
per minute or more Aged 5 years, high risk criteria
27–28 breaths met
Aged 6–7 years,
27 breaths per minute or per minute
more Aged 6–7 years,
Aged 8–11 years, 24–26 breaths
25 breaths per minute or per minute
more Aged 8–11 years,
Moderate or severe chest 22–24 breaths
indrawing per minute
Circulation and Rapid heart rate: Rapid heart rate: No high risk or
hydration Aged 5 years, 130 beats Aged 5 years, moderate to
per minute or more 120–129 beats high risk criteria
per minute met
Aged 6–7 years,
120 beats per minute or Aged 6–7 years,
more 110–119 beats
Aged 8–11 years, per minute
115 beats per minute or Aged 8–11 years,
more 105–114 beats
Heart rate less than 60 per minute
beats per minute Capillary refill
Not passed urine in last time of 3 seconds
18 hours or more
For catheterised patients, Reduced urine
passed less than 0.5 output
ml/kg of urine per hour For catheterised
patients, passed
0.5–1 ml/kg of
urine per hour
Skin Colour of skin, lips or
tongue is pale, mottled,

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ashen or blue
Non-blanching rash
Other Temperature less than Leg pain No high risk or
36°C Cold hands or moderate to
feet high risk criteria
met
1

2 1.3.5 Recognise that children aged 5–11 years with any of the symptoms
3 or signs below are at high risk of severe illness or death from
4 sepsis:

5  has objective evidence of altered behaviour or mental, or


6 appears ill to a healthcare professional, or does not wake (or if
7 roused, does not stay awake)
8  respiratory rate:
9  aged 5 years, 29 breaths per minute or more
10  aged 6–7 years, 27 breaths per minute or more
11  aged 8–11 years, 25 breaths per minute or more
12  or moderate or severe chest indrawing
13  heart rate:
14  aged 5 years, 130 beats per minute or more
15  aged 6–7 years, 120 beats per minute or more
16  aged 8–11 years, 115 beats per minute or more
17  or heart rate less than 60 beats per minute at any age
18  not passed urine in last 18 hours or for catheterised patients,
19 passed less than 0.5 ml/kg of urine per hour
20  colour of skin, lips or tongue is pale, mottled, ashen or blue
21  non-blanching rash
22  has temperature less than 36°C .

23 1.3.6 Recognise that children aged 5–11 years with any of the symptoms
24 or signs below are at moderate to high risk of severe illness or
25 death from sepsis:

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1  not responding normally to social cues or decreased activity, or


2 parent or carer concern that the child is behaving differently from
3 usual
4  respiratory rate:
5  aged 5 years, 27–28 breaths per minute
6  aged 6–7 years, 24–26 breaths per minute
7  aged 8–11 years, 22–24 breaths per minute
8  heart rate:
9  aged 5 years, 120–129 beats per minute
10  aged 6–7 years, 110–119 beats per minute
11  aged 8–11 years, 105–114 beats per minute
12  or capillary refill time of 3 seconds or more
13  reduced urine output or for catheterised patients, passed 0.5–
14 1 ml/kg of urine per hour
15  have leg pain or cold hands and feet.

16 1.3.7 Consider children aged 5–11 years who do not meet any high or
17 moderate to high risk criteria to be at low risk of severe illness or
18 death from sepsis.

19 Children aged under 5 years

20 Table 3 Risk stratification tool for children aged under 5 years with
21 suspected sepsis
22 This table is adapted from NICE’s guideline on fever in under 5s.

High risk criteria Moderate to high risk Low risk


criteria criteria

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Behaviour No response to Not responding normally to Responds


social cues social cues normally to
Appears ill to a No smile social cues
healthcare Wakes only with prolonged Content or
professional stimulation smiles
Does not wake, or if Decreased activity Stays awake or
roused does not awakens quickly
Parent or carer concern that
stay awake Strong normal
child is behaving differently
Weak high-pitched from usual cry or not crying
or continuous cry
Respirator Grunting Nasal flaring No high risk or
y Raised respiratory Raised respiratory rate: moderate to high
rate: risk criteria met
Under 1 year 50–59 breaths
Under 1 year, per minute
60 breaths per 1–2 years, 40–49 breaths per
minute or more minute
1–2 years, 3–4 years, 35–39 breaths per
50 breaths per minute
minute or more
Oxygen saturation of less
3–4 years, than 95% in air
40 breaths per
Crackles in the chest
minute or more
Moderate or severe
chest indrawing
Circulation Rapid heart rate Rapid heart rate: No high risk or
and Under 1 year, Under 1 year, 150-159 beats moderate to high
hydration 160 beats per per minute risk criteria met
minute or more 1–2 years, 140-149 beats per
1–2 years, minute
150 beats per 3–4 years, 130–139 beats
minute or more per minute
3–4 years, Capillary refill time
140 beats per of3 seconds or more
minute or more
Poor feeding in infants
Bradycardia: heart
Reduced urine output
rate less than 60
beats per minute For catheterised patients,
passed 0.5–1 ml/kg of urine
Reduced skin turgor
per hour
No wet nappies or
not passed urine in
past 18 hours
For catheterised
patients, passed
less than 0.5 ml/kg
of urine per hour
Skin Colour of lips, skin Pale, pallor or flushed Normal colour
or tongue is pale, Pallor reported by carer
mottled, ashen or
blue
Non-blanching rash

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Other Age <3 months and Age 3–6 months temperature No high risk or
temperature 38°C or 39°C or more high to moderate
more Leg pain risk criteria met
Temperature less Cold hands or feet
than 36°C
Cold hands or feet
1

2 1.3.8 Recognise that children aged under 5 years with any of the
3 symptoms or signs below are at high risk of severe illness or death
4 from sepsis:

