What is the recommended early recognition and initial management for an adult with suspected sepsis (SOFA score increase ≥2 or positive qSOFA criteria)?

Early Recognition and Initial Management of Suspected Sepsis in Adults

For adults with suspected sepsis (SOFA score increase ≥2 or positive qSOFA criteria), immediately calculate the NEWS2 score to stratify risk and determine the urgency of antibiotic administration, while simultaneously initiating rapid crystalloid resuscitation and obtaining blood cultures before antibiotics. 1

Risk Stratification Using NEWS2

The 2024 NICE guidance mandates NEWS2 scoring as the primary tool for determining sepsis risk level and treatment urgency in acute hospital, mental health, and ambulance settings. 1

NEWS2 Risk Categories and Interpretation:

• Score 0: Very low risk of severe illness or death 1
• Score 1-4: Low risk of severe illness or death 1
• Score 5-6: Moderate risk 1
• Score ≥7: High risk of severe illness or death 1
• Score 3 in any single parameter: May indicate increased sepsis risk requiring immediate attention 1

The NEWS2 score incorporates six physiological measurements: respiratory rate, oxygen saturation (with two scales for hypercapnic patients), supplemental oxygen requirement, systolic blood pressure, pulse rate, consciousness level (Alert vs CVPU), and temperature. 1

Immediate Resuscitation Protocol

Fluid Resuscitation:

• Begin rapid intravenous crystalloid bolus immediately upon sepsis recognition to restore intravascular volume 1, 2
• Crystalloid solutions are the first-line choice because they are well-tolerated and cost-effective 1
• Infuse rapidly to induce quick response but monitor for signs of fluid overload (basal lung crepitations) 1
• Titrate resuscitation to clinical response rather than following a rigid predetermined protocol 1
• Maintain mean arterial pressure (MAP) ≥65 mmHg to protect cerebral perfusion 2

Vasopressor Support:

• Add vasopressor agents when fluid resuscitation alone fails to maintain adequate perfusion 1
• Vasopressors augment and assist fluid therapy, particularly in refractory hypotension 1

Antibiotic Administration Timing Based on NEWS2 Risk

The person's NEWS2 risk level determines the time window for antibiotic administration: 1

• High risk (NEWS2 ≥7): Administer empiric broad-spectrum antibiotics within 1 hour of sepsis recognition 2, 3
• Moderate risk (NEWS2 5-6): Antibiotics should be given promptly, with timing guided by clinical deterioration 1
• Low risk (NEWS2 1-4): Antibiotics within a reasonable timeframe while investigating infection source 1

Critical caveat: Delays in antibiotic administration beyond the first hour increase mortality in high-risk patients. 2, 3

Diagnostic Workup Before Treatment

Blood Cultures:

• Obtain at least two sets of aerobic and anaerobic blood cultures before administering antibiotics 2
• Never delay antibiotics beyond the appropriate time window to obtain cultures 3

Laboratory Assessment:

• Measure serum lactate immediately; levels >2 mmol/L indicate tissue hypoperfusion and guide resuscitation intensity 1, 2
• Complete blood count: leukocytosis >12×10³/µL or leukopenia <4×10³/µL supports sepsis diagnosis 2
• Comprehensive metabolic panel to assess organ dysfunction (creatinine, bilirubin, glucose) 2
• Monitor for oliguria (<0.5 mL/kg/hr for ≥2 hours) as a sign of organ dysfunction 2

Note on lactate: Elevated lactate (>4 mmol/L) is no longer part of organ dysfunction criteria for defining sepsis but remains crucial for identifying septic shock and guiding resuscitation. 1

Clinical Recognition Criteria

qSOFA Score Components (≥2 indicates higher mortality risk): 4, 5

• Systolic blood pressure ≤100 mmHg 4
• Respiratory rate ≥22/min 4, 5
• Altered mental status 4, 5

SOFA Score Interpretation:

• An increase of ≥2 points indicates life-threatening organ dysfunction with in-hospital mortality >10% 5
• SOFA components include PaO₂/FiO₂ ratio, Glasgow Coma Scale, mean arterial pressure/vasopressor requirement, bilirubin, platelets, and creatinine 1

Source Control and Additional Investigations

Imaging When Indicated:

• Perform contrast-enhanced CT of the abdomen for severe abdominal pain or peritoneal signs to identify surgically drainable sources 2
• Obtain chest radiography if respiratory distress or signs of acute respiratory distress syndrome develop 2

Surgical Evaluation:

• Severe abdominal pain with peritoneal signs suggests complicated intra-abdominal infection requiring urgent surgical evaluation and source control within 24 hours 2

Common Pitfalls to Avoid

Do not rely solely on SIRS criteria: The Sepsis-3 definition removed SIRS from sepsis criteria because of inadequate specificity and sensitivity. 5 While SIRS may still have utility in certain populations, NEWS2 and qSOFA provide better risk stratification. 1, 4

Do not wait for "severe sepsis": This term is now redundant; sepsis itself is defined as life-threatening organ dysfunction. 5 Any patient meeting sepsis criteria requires immediate intervention.

Do not delay antibiotics for complete workup: In high-risk patients (NEWS2 ≥7), the 1-hour window for antibiotics is absolute and takes priority over comprehensive diagnostic testing. 2, 3

Monitor response continuously: Use repeat NEWS2 scoring to gauge treatment response and detect clinical deterioration, as failing to recognize deterioration promptly can be life-threatening. 1