Acute infection and emergencies

Sepsis and septic shock

Overview and approach

Sepsis is life-threatening organ dysfunction from a dysregulated response to infection.

  • Sepsis is a time-critical medical emergency. Use the locally approved sepsis pathway (state pathways e.g. NSW Between the Flags/SEPSIS KILLS, Qld QADDS) and the principles recognise, resuscitate, refer, review (1).
  • Higher-risk groups: neonates and young children, older people, immunosuppressed or on cancer treatment, recent surgery or burns, pregnant or postpartum, indwelling devices, previous sepsis. Incidence is significantly higher in Aboriginal and Torres Strait Islander peoples, so ask about identity and involve Aboriginal health workers/liaison officers (1).
  • A clinician experienced in sepsis should be involved in care for the first 48 hours and beyond (1). Early involvement of senior clinicians with sepsis experience.
  • Sepsis pathway: identify sepsis from risk factors, signs and symptoms of infection, and the criteria for sepsis/septic shock (dysregulated host response). Any patient with signs and symptoms of infection should be screened.

Sepsis pathway (NSW)

Assessment and clinical features

ABCDE, vital signs, mental state, urine output and perfusion; identify probable source, recent procedures, resistant organisms and immunosuppression.

  • Consider sepsis in any acute illness or deterioration that may be due to infection. Take a full set of observations: respiratory rate, SpO2, heart rate, systolic BP, temperature, mental state (confusion, delirium), perfusion (cool peripheries, delayed capillary refill, mottled skin) and venous lactate (1).
  • Older people: fever, raised white cell count and raised CRP are often absent; hypothermia, delirium and falls are more likely. Children: hypotension is not needed to diagnose septic shock; red flags include non-blanching rash, mottled skin, floppiness, low urine output (1).
  • Red flags that should lower your threshold: family or carer concern, repeat acute presentation with infection signs, indwelling device, deterioration despite treatment, recent surgery or burns, cancer treatment or immunosuppression (1).
  • qSOFA alone is not a sensitive or specific screening tool; the 2021 Surviving Sepsis Campaign recommends against using it as a single screening tool. Use a locally agreed decision-support tool plus clinical judgement (1)(2).
  • History: past history (previous infections, recent surgery or injury, recent travel); open questions about symptoms, then a systems review for meningitis, UTI, pneumonia, gallbladder infection and gastroenteritis.
  • Examination: top to toe; look at cannula, line and surgical sites; look for ulcers, pressure sores and rashes.
Differentials and investigations

Take blood cultures and lactate promptly without delaying treatment; obtain source cultures, organ-function blood tests and targeted imaging.

  • Blood cultures: 2 sets in adults (1 set in children) before antimicrobials, only if this does not delay treatment. Also collect source-relevant cultures (urine, wound, sputum etc.) ideally before antimicrobials (1).
  • Venous lactate: helps recognition and risk assessment but is not diagnostic alone; point-of-care lactate is useful in rural and remote settings (1). The 2021 SSC suggests guiding resuscitation to lower an elevated lactate, with capillary refill time as an adjunct measure (2).
  • Uncertain infection, no shock (adult): rapidly investigate alternative diagnoses; if concern for infection persists, start antimicrobials as soon as possible and no later than 3 hours from initial clinical review (1).
  • Further investigations: radiology and other tests directed at the likely source.
  • Organ-dysfunction bloods (FBC, UEC, LFT, coagulation, gas) and imaging for source are standard practice.
Management and follow-up

Escalate immediately; give source-appropriate IV antimicrobials within 60 minutes of infection-related organ dysfunction and as soon as possible in shock. Reassess fluids and arrange source control.

  • Your management sequence: blood cultures before antibiotics, then fluid resuscitation and vasopressors if required, work out the likely source, give appropriate antibiotics for the suspected source, further investigations, source control, ongoing review.
  • Antimicrobials: start within 60 minutes of recognising infection-related organ dysfunction, and as soon as possible if shock is present. Do not wait for test results (1). Aim for within the hour, particularly in septic shock. Examples of empirical agents: flucloxacillin and gentamicin.
  • Choice and dose: empirical therapy should follow the current Therapeutic Guidelines or locally endorsed guideline, match the likely source, local resistance and patient factors (1). Patients with sepsis often need higher doses. Discuss with an ID physician or microbiologist if unsure (1). For Aboriginal and Torres Strait Islander patients, consider higher rates of multidrug-resistant organisms and CARPA guidance where relevant (1).
  • Before transfer: take cultures and give the first antimicrobial dose before transfer (1).
  • Fluids and vasopressors (SSC 2021, weak recommendations): balanced crystalloids over 0.9% saline; IV corticosteroids for septic shock with an ongoing vasopressor requirement; start vasopressors peripherally rather than delaying for central access (2).
  • Source control: investigate and treat the source, which may need surgery or drainage; arrange multidisciplinary input (1).
  • Ongoing review: sepsis is dynamic; patients can improve then deteriorate again, so repeat lactate, repeat clinical review, follow up results, confirm the diagnosis and review antibiotics.
  • Review at 24-48 hours: document indication and intended duration/review date; review spectrum, dose, route, and de-escalate or stop on culture results (1).
  • After discharge: GP-coordinated follow-up; counsel on fatigue, cognitive and emotional effects, infection prevention and keeping vaccinations up to date (1).
Red flags and clinical pearls

A normal lactate or absent fever does not exclude sepsis. Avoid fixed fluid volumes without repeated assessment and review antimicrobials within 48 hours.

  • A normal lactate, absent fever or normal CRP/white cell count does not exclude sepsis, especially in older people (1).
  • Cases have been missed by not listening to patient, family or carer concern; any clinician can activate the sepsis pathway (1).
  • Early antimicrobials save lives but do not skip cultures and source control; review at 48 hours (1).
  • Viva: What is sepsis? Life-threatening organ dysfunction from a dysregulated response to infection. When should antimicrobials start? Within 60 minutes of recognition of organ dysfunction (1). Why not qSOFA alone? Poor sensitivity and specificity (2).
References
  1. Australian Commission on Safety and Quality in Health Care: Sepsis Clinical Care Standard (2022)
  2. Med Klin Intensivmed Notfmed: What is new and different in the 2021 Surviving Sepsis Campaign guidelines (PMC, read in part)

Last updated from Sen’s notes on 9 October 2026.