Adult Sepsis Management Guidelines

Sepsis is the life-threatening organ dysfunction caused by a dysregulated host response to infection.

• Introduction
• Management Summary
• Antimicrobial Prescribing
• Follow up to BUFALOS
• Consultant Review
• Suggested triggers for Critical Care review
• Amber Flag Sepsis
• Blood Cultures
• Source control
• Foreign Travel
• ICU/HDU Based Care
• Special Patient Groups
• Documentation/Coding of Sepsis
• Further support
• Appendix
• Sepsis Screening Tool
• Sepsis Screening Tool
• Educational Infographic

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Introduction

This guidance applies to all adult (16+) inpatient areas, acute admission areas and the emergency department.

This guidance applies to all clinical staff - nursing, medical and AHP (including temporary, agency staff and students). All staff must take responsibility for following the process described in these guidelines within their clinical competencies. When actions need to be taken that require another, or a more senior, member of the clinical team then referral must be made promptly and documented. Good team communication is key.

The management of Neutropenic sepsis is outside the scope of this document – please see Guidelines for the Management of Suspected Neutropenic Sepsis (Adults).

The management of sepsis in children is outside the scope of this document – please see “Considering Sepsis in Paediatrics” and “Guideline for the management of septic shock in children after the first hour - Paediatric Intensive Care Unit”.

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Management Summary

RED FLAG SEPSIS IS A MEDICAL EMERGENCY AND SHOULD BE MANAGED AS SUCH

This process can be initiated by any member of the clinical team. When actions are required that are beyond your clinical competencies then refer promptly and document that you have done so. Teamwork and communication are key.

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Antimicrobial Prescribing

If source identified please follow: “Management of Infection Guidance for Secondary Care”.

If Sepsis of Unknown Source:

*Linezolid has a number of drug interactions/contraindications. Please see full guidance to check suitability for the patient.

$Use of linezolid and teicoplanin in intra-abdominal infection and sepsis of unknown source is off-label and the patient should be informed of this.

A label of Sepsis of Unknown Source should be temporary. Identification of a source and targeted antimicrobials should be a high priority.

Follow up to BUFALOS

• Ensure source control considered and expedited if appropriate
• Ensure all appropriate samples sent
  • Full clinical details should be on request form
  • All patients
    • Cultures - Blood/urine/sputum/abscess pus
    • Consider HIV screen (see https://www.bhiva.org/guidelines)
  • Pneumonia
    • Nose/throat swab for Respiratory Virus (inc. Mycoplasma) PCR
    • Urine for legionella
  • Other
    • Consider CSF sampling – microscopy, culture and PCR
    • Consider EDTA sample for meningococcal and pneumococcal PCR
    • Consider need for viral testing/empirical antivirals
    • Consider sampling from indwelling lines/devices
• Ensure RESPECT form completed after discussion with patient and/or their next of kin.
• Ensure Day 3 review of Antibiotics including identification of source where “Sepsis of unknown origin” was initial indication.

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Consultant Review

Failure to improve within 1 hour of instigation of treatment should prompt immediate discussion with the Consultant responsible for the patient.

Failure to improve could include any one of the following:

• Systolic BP persistently below 90mmHg
• Persistently reduced level of consciousness
• A NEWS score that is not reducing
• Lactate not reduced by at least 20%

This list does not cover all possibilities, clinical judgement should be used.

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Suggested triggers for Critical Care review

• Red Flag Sepsis
• As per NEWS graded response (NEWS >7 or >3 in 1 parameter)
• Senior clinician concern
• Failure to achieve BP target despite 30ml/kg total fluid boluses
• Rising lactate despite treatment

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Amber Flag Sepsis

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Blood Cultures

Blood cultures should be taken (see Blood Culture SOP) even if the above triggers are not met. Indications include:

• Red or Amber Flag Sepsis
• New temp >38^oC
• Rigors
• If a patient is deemed to require intravenous antibiotics (excluding prophylaxis)

These should be taken before antibiotics are given/changed. The only exception to this is if that would result in a significant (>45 minute) delay in antibiotic administration. This should be a rare occurrence.

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Source Control

Patients with sepsis should have urgent imaging in line with the clinical history and signs. Chest radiograph in all patients with ultrasound and computed tomography as appropriate.

Aim for removal of all infected invasive devices immediately and send line/catheter tips to microbiology (in line with Guideline 1599 Management of infected temporary central venous catheters and arterial catheters in adults). Consider urgent surgical intervention if patient has a source amenable to draining or removal.