5  no response to social cues


6  appears ill to a healthcare professional
7  does not wake, or if roused does not stay awake
8  weak, high-pitched or continuous cry
9  grunting
10  heart rate:
11  aged under 1 year, 160 beats per minute or more
12  aged 1–2 years, 150 beats per minute or more
13  aged 3–4 years, 140 beats per minute or more
14  heart rate less than 60 beats per minute at any age
15  reduced skin turgor
16  no wet nappies or not passed urine in past 18 hours or for
17 catheterised children, passed less than 0.5 ml/kg of urine per
18 hour
19  respiratory rate:
20  aged under 1 year, 60 breaths per minute or more
21  aged 1–2 years, 50 breaths per minute or more
22  aged 3–4 years, 40 breaths per minute or more
23  moderate or severe chest indrawing
24  colour of skin, lips or tongue is pale, mottled, ashen or blue
25  other symptoms and signs:
26  age under 3 months and temperature 38°C or more
27  non-blanching rash

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1  temperature less than 36°C ,


2 [This recommendation is adapted from NICE’s guideline on fever in
3 under 5s]

4 1.3.9 Recognise that children aged under 5 years with any of the
5 symptoms or signs below are at moderate to high risk of severe
6 illness or death from sepsis:

7  not responding normally to social cues


8  no smile
9  wakes only with prolonged stimulation
10  decreased activity
11  parent or carer concern that the child is behaving differently from
12 usual
13  nasal flaring
14  respiratory rate:
15  aged under 1 year, 50−59 breaths per minute
16  aged 1–2 years, 40−49 breaths per minute
17  aged 3–4 years, 35−39 breaths per minute
18  oxygen saturation 95% or less in air
19  crackles in the chest
20  heart rate:
21  aged under 1 year, 150−159 beats per minute
22  aged 1–2 years, 140−149 beats per minute
23  aged 3–4 years 130−139 beats per minute
24  capillary refill time of 3 seconds or more
25  poor feeding in infants
26  reduced urine output or for catheterised patients, passed 0.5–
27 1 ml/kg of urine per hour
28  is pale or flushed or has pallor of skin, lips or tongue reported by
29 parent or carer
30  other symptoms and signs: age 3–6 months and temperature
31 39°C or over, leg pain, cold hands or feet.

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1 [This recommendation is adapted from NICE’s guideline on fever in


2 under 5s]

3 1.3.10 Consider children aged under 5 years who do not meet any high or
4 moderate to high risk criteria to be at low risk of severe illness or
5 death from sepsis. [This recommendation is adapted from NICE’s
6 guideline on fever in under 5s]

7 Children, young people and adults with suspected sepsis

8 Temperature
9 1.3.11 Do not use a person’s temperature as the sole predictor of sepsis.

10 1.3.12 Do not rely on fever or hypothermia to rule sepsis either in or out.

11 1.3.13 Ask the person with suspected sepsis and their family or carers
12 about any recent fever or rigors

13 1.3.14 Take into account that some groups of people with sepsis may not
14 develop a raised temperature. These include:

15  people who are older or very frail


16  people having treatment for cancer
17  people severely ill with sepsis
18  young infants or children.

19 1.3.15 Take into account that a rise in temperature can be a physiological


20 response for example after surgery or trauma.

21 Heart rate in suspected sepsis


22 1.3.16 Interpret the heart rate of a person with suspected sepsis in
23 context, taking into account that:

24  baseline heart rate may be lower in young people and adults


25 who are fit
26  baseline heart rate in pregnancy is 10–15 beats per minute more
27 than normal

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1  older people with an infection may not develop an increased


2 heart rate
3  older people may develop a new arrhythmia in response to
4 infection rather than an increased heart rate
5  heart rate response may be affected by medicines such as beta-
6 blockers.

7 Blood pressure in suspected sepsis


8 1.3.17 Interpret blood pressure in the context of a person’s previous blood
9 pressure, if known.

10 Confusion, mental state and cognitive state in suspected sepsis


11 1.3.18 Interpret a person’s mental state in the context of their normal
12 function and treat changes as being significant.

13 1.3.19 Be aware that changes in cognitive function may be subtle and


14 assessment should include history from patient and family or
15 carers.

16 1.3.20 Take into account that changes in cognitive function may present
17 as changes in behaviour or irritability in both children and in adults
18 with dementia.

19 1.3.21 Take into account that changes in cognitive function in older people
20 may present as acute changes in functional abilities.

21 Oxygen saturation
22 1.3.22 Take into account that if peripheral oxygen saturation is difficult to
23 measure in a person with suspected sepsis, this may indicate poor
24 peripheral circulation because of shock.

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1 1.4 Managing suspected sepsis outside acute hospital


2 settings
3 1.4.1 Refer all people with suspected sepsis outside acute hospital
4 settings for emergency medical care by the most appropriate
5 means of transport (usually 999 ambulance) if:

6  they meet any high risk criteria (see table 1) or


7  they are aged under 17 years, and their immunity is
8 compromised and they have any moderate to high risk criteria.

9 1.4.2 Arrange review by a GP or other doctor within 1 hour when any


10 moderate to high risk criteria in a person with suspected sepsis are
11 identified by a non-medical practitioner outside an acute hospital
12 setting.

13 1.4.3 Assess (by GP or other doctor) all people with suspected sepsis
14 outside acute hospital settings with any moderate to high risk
15 criteria for:

16  definitive diagnosis of their condition


17  whether they can be treated safely outside hospital.

18 If a definitive diagnosis is not reached or the person cannot be


19 treated safely outside an acute hospital setting, refer them urgently
20 to the emergency department.

21 1.4.4 Arrange review by a GP or other doctor for a person with suspected


22 sepsis but no high or moderate to high risk criteria if they have had
23 their first assessment by a non-medical practitioner outside an
24 acute hospital setting.

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1 1.5 Managing and treating sepsis in hospital

2 Adults and children and young people aged 12 years and over who meet
3 1 or more high risk criteria
4 1.5.1 For adults and children and young people aged 12 years and over
5 who have suspected sepsis and 1 or more high risk criteria:

6  arrange for immediate review by the senior clinical decision


7 maker1
8  carry out a venous blood test for the following:
9  blood culture
10  full blood count
11  C-reactive protein
12  urea and electrolytes
13  creatinine
14  clotting screen
15  blood gas to include lactate measurement
16  give a broad-spectrum antimicrobial at the maximum
17 recommended dose as soon as possible (within 1 hour of
18 identifying that they meet any high risk criteria) in line with
19 recommendations in section 1.6
20  discuss with consultant.

