Hospital Admission for Sepsis
Patients with sepsis should always be admitted to the hospital, with severe cases requiring ICU admission based on specific criteria including respiratory failure requiring mechanical ventilation or septic shock requiring vasopressors. 1, 2
Rationale for Hospital Admission
Sepsis represents a dysregulated host response to infection that can rapidly progress to organ dysfunction and death if not promptly treated. The Surviving Sepsis Campaign guidelines emphasize early intervention as critical for improving outcomes:
- Early administration of effective intravenous antimicrobials within the first hour of recognition of septic shock and severe sepsis is strongly recommended (grade 1B for septic shock, grade 1C for severe sepsis) 1
- Rapid fluid resuscitation and hemodynamic support are essential components of early management 1
- Continuous monitoring of vital signs and organ function is necessary to guide ongoing therapy 2
These interventions require hospital-level care with appropriate resources and expertise.
Levels of Care Based on Severity
The appropriate level of care depends on the severity of sepsis:
General Ward Admission
- Patients with sepsis without shock or significant organ dysfunction
- Patients who meet SIRS criteria with suspected infection but without evidence of hypoperfusion 3
- Patients who can be adequately monitored in a non-ICU setting
ICU Admission Criteria
Patients should be admitted directly to the ICU if they have:
Major Criteria (any one warrants ICU admission) 1, 2:
- Need for mechanical ventilation with endotracheal intubation
- Septic shock requiring vasopressors
Minor Criteria (two or more warrant ICU consideration) 1, 2:
- Respiratory rate ≥30/min
- PaO₂/FiO₂ ratio <250
- Multilobar infiltrates
- Confusion/disorientation
- Systolic BP <90 mmHg despite adequate fluid resuscitation
- Blood urea nitrogen >19.1 mg/dl
- Thrombocytopenia, leukopenia, or hypothermia
Evidence on Outcomes
The mortality rate for sepsis varies significantly based on severity and treatment setting:
- Overall mortality for sepsis patients identified in the emergency department can be as low as 2.7% 3
- ICU mortality rates for septic shock can exceed 50% 4
- Delayed transfer to ICU is associated with increased mortality, with up to 45% of patients who ultimately require ICU initially admitted to non-ICU settings 2
This stark difference in mortality rates underscores the importance of appropriate triage and early intervention.
Special Considerations
Diagnostic Uncertainty
It's important to note that not all patients initially diagnosed with sepsis actually have an infectious etiology:
- In one study, over 50% of patients treated for severe sepsis in the ED had negative cultures 5
- 18% had noninfectious conditions that mimicked sepsis 5
Despite this diagnostic uncertainty, the potential consequences of delaying treatment for true sepsis outweigh the risks of unnecessary hospitalization.
Outpatient Management
There is no evidence in current guidelines supporting outpatient management of patients meeting sepsis criteria. The Surviving Sepsis Campaign guidelines emphasize the need for:
- Prompt antimicrobial therapy within one hour 1
- Aggressive fluid resuscitation 1
- Continuous monitoring 2
These interventions cannot be safely provided in an outpatient setting.
Conclusion
The evidence clearly demonstrates that all patients with sepsis require hospital admission. The decision between general ward and ICU admission should be based on specific criteria related to organ dysfunction, hemodynamic stability, and respiratory status. Early recognition and appropriate level-of-care decisions are critical for optimizing outcomes in this potentially life-threatening condition.