Patients with an indwelling catheter and symptomatic urinary tract infection should ideally have their catheter changed in addition to appropriate antibiotic treatment for infection (See Catheter Associated Infection guideline)

Whenever feasible significant sources of infection should be drained or removed within 12 hours of onset of severe sepsis/ shock in order to improve outcomes. Antibiotics alone are often inadequate to control systemic infection in the presence of collections of undrained pus or infected prosthetic devices such as intravascular lines or urinary catheters.

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Foreign Travel

Please ensure a travel history is taken in all septic patients.

Recent foreign travel, if present, should be included on all microbiology request forms.

Returning travellers may require special consideration and a discussion with the Infectious Diseases team is advised.

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ICU/HDU Based Care

• Patient specific approach required
• Screening tool does not apply to patients in Critical Care. However, vigilance is required as new sepsis can be insidious in the critically ill.
• Typical aims:
  • Oxygen sats
    • >94% in unintubated patient with no respiratory comorbidity
    • 88-92% in intubated patients
  • Euvolaemia
    • Assessment options: history, straight leg raise, LiDCO or echocardiography
  • MAP 65 mmHg
    • First line peripheral vasopressor phenylephrine
    • First line central vasopressor noradrenaline
  • UO >0.5ml/kg/hr
  • Hb >70g/dl (90 in patients with cardiac history)
  • Ensure appropriate antibiotics prescribed on e-meds (see antimicrobial guidance) and source control has been considered
• Send baseline procalcitonin
• Ensure all appropriate samples sent (e.g. blood cultures, atypical serology)
• Ensure RESPECT form completed if feasible

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Special Patient Groups

People with Learning Disabilities are at a higher risk of poor outcomes. Sepsis symptoms may be overlooked or falsely attributed to their Learning Disability.  Please consider reasonable adjustments to help assessment, such as checking their hospital passport for supportive strategies or talking to people who know them well.

Other patient groups where diagnosis and management of sepsis can be more challenging include people with dementia and mental health conditions.

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Documentation/Coding of Sepsis

Sepsis may arise from a range of infective sources e.g. urinary, respiratory, abdominal etc. As such, a huge range of terms are used for diagnosis, which makes it difficult to identify cases of sepsis – e.g. they may be coded as pneumonia, or urinary infection, rather than sepsis.

The terms ‘sepsis’, ‘severe sepsis’, ‘sepsis with organ failure’, or ‘septic shock’ should be routinely documented in the medical notes alongside associated source of infection, e.g. pneumonia, UTI and/or identified bacteria as grown on culture. This will ensure appropriate coding.

On discharge from hospital the diagnosis should again be clearly documented as above alongside an appropriate follow up plan.

Death certificates must align to cause of death and in cases of sepsis must align to this e.g. ‘UTI’ is not acceptable but ‘urinary sepsis’ is.

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Appendix

Definitions

Many different terms get used to describe sepsis and its sequelae and this can cause confusion in terms of both understanding and communication. Below are a set of definitions. Those highlighted in red are the terms that are used throughout document and in the Sepsis Screening Tool.

• Care bundle: A set of evidence-based steps that when performed collectively and reliably have been proven to achieve a specific outcome.
• Infection: microbiological phenomenon characterised by an inflammatory response in the presence of micro-organisms.
• Systemic Inflammatory Response Syndrome (SIRS); group of clinic signs which the presence of two or more abnormalities may be an indicator of sepsis.
• Sepsis: Sepsis is a life-threatening condition that arises when the body's response to an infection injures its own tissues and organs. Sepsis can lead to shock, multiple organ failure and death.
• Sepsis Screening Tool: The initial response to a patient who shows altered physiology (NEWS2 score) or an infection to identify the possibility of sepsis in adult patients.
• Red Flag Sepsis: The presence of any of the “Red Flag” features on the screening tool. Predicts if the patient is at a higher risk of severe sepsis or septic shock. The Red Flag features correlate with markers of severity from the NEWS2 scoring tool.
• Amber Flag Sepsis: A patient without any Red Flag features from screening but with one or more Amber features. Represents a patient at risk of deterioration.
• Severe Sepsis: The presence of one or more organ system dysfunctions in the context of sepsis defines severe sepsis for example Acute Kidney Injury in a patient with pneumonia.
• Septic shock: There is inadequate tissue perfusion to key organs. Severe sepsis plus hypotension (Mean Arterial Pressure ≤65mmHg or systolic BP ≤ 90mmHg) following an initial fluid bolus.
• BUFALOS: The seven clinical management steps that should be applied within the first hour of identifying Red Flag Sepsis. Also known as the Sepsis Six (the additional item being senior review).
• Time Zero: The time point where the patient first displays a NEWS score ≥5 or ≥3 in one category, or presents with signs and symptoms of an infection.

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Sepsis Screening Tool

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Educational Infographic