21 1.5.2 For adults and children and young people aged 12 years and over
22 with suspected sepsis and any high risk criteria and lactate over
23 4 mmol, or blood pressure less than 90 mmHg:

24  give fluids as soon as possible (within 1 hour of identifying that


25 they meet any high risk criteria) in line with recommendations in
26 section 1.7 and

1
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 an
advanced nurse practitioner with antibiotic prescribing rights, depending on local
arrangements. A ‘senior decision maker’ for people aged 12–17 years is a paediatric qualified
doctor of grade ST4 or above.

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DRAFT FOR CONSULTATION

1  refer to critical care for review of central venous access and


2 initiation of inotropes or vasopressors and admission to critical
3 care.

4 1.5.3 For adults and children and young people aged 12 years and over
5 with suspected sepsis and any high risk criteria and lactate
6 between 2 and 4 mmol/litre:

7  give fluids as soon as possible (within 1 hour of identifying that


8 they meet any high risk criteria) in line with recommendations in
9 section 1.7.

10 1.5.4 For adults and children and young people aged 12 years and over
11 with suspected sepsis and any high risk criteria and lactate below
12 2 mmol/litre:

13  consider giving fluids (in line with recommendations in


14 section 1.7 ).

15 1.5.5 Monitor people with suspected sepsis who meet any high risk
16 criteria continuously, or a minimum of once every 30 minutes
17 depending on setting. Physiological track and trigger systems
18 should be used to monitor all adult patients in acute hospital
19 settings. [This recommendation is from NICE’s guideline on acutely
20 ill patients in hospital]

21 1.5.6 Monitor the mental state of adults and children and young people
22 aged 12 years and over with suspected sepsis. Consider using a
23 scale such as the Glasgow Coma Score (GCS) or AVPU (‘alert,
24 voice, pain, unresponsive’) scale.

25 1.5.7 Alert a consultant to attend in person if an adult or child or young


26 person aged 12 years or over with suspected sepsis and any high
27 risk criteria fails to respond within 1 hour of initial antibiotic and/or
28 intravenous fluid resuscitation. Failure to respond is indicated by
29 any of:

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DRAFT FOR CONSULTATION

1  systolic blood pressure persistently below 90 mmHg


2  reduced level of consciousness despite resuscitation
3  respiratory rate over 30 breaths per minute
4  lactate not reduced by more than 20% within 1 hour.

5 Adults and children and young people aged 12 years and over who meet
6 2 or more moderate to high risk criteria
7 1.5.8 For adults and children and young people aged 12 years and over
8 with suspected sepsis and 2 or more moderate to high risk criteria,
9 carry out a venous blood test for the following:

10  blood culture
11  full blood count
12  C-reactive protein
13  urea and electrolytes
14  creatinine
15  blood gas to include lactate measurement
16  arrange for a clinician2 to review the person’s condition and test
17 results within 1 hour of meeting 2 or more moderate to high risk
18 criteria.

19 1.5.9 For adults and children and young people aged 12 years and over
20 with suspected sepsis who meet 2 or more moderate to high risk
21 criteria and have lactate over 2 mmol/litre or evidence of acute
22 kidney injury3, treat as high risk and follow recommendations 1.5.1–
23 1.5.7.

24 1.5.10 For adults and children and young people aged 12 years and over
25 with suspected sepsis who meet 2 or more moderate to high risk
26 criteria, have lactate of less than 2 mmol/litre, no evidence of acute
27 kidney injury3 and in whom a definitive condition cannot be
28 identified:

2
A ‘clinician’ should be a medically qualified practitioner who has antibiotic prescribing rights
3
For definition of acute kidney injury, see Acute kidney injury (NICE guideline CG169)].

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DRAFT FOR CONSULTATION

1  repeat structured assessment at least hourly


2  ensure review by a senior clinical decision maker within 3 hours
3 of meeting 2 or more moderate to high risk criteria for
4 consideration of antibiotics.

5 1.5.11 For adults and children and young people aged 12 years and over
6 with suspected sepsis who meet 2 moderate to high risk criteria,
7 have lactate of less than 2 mmol/litre, no evidence of acute kidney
8 injury4and in whom a definitive condition or infection can be
9 identified and treated:

10  manage the definitive condition


11  if appropriate, discharge with information (see recommendations
12 1.10.5 and 1.10.6) depending on the setting.

13 Adults and children and young people aged 12 years and over who meet
14 only 1 moderate to high risk criterion
15 1.5.12 For adults and children and young people aged 12 years and over
16 with suspected sepsis who meet only 1 moderate to high risk
17 criterion:

18  arrange clinician5 review within 1 hour of meeting criterion for


19 clinical assessment
20  perform blood tests if indicated.

21 1.5.13 For adults and children and young people aged 12 years and over
22 with suspected sepsis who meet only 1 moderate to high risk
23 criterion and in whom a definitive condition can be identified and
24 treated:

25  manage the definitive condition


26  if appropriate, discharge with information depending on setting
27 (see recommendations 1.10.5 and 1.10.6).

4
For definition of acute kidney injury, see Acute kidney injury (NICE guideline CG169)].
5
A ‘clinician’ should be a medically qualified practitioner who has antibiotic prescribing rights

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DRAFT FOR CONSULTATION

1 1.5.14 For adults and children and young people aged 12 years and over
2 with suspected sepsis who meet only 1 moderate to high risk
3 criterion, have lactate of less than 2 mmol/litre, no evidence of
4 acute kidney injury6 and in whom a definitive condition cannot be
5 identified:

6  repeat structured assessment at least hourly


7  ensure review by a senior clinical decision maker within 3 hours
8 of meeting moderate to high criterion for consideration of
9 antibiotics.

