What is the management approach for an adult patient, possibly elderly or with compromised immune systems, suspected of sepsis and identified using the Phoenix sepsis score?

Phoenix Sepsis Score: Clarification and Management Approach

The Phoenix Sepsis Score is a pediatric-specific tool and should NOT be used for adult patients—use NEWS2 scoring instead for adults aged 16 and over with suspected sepsis. 1, 2

Critical Distinction: Phoenix vs. Adult Sepsis Scoring

The Phoenix criteria were developed specifically for children to identify life-threatening organ dysfunction due to infection, defining pediatric sepsis as a Phoenix Sepsis Score ≥2 points. 3, 4 However, for adult patients (including elderly and immunocompromised populations), the NEWS2 (National Early Warning Score 2) is the recommended risk stratification tool. 1, 2

Adult Sepsis Management Using NEWS2

Initial Risk Stratification

Calculate the NEWS2 score immediately upon suspicion of infection using seven physiological parameters: 1, 2

• Respiratory rate (per minute)
• Oxygen saturation (SpO2)
• Supplemental oxygen use (room air vs. oxygen)
• Systolic blood pressure (mm Hg)
• Heart rate (per minute)
• Level of consciousness (Alert vs. CVPU: Confusion, Voice, Pain, Unresponsive)
• Temperature (°C)

NEWS2 Score Interpretation and Risk Categories

High Risk (NEWS2 ≥7): Indicates high risk of severe illness or death from sepsis 1, 2, 5

Moderate Risk (NEWS2 5-6): Indicates moderate risk of severe illness or death 1, 2, 5

Low Risk (NEWS2 1-4): Indicates low risk of severe illness or death 1, 5

Very Low Risk (NEWS2 0): Indicates very low risk 1, 5

Critical caveat: A score of 3 in ANY single parameter warrants urgent evaluation regardless of total score. 1

Immediate Red Flags Requiring Urgent Assessment

Evaluate for high risk immediately if ANY of the following are present, regardless of NEWS2 score: 1

• Mottled or ashen appearance
• Non-blanching petechial or purpuric rash
• Cyanosis of skin, lips, or tongue

Risk-Stratified Management Algorithm

For High-Risk Patients (NEWS2 ≥7):

Antibiotic administration: Within 1 hour of risk assessment 2, 5

Monitoring frequency: Re-calculate NEWS2 every 30 minutes 1, 2, 5

Immediate actions: 1

• Obtain blood cultures before antibiotics (but do not delay antibiotics beyond 1 hour)
• Initiate fluid resuscitation with crystalloid bolus (500 mL initial bolus for adults)
• Target mean arterial pressure (MAP) ≥65 mmHg
• Start norepinephrine as first-line vasopressor if hypotensive despite fluids
• Measure serum lactate (>2 mmol/L despite adequate resuscitation defines septic shock)

ICU-level care: Arrange immediate transfer to intensive care setting 5

For Moderate-Risk Patients (NEWS2 5-6):

Antibiotic administration: Within 3 hours of risk assessment 2, 5

Monitoring frequency: Re-calculate NEWS2 every hour 1, 2, 5

Fluid resuscitation: Initiate if signs of hypoperfusion present 1

For Low-Risk Patients (NEWS2 1-4):

Antibiotic administration: Within 6 hours of risk assessment 2, 5

Monitoring frequency: Re-calculate NEWS2 every 4-6 hours 1, 2, 5

Special Considerations for Elderly and Immunocompromised Patients

Interpret NEWS2 scores in the context of baseline physiology and comorbidities. 1, 2 Elderly patients may present with atypical vital signs and are at significantly higher risk for sepsis-related mortality. 2

For immunocompromised patients, obtain detailed history including: 2

• Neutropenia status
• HIV/AIDS
• Splenectomy
• Chronic steroid use
• Active chemotherapy
• Transplant status
• Congenital or acquired immunodeficiencies

Consider escalating risk category if the patient's condition is deteriorating or has not improved since any previous NEWS2 calculation or intervention. 1

Hemodynamic Resuscitation Targets

Initial resuscitation should be achieved within 3 hours and target: 1

• MAP ≥65-70 mmHg
• Lactate <2 mmol/L
• Urine output >0.5 mL/kg/hour
• Capillary refill time <2 seconds
• Normal mental status

Use crystalloid solutions as first-line fluid therapy. 1 Avoid fluid overload, which can worsen outcomes and increase intra-abdominal pressure. 1

Norepinephrine is the first-line vasopressor and is more effective than dopamine for reversing hypotension in septic shock. 1

Source Control and Antimicrobial Therapy

Administer broad-spectrum intravenous antibiotics promptly according to the risk-stratified timeline above. 5 Early antimicrobial therapy is critical for mortality reduction. 5

Identify and control the source of infection urgently, with surgical intervention if indicated (e.g., perforated viscus, necrotizing soft tissue infection, abscess drainage). 5

Consider antibiotic de-escalation once culture results are available and clinical improvement is evident, as part of antimicrobial stewardship. 1

Common Pitfalls to Avoid

Do not be falsely reassured by a low NEWS2 score—patients with sepsis can deteriorate rapidly, particularly elderly and immunocompromised individuals. 1

Do not delay antibiotics in high-risk patients beyond 1 hour while waiting for diagnostic studies. 1, 5

Do not perform lumbar puncture in patients with predominantly sepsis or rapidly evolving rash—prioritize antibiotics and hemodynamic stabilization first. 1

Do not use excessive fluid resuscitation—avoid fluid overload which can worsen organ dysfunction. 1