Life-threatening organ dysfunction caused by a dysregulated host response to infection. Time-critical: every hour of delayed antibiotic worsens outcome.
⚠ Red flags
- Lactate >4 mmol/L — high mortality
- Anuric AKI — consider early RRT
- Coagulopathy, DIC, thrombocytopenia
- Failure to improve despite source control and antibiotics at 48h
Diagnostic criteria
Clinical
- Suspected or confirmed infection with new organ dysfunction
- Quick SOFA (qSOFA) ≥2: RR ≥22, altered mentation, SBP ≤100 mmHg
- Septic shock: requirement for vasopressors to maintain MAP ≥65 plus lactate >2 mmol/L
Investigations
- SOFA score increase ≥2 from baseline
- Lactate elevation as marker of tissue hypoperfusion
Scoring tools
- SOFA / qSOFA
- NEWS2
Investigations
Essential
- Blood cultures ×2 (within 45 min, before antibiotics)
- FBC, CRP, procalcitonin, lactate, U&E, LFTs, coagulation
- ABG (acidosis, lactate)
- Urinalysis, MSU, CXR
Optional
- CT or USS to identify source
- Echo if cardiac dysfunction or persistent shock
- Specific source samples (CSF, joint aspirate, drain fluid)
Management
Acute
- Hour-1 Bundle (Surviving Sepsis Campaign):
- 1. Measure lactate; re-measure if initial >2
- 2. Blood cultures ×2 before antibiotics
- 3. Broad-spectrum antibiotics within 1 hour
- 4. 30 mL/kg crystalloid IV for hypotension or lactate ≥4
- 5. Vasopressors if MAP <65 despite resuscitation
- Source control: drain abscess, remove infected line/device, debride
- Hydrocortisone 200 mg/day IV in refractory septic shock
Long-term
- Daily SOFA reassessment
- De-escalate antibiotics at 48–72h based on cultures
- Post-sepsis syndrome screening at 3 months (cognitive, physical, psychological)
Non-pharmacological
- DVT prophylaxis (mechanical + pharmacological unless contraindicated)
- Stress ulcer prophylaxis if mechanical ventilation or coagulopathy
- Glycaemic control 7.8–10 mmol/L
- Early mobilisation when stable
Pharmacological
| Drug | Dose | Notes |
|---|---|---|
| Piperacillin-tazobactam | 4.5 g IV TDS | Common first-line empirical choice; broad gram-negative + anaerobic cover. |
| Vancomycin | Loading 25 mg/kg IV; trough 15–20 | Add if MRSA risk or prosthetic device. |
| Meropenem | 1 g IV TDS | ESBL or critically ill patient. |
| Noradrenaline | 0.05–3 µg/kg/min IV titrated to MAP ≥65 | First-line vasopressor. |
| Hydrocortisone | 200 mg/day IV (50 mg QDS or infusion) | Refractory septic shock on high-dose vasopressors. |
Monitoring
- MAP, lactate clearance, urine output every 1–2h
- Antibiotic levels (vancomycin, aminoglycosides) per local protocol
- Daily cultures review and antibiotic de-escalation
Referral criteria
- All patients with sepsis — ICU/HDU consult early
- Refractory shock, multi-organ failure, RRT requirement
Complications
- Septic shock and multi-organ dysfunction
- ARDS
- AKI requiring RRT
- DIC
- Post-sepsis syndrome (cognitive and functional decline)
Special populations
- Pregnancy
- Lower threshold for sepsis bundle; involve obstetrics early. Avoid teratogenic antibiotics where possible.
- Renal impairment
- Adjust antibiotic doses; account for AKI when calculating fluid bolus and vasopressor titration.
- Hepatic impairment
- Watch for cholestasis with co-amoxiclav; metabolism affected for some agents.
- Elderly
- Atypical presentation (delirium, falls). Lower BP thresholds for treatment given frailty.
- Paediatric
- Weight-based fluid bolus 10–20 mL/kg, reassess. Use paediatric SIRS / pSOFA criteria.