10 Adults and children and young people aged 12 years and over with no
11 high risk or moderate to high risk criteria
12 1.5.15 Arrange clinical assessment7 of adults and children and young
13 people aged 12 years and over who have suspected sepsis and no
14 high risk or moderate to high risk criteria and manage according to
15 clinical judgement.

16 Children aged 5–11 years who meet 1 or more high risk criteria
17 1.5.16 For children aged 5–11 years who have suspected sepsis and 1 or
18 more high risk criteria:

19  arrange for immediate review by the senior clinical decision


20 maker8
21  carry out a venous blood test for the following:
22  blood culture
23  full blood count
24  C-reactive protein
25  urea and electrolytes
26  creatinine
27  clotting screen

6
For definition of acute kidney injury, see NICE’s guideline on acute kidney injury.
7
Clinical assessment should be carried out by a medically qualified practitioner who has
antibiotic prescribing rights
8
A ‘senior clinical decision maker’ for children aged 5– 11 years is a paediatric qualified doctor
of grade ST4 or above.

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DRAFT FOR CONSULTATION

1  blood gas for glucose and lactate


2  give a broad-spectrum antimicrobial (see section 1.6) at the
3 maximum recommended dose as soon as possible (within
4 1 hour of identifying that they meet any high risk criteria)
5  discuss with consultant.

6 1.5.17 For children aged 5–11 years with suspected sepsis and any high
7 risk criteria and lactate over 4 mmol:

8  give fluids as soon as possible (within 1 hour of identifying that


9 they meet any high risk criteria in line with recommendations in
10 section 1.7 and
11  refer to critical care for review of central access and initiation of
12 inotropes or vasopressors and admission to critical care.

13 1.5.18 For children aged 5–11 years with suspected sepsis and any high
14 risk criteria and lactate between 2 and 4 mmol/litre:

15  give fluids as soon as possible (within 1 hour of identifying that


16 they meet any high risk criteria) in line with recommendations in
17 section 1.7.

18 1.5.19 For children aged 5–11 years with suspected sepsis and any high
19 risk criteria and lactate below 2 mmol/litre:

20  consider giving fluids in line with recommendations in section


21 1.7.

22 1.5.20 Monitor children with suspected sepsis who meet any high risk
23 criteria continuously, or a minimum of once every 30 minutes
24 depending on setting. Physiological track and trigger systems
25 should be used to monitor all children in acute hospital
26 settings.[This recommendation is adapted from NICE’s guideline on
27 acutely ill patients in hospital.]

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DRAFT FOR CONSULTATION

1 1.5.21 Monitor the mental state of children aged 5-11 years with
2 suspected sepsis Consider using the Glasgow Coma Score (GCS)
3 or AVPU (‘alert, voice, pain, unresponsive’) scale.

4 1.5.22 Alert a consultant to attend in person if a child aged 5–11 years


5 with suspected sepsis and any high risk criteria fails to respond
6 within 1 hour of initial antibiotic and/or intravenous fluid
7 resuscitation. Failure to respond is indicated by any of:

8  reduced level of consciousness despite resuscitation,


9  heart rate or respiratory rate fulfil high risk criteria
10  lactate remains over 2 mmol/litre after 1 hour.

11 Children aged 5–11 years who meet 2 or more moderate to high risk
12 criteria
13 1.5.23 For children aged 5–11 years with suspected sepsis and 2 or more
14 moderate to high risk criteria:

15  carry out a venous blood test for the following:


16  blood culture
17  full blood count
18  C-reactive protein
19  urea and electrolytes
20  creatinine
21  blood gas for glucose and lactate
22  arrange for a clinician to review the person’s condition and test
23 results within 1 hour of meeting 2 or more moderate to high risk
24 criteria.

25 1.5.24 For children aged 5–11 years with suspected sepsis who meet 2 or
26 more moderate to high risk criteria and have lactate over
27 2 mmol/litre or evidence of acute kidney injury9, treat as high risk
28 and follow recommendations 1.5.16–1.5.22.

9
For definition of acute kidney injury, see NICE’s guideline on acute kidney injury.

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DRAFT FOR CONSULTATION

1 1.5.25 For children aged 5–11 years with suspected sepsis who meet 2 or
2 more moderate to high risk criteria, have lactate of less than
3 2 mmol/litre, no evidence of acute kidney injury10 and in whom a
4 definitive condition cannot be identified:

5  repeat structured assessment at least hourly


6  ensure review by a senior clinical decision maker within 3 hours
7 of meeting 2 or more moderate to high risk criteria for
8 consideration of antibiotics.

9 1.5.26 For children aged 5–11 years with suspected sepsis who meet 2 or
10 more moderate to high risk criteria, have lactate of less than
11 2 mmol/litre, no evidence of acute kidney injury11 and in whom a
12 definitive condition or infection can be identified and treated:

13  manage the definitive condition, and


14  if appropriate, discharge with information depending on setting
15 (see recommendations 1.10.5 and 1.10.6).

16 Children aged 5–11 years who meet only 1 moderate to high risk
17 criterion
18 1.5.27 For children aged 5–11 years with suspected sepsis who meet only
19 1 moderate to high risk criterion:

20  arrange clinician12 review within 1 hour of meeting 1 moderate to


21 high risk criterion for clinical assessment and
22  perform blood tests if indicated.

23 1.5.28 For children aged 5–11 years with suspected sepsis who meet only
24 1 moderate to high risk criterion and in whom a definitive condition
25 can be identified and treated:

26  manage the definitive condition

10
For definition of acute kidney injury, see NICE’s guideline on acute kidney injury.
11
For definition of acute kidney injury, see NICE’s guideline on acute kidney injury.
12
A ‘clinician’ should be a medically qualified practitioner who has antibiotic prescribing rights.

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DRAFT FOR CONSULTATION

1  if appropriate, discharge with information depending on setting


2 (see recommendations 1.10.5 and 1.10.6).

3 1.5.29 For children aged 5–11 years with suspected sepsis who meet only
4 1 moderate to high risk criterion, have lactate of less than
5 2 mmol/litre, no evidence of acute kidney injury13 and in whom a
6 definitive condition cannot be identified:

7  repeat structured assessment at least hourly


8  ensure review by a senior clinical decision maker within 3 hours
9 of meeting a moderate to high risk criterion for consideration of
10 antibiotics.

11 Children aged 5–11 years with no high risk or moderate to high risk
12 criteria
13 1.5.30 Arrange clinical assessment14 of children aged 5–11 years who
14 have suspected sepsis and no high risk or moderate to high risk
15 criteria and manage according to clinical judgement.

16 Children aged under 5 years

17 Children aged under 5 years who meet 1 or more high risk criteria
18 1.5.31 For children aged under 5 years who have suspected sepsis and 1
19 or more high risk criteria:

20  arrange for immediate review by the senior clinical decision


21 maker15
22  carry out a venous blood test for the following:
23  blood culture
24  full blood count
25  C-reactive protein
26  urea and electrolytes

13
For definition of acute kidney injury, see Acute kidney injury (NICE guideline CG169)].
14
This could be by a medically qualified practitioner with prescribing rights.
15
A ‘senior clinical decision maker’ for children aged under 5 years is a paediatric qualified
doctor of grade ST4 or above.

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DRAFT FOR CONSULTATION

1  creatinine
2  clotting screen
3  blood gas for glucose and lactate
4  give parenteral antibiotics (within 1 hour of identifying that they
5 meet any high risk criteria; see section 1.6).
6  discuss with consultant.

7 1.5.32 For children aged under 5 years with suspected sepsis and any
8 high risk criteria and lactate over 4 mmol:

9  give fluids (in line with recommendations in section 1.7) and


10  refer to critical care for review of central access and initiation of
11 inotropes or vasopressors and admission to critical care.

12 1.5.33 For children aged under 5 years with suspected sepsis and any
13 high risk criteria and lactate between 2 and 4 mmol/litre:

14  give fluids as soon as possible (within 1 hour of identifying that


15 they meet any high risk criteria) in line with recommendations in
16 section 1.7.

17 1.5.34 For children aged under 5 years with suspected sepsis and any
18 high risk criteria and lactate below 2 mmol/litre, consider giving
19 fluids in line with recommendations in section 1.7.

20 1.5.35 Monitor children aged under 5 years with suspected sepsis who
21 meet any high risk criteria continuously, or a minimum of once
22 every 30 minutes depending on setting. Physiological track and
23 trigger systems should be used to monitor all children in acute
24 hospital settings. [This recommendation is adapted from NICE’s
25 guideline on acutely ill patients in hospital.]

26 1.5.36 Monitor the mental state of children under 5 years with suspected
27 sepsis. Consider using the Glasgow Coma Score (GCS) or AVPU
28 (‘alert, voice, pain, unresponsive’) scale.

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DRAFT FOR CONSULTATION

1 1.5.37 Alert a consultant to attend in person if a child aged under 5 years


2 with suspected sepsis and any high risk criteria fails to respond
3 within 1 hour of initial antibiotic and/or intravenous fluid
4 resuscitation. Failure to respond is indicated by any of:

5  reduced level of consciousness despite resuscitation


6  heart rate or respiratory rate fulfil high risk criteria
7  lactate over 2 mmol/litre after 1 hour.

8 1.5.38 Give parenteral antibiotics to infants aged under 3 months as


9 follows:

10  infants younger than 1 month with fever


11  all infants aged 1–3 months with fever who appear unwell
12  infants aged 1–3 months with white blood cell count less than
13 5×109/litre or greater than 15×109/litre.

14 [This recommendation is from NICE’s guideline on fever in under


15 5s.]

16 Children aged under 5 years who meet 2 or more moderate to high risk
17 criteria
18 1.5.39 For children aged under 5 years with suspected sepsis and 2 or
19 more moderate to high risk criteria carry out a venous blood test for
20 the following:

21  blood culture
22  full blood count
23  C-reactive protein
24  urea and electrolytes
25  creatinine
26  blood gas for glucose and lactate

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DRAFT FOR CONSULTATION

1  arrange for a clinician16 to review the person’s condition and test


2 results within 1 hour of meeting 2 or more moderate to high risk
3 criteria.

4 1.5.40 For children aged under 5 years with suspected sepsis who meet 2
5 or more moderate to high risk criteria and have lactate over
6 2 mmol/litre or evidence of acute kidney injury, treat as high risk
7 and follow recommendations 1.5.31 to 1.5.38.

8 1.5.41 For children aged under 5 years with suspected sepsis who meet 2
9 or more moderate to high risk criteria, have lactate of less than
10 2 mmol/litre, no evidence of acute kidney injury and in whom a
11 definitive condition cannot be identified:

12  repeat structured assessment at least hourly


13  ensure review by a senior clinical decision maker within 3 hours
14 of meeting 2 or more moderate to high risk criteria for
15 consideration of antibiotics.

16 1.5.42 For children aged under 5 years with suspected sepsis who meet 2
17 or more moderate to high risk criteria, have lactate of less than
18 2 mmol/litre, no evidence of acute kidney injury and in whom a
19 definitive condition or infection can be identified and treated:

20  manage the definitive condition and


21  if appropriate, discharge with information (see recommendations
22 1.10.5 and 1.10.6) depending on the setting.

23 Children aged under 5 years who meet only 1 moderate to high risk
24 criterion
25 1.5.43 For children aged under 5 years with suspected sepsis who meet
26 only 1 moderate to high risk criterion:

27  arrange clinician review within 1 hour of meeting a moderate to


28 high risk criterion for clinical assessment and

16
A ‘clinician’ should be a medically qualified practitioner who has antibiotic prescribing rights

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DRAFT FOR CONSULTATION

1  perform blood tests if indicated.

2 1.5.44 For children aged under 5 years with suspected sepsis who meet
3 only 1 moderate to high risk criterion and in whom a definitive
4 condition can be identified and treated:

5  manage the definitive condition


6  if appropriate, discharge with information depending on setting
7 (see recommendations 1.10.5 and 1.10.6).

8 1.5.45 For children aged under 5 years with suspected sepsis who meet
9 only 1 moderate to high risk criterion, have lactate of less than
10 2 mmol/litre, no evidence of acute kidney injury17 and in whom a
11 definitive condition cannot be identified:

12  repeat structured assessment at least hourly


13  ensure review by a senior clinical decision maker within 3 hours
14 for consideration of antibiotics.

15 Children aged under 5 years with no high risk or moderate to high risk
16 criteria
17 1.5.46 Arrange clinical assessment18 of children aged under 5 years who
18 have suspected sepsis and no high risk or moderate to high risk
19 criteria and manage according to clinical judgement.

20 1.6 Antibiotic treatment


21 1.6.1 Pre-alert secondary care (through GP or ambulance service) when
22 any high risk criteria are met in a person with suspected sepsis
23 outside of a hospital, and transfer them immediately.

24 1.6.2 Ensure urgent assessment mechanisms are in place to deliver


25 antibiotics when any high risk criteria are met in secondary care
26 (within 1 hour of meeting a high risk criterion).

17
For definition of acute kidney injury, see Acute kidney injury (NICE guideline CG169)].
18
Clinical assessment should be carried out by a medically qualified practitioner who has
antibiotic prescribing rights

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DRAFT FOR CONSULTATION

1 1.6.3 Ensure GPs and ambulance services have mechanisms in place to


2 give antibiotics in the pre-hospital setting if transfer time is likely to
3 be more than 1 hour.

4 1.6.4 For patients in hospital who have suspected infections, take


5 microbiological samples before prescribing an antimicrobial and
6 review the prescription when the results are available. For people
7 with suspected sepsis take blood cultures before antibiotics are
8 given. [This recommendation is adapted from NICE’s guideline on
9 antimicrobial stewardship.]

10 1.6.5 If meningococcal disease is specifically suspected (fever and


11 purpuric rash) give appropriate doses of parenteral benzyl penicillin
12 in community settings and intravenous ceftriaxone in hospital
13 settings. [This recommendation is adapted from NICE’s guideline
14 on meningitis (bacterial) and meningococcal septicaemia in under
15 16s.]

16 1.6.6 For people aged 18 years and over who need an empirical
17 intravenous antimicrobial for a suspected infection but who have no
18 confirmed diagnosis, use an intravenous antimicrobial from the
19 agreed local formulary and in line with local (where available) or
20 national guidelines . [This recommendation is adapted from NICE’s
21 guideline on antimicrobial stewardship.]

22 1.6.7 For people aged up to 17 years with suspected community


23 acquired sepsis of any cause give ceftriaxone 80 mg/kg once a day
24 with a maximum dose of 4g daily at any age. [This recommendation
25 is adapted from NICE’s guideline on meningitis (bacterial) and
26 meningococcal septicaemia in under 16s.]

27 1.6.8 For people aged up to 17 years with suspected sepsis who are
28 already in hospital, or who are known to have previously been
29 infected with ceftriaxone-resistant bacteria, consult local guidelines
30 for choice of antibiotic.

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DRAFT FOR CONSULTATION

1 1.6.9 For children younger than 3 months, give an additional antibiotic


2 active against listeria (for example, ampicillin or amoxicillin). [This
3 recommendation is adapted from NICE’s guideline on fever in
4 under 5s.]

5 1.6.10 Treat neonates presenting in hospital with suspected sepsis with


6 intravenous benzylpenicillin and gentamicin. [This recommendation
7 is from NICE’s guideline on neonatal infection.]

8 1.6.11 Treat neonates who are more than 40 weeks postmenstrual age
9 who present with community acquired sepsis with ceftriaxone
10 50 mg/kg unless already receiving an intravenous calcium infusion
11 at the time. If 40 weeks postmenstrual age or below or receiving an
12 intravenous calcium infusion use cefotaxime 50 mg/kg.

13 1.7 Fluids
14 1.7.1 If patients over 16 years need intravenous fluid resuscitation, use
15 crystalloids that contain sodium in the range 130–154 mmol/litre
16 with a bolus of 500 ml over less than 15 minutes. [This
17 recommendation is from NICE’s guideline on intravenous fluid
18 therapy in over 16s in hospital.]

19 1.7.2 If children and young people up to 16 years need intravenous fluid


20 resuscitation, use glucose-free crystalloids that contain sodium in
21 the range 130–154 mmol/litre, with a bolus of 20 ml/kg over less
22 than 10 minutes. [This recommendation is from NICE’s guideline on
23 intravenous fluid therapy in over 16s in hospital]

24 1.7.3 If neonates need intravenous fluid resuscitation, use glucose-free


25 crystalloids that contain sodium in the range 130–154 mmol/litre,
26 with a bolus of 10–20 ml/kg over less than 10 minutes. [This
27 recommendation is from NICE’s guideline on intravenous fluid
28 therapy in children and young people in hospital.]

29 1.7.4 Reassess patient after completion of the intravenous fluid bolus,


30 and if no improvement give second bolus. If there is no

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DRAFT FOR CONSULTATION

1 improvement after second bolus alert consultant to attend (in line


2 with recommendations 1.5.7, 1.5.22 and 1.5.37).

3 1.7.5 Use a pump, or syringe if no pump is available, to deliver fluids for


4 resuscitation to people with suspected sepsis who need fluids in
5 bolus form.

6 1.7.6 Do not use tetrastarch for fluid resuscitation for people with sepsis.
7 [This recommendation is adapted from NICE’s guideline on
8 intravenous fluid therapy in over 16s in hospital.]

9 1.7.7 Consider human albumin solution 4–5% for fluid resuscitation only
10 in patients with sepsis with shock. [This recommendation is
11 adapted from NICE’s guideline on intravenous fluid therapy in over
12 16s in hospital.]

13 1.8 Using oxygen


14 1.8.1 Give oxygen to achieve a target saturation of 94−98% for adult
15 patients or 88−92% for those at risk of hypercapnic respiratory
16 failure.

17 1.8.2 Oxygen should be given to children with suspected sepsis who


18 have signs of shock or oxygen saturation (SpO2) of less than 92%
19 when breathing air. Treatment with oxygen should also be
20 considered for children with an SpO2 of greater than 92%, as
21 clinically indicated. [This recommendation is adapted from NICE’s
22 guideline on fever in under 5s.].

23 1.9 Finding the source of infection


24 1.9.1 Carry out a thorough clinical examination to look for sources of
25 infection.

26 1.9.2 Tailor investigations to the person’s clinical history and findings on


27 examination.

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DRAFT FOR CONSULTATION

1 1.9.3 Consider urine analysis and chest X-ray in all people aged over
2 5 years with suspected sepsis.

3 1.9.4 Consider imaging of the abdomen and pelvis if no likely source is


4 identified after clinical examination and initial tests.

5 1.9.5 Involve the adult or paediatric surgical and gynaecological teams


6 early on if intra-abdominal or pelvic infection is suspected in case
7 surgical treatment is needed.

8 1.9.6 Do not perform a lumbar puncture if any of the following


9 contraindications are present:

10  signs suggesting raised intracranial pressure or reduced or


11 fluctuating level of consciousness (Glasgow Coma Scale score
12 less than 9 or a drop of 3 points or more)
13  relative bradycardia and hypertension
14  focal neurological signs
15  abnormal posture or posturing
16  unequal, dilated or poorly responsive pupils
17  papilloedema
18  abnormal ‘doll’s eye’ movements
19  shock
20  extensive or spreading purpura
21  after convulsions until stabilised
22  coagulation abnormalities or coagulation results outside the
23 normal range or platelet count below 100x109/litre or receiving
24 anticoagulant therapy
25  local superficial infection at the lumbar puncture site
26  respiratory insufficiency in children.

27 [This recommendation is adapted from NICE’s guideline on


28 meningitis (bacterial) and meningococcal septicaemia in under
29 16s.]

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DRAFT FOR CONSULTATION

1 1.9.7 Perform lumbar puncture in the following children with suspected


2 sepsis (unless contraindicated, please see contraindications in
3 recommendation 1.9.6):

4  infants younger than 1 month


5  all infants aged 1–3 months who appear unwell
6  infants aged 1–3 months with a white blood cell count less than
7 5×109/litre or greater than 15×109/litre.

8 [This recommendation is adapted from NICE’s guideline on fever in


9 under 5s.]

10 1.10 Information and support for people with sepsis and


11 their families and carers

12 People who have sepsis and their families and carers


13 1.10.1 Ensure a care team member is nominated to give information to
14 families and carers, particularly in emergency situations such as in
15 the emergency department. This should include:

16  an explanation that the person has sepsis, and what this means
17  an explanation of any investigations and the management plan
18  regular and timely updates on treatment, care and progress.

19 1.10.2 Ensure information is given without using medical jargon. Check


20 regularly that people understand the information and explanations
21 they are given.

22 1.10.3 Give people with sepsis and their family members and carers
23 opportunities to ask questions about diagnosis, treatment options,
24 prognosis and complications. Be willing to repeat any information
25 as needed.

26 1.10.4 Give people with sepsis and their families and carers information
27 about national charities and support groups that provide information
28 about sepsis and the causes of sepsis.

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DRAFT FOR CONSULTATION

1 Information at discharge for people assessed for possible sepsis, but


2 not diagnosed with sepsis
3 1.10.5 Give people who have been assessed for sepsis but have been
4 discharged without a diagnosis of sepsis (and their family or carers,
5 if appropriate) verbal and written information about:

6  what sepsis is, and why it was suspected


7  what tests and investigations have been done
8  instructions about which symptoms to monitor
9  when to get medical attention if their illness continues.

10 1.10.6 Confirm that people understand the information they have been
11 given, and what actions they should take to get help if they need it.

12 Information at discharge for people at increased risk of sepsis


13 1.10.7 Ensure people who are at increased risk of sepsis (for example
14 after surgery) are told before discharge about symptoms that
15 should prompt them to get medical attention.

16 See NICE’s guideline on neutropenic sepsis for information for


17 people with neutropenic sepsis (recommendation 1.1.1.1).

18 Information at discharge for people who have had sepsis


19 1.10.8 Ensure people and their families and carers if appropriate have
20 been informed that they have had sepsis.

21 1.10.9 Ensure discharge notifications to GPs include the diagnosis of


22 sepsis.

23 1.10.10 Give people who have had sepsis (and their families and carers,
24 when appropriate) opportunities to discuss their concerns. These
25 may include:

26  why they developed sepsis


27  whether they are likely to develop sepsis again
28  if more investigations are necessary

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1  details of any community care needed, for example, related to


2 peripherally inserted central venous catheters (PICC) lines or
3 other intravenous catheters
4  what they should expect during recovery
5  arrangements for follow-up, including specific critical care follow
6 up if relevant
7  possible short-term and long-term problems.

8 1.10.11 Give people who have had sepsis and their families and carers
9 information about national charities and support groups that provide
10 information about sepsis and causes of sepsis.

11 1.10.12 Advise carers they have a legal right to have a carer’s assessment
12 of their needs, and give them information on how they can get this.

13 See NICE’s guideline on rehabilitation after critical illness in adults


14 for recommendations on rehabilitation and follow up after critical
15 illness.

16 See NICE’s guideline on meningitis (bacterial) and meningococcal


17 septicaemia in under 16s for follow up of people who have had
18 meningococcal septicaemia.

19 1.11 Training and education


20 1.11.1 Ensure all healthcare staff and professionals are given regular
21 appropriate training in sepsis recognition. This includes:

22  ambulance clinicians
23  allied health professionals
24  medical students and doctors of all grades
25  healthcare assistants
26  midwives
27  nurses
28  operating department assistants
29  receptionists in a clinical setting.

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1 1.11.2 Ensure all healthcare professionals are given regular appropriate


2 training in identifying, assessing and managing sepsis. This should
3 include:

4  risk stratification strategies


5  local protocols for early treatments, including antibiotics and
6 fluids
7  criteria for escalation to critical care.

[The following sentence is for post-consultation versions only] You can also
see this guideline in the NICE pathway on [pathway title].

To find out what NICE has said on topics related to this guideline, see our web
page on [add and link topic page title or titles].

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

19 Sepsis is difficult to diagnose with certainty. Although people with sepsis may
20 have a history of infection, fever is not present in all cases. The signs and
21 symptoms of sepsis are usually very non-specific and can be missed if
22 clinicians do not think ‘could this be sepsis?’.

23 Detailed guidelines exist for the management of sepsis in adult and paediatric
24 intensive care units, and by intensive care clinicians called to other settings.
25 To reduce avoidable deaths, people with sepsis need to be recognised early

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1 and treatment initiated. This guideline aims to ensure healthcare systems in


2 all clinical settings consider sepsis as an immediate life-threatening condition
3 that should be recognised and treated as an emergency. The guideline
4 outlines the immediate actions needed for those with suspicion of sepsis and
5 who are at highest risk of morbidity and mortality from sepsis. It provides a
6 framework for risk assessment, treatment and follow-up or ‘safety-netting’ of
7 people not needing immediate resuscitation. The intention of this guideline is
8 to ensure that all people with sepsis due to any cause are recognised and
9 initial treatment initiated before definitive treatment on other specific pathways
10 is instituted.

11 At the time of writing, the terminology around sepsis is changing and new
12 international consensus definitions are imminent. Previous terminology
13 included terms SIRS (systematic inflammatory response syndrome), severe
14 sepsis and septic shock. The guideline recommendations do not use the
15 terms SIRS or severe sepsis, but use the term ‘sepsis’ and recommends
16 actions according to clinical parameters.

17 There is significant overlap between this guideline and other NICE guidance,
18 in particular the care of acutely ill patients in hospital (Acutely ill patients in
19 hospital), the assessment and initial management of fever in under 5s,
20 bacterial meningitis and meningococcal septicaemia (Meningitis (bacterial)
21 and meningococcal septicaemia in under 16s), neutropenic sepsis, antibiotics
22 for prevention and treatment of neonatal infection, and pneumonia in adults.

23 Recommendations for research


24 The guideline committee has made the following recommendations for
25 research.

26 1 Creation of a UK sepsis registry


27 A UK sepsis registry should be established to collect clinical and
28 epidemiological data to provide information to support clinical audit and to
29 inform the research agenda.

30 Why this is important

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1 The lack of robust UK based epidemiological studies and a lack of


2 coordinated service evaluation within the NHS has been clear throughout the
3 guideline development process. The development of a UK register would
4 allow collection of information about where sepsis is being treated, patient
5 interventions and patient outcomes. This would support audit, provide
6 comparative information for clinicians about performance of institutions and
7 provide population based statistics on epidemiology of sepsis. Complex
8 healthcare interventions, such as trauma services, have benefited greatly from
9 robust, standardised and centralised registries that have gathered
10 epidemiological, service evaluation and outcome data. Subsequent
11 improvements in services have then been developed in a data driven strategy.
12 The mortality and morbidity and service complexity associated with severe
13 infection justifies a similar investment in an NHS registry for patients with
14 severe infection, gathering data on all patients meeting the NICE high risk
15 criteria.

16 2 A complex service evaluation of implementation of NICE


17 Sepsis guideline
18 What effect will the NICE sepsis guideline have on patient care processes and
19 outcomes in the UK over the next 5 years?

20 Why this is important

21 Implementation of NICE’s guideline on sepsis will be a challenge to the NHS.


22 A robust evaluation of how NHS service providers adhere to the
23 recommended care processes needs to be carried out over the next 5 years.

24 A complex evaluation is needed to understand the effect of guidelines on


25 services and on patient outcomes. Evaluation should include assessment of
26 costs and cost effectiveness, the use of a universal audit tool for sepsis
27 patient care that includes evaluation of pre-hospital and secondary care and
28 monitoring of broad spectrum antibiotic use, development of multi-resistant
29 organisms and incidence of antibiotic-related infection such as C. difficile.

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1 3 Use of biomarkers to diagnose and initiate treatment


2 What is the clinical and cost effectiveness of procalcitonin (PCT) point-of-care
3 tests at initial triage for diagnosis of serious infection and the initiation of
4 appropriate antibiotic therapy?

5 Why this is important

6 There is an urgent clinical need for accurate biomarkers of serious bacterial


7 infection (SBI) which provide early diagnosis of SBI, and prompt clinical
8 interventions to improve outcomes. The current tests used in the NHS (white
9 cell count and C-reactive protein) are non-specific and not sensitive enough.
10 Biomarker-guided initiation and termination of antibiotic therapy might be an
11 effective strategy to reduce unnecessary antibiotic use and help prevent
12 further multidrug resistance. The NICE diagnostic guidance on procalcitonin
13 for diagnosing and monitoring sepsis has shown there is not enough evidence
14 in this area.

15 4 Validation of clinical early warning scores in pre-hospital


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

21 Why this is important

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

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1 5 Derivation of clinical decision rules in suspected sepsis


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

5 Why this is important

6 In primary care and emergency departments people with suspected sepsis


7 are often seen by relatively inexperienced doctors. Many of these people will
8 be in low and medium risk groups but evidence is lacking as to who can be
9 sent home safely and who needs intravenous or oral antibiotics. The
10 consequences of getting the decision making wrong can be catastrophic and
11 therefore many patients are potentially over-investigated and admitted
12 inappropriately. Current guidance is dependent on use of individual variables
13 informed by low quality evidence.

14 ISBN

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