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Referral and warning signs
When to refer
IMMEDIATE URGENT REFERRAL/ADMISSION to Hospital (H/RR) for ALL suspected cases of sepsis. Needs urgent resuscitation and investigation. Transfer to ICU if septic shock, respiratory failure, or need for advanced organ support.
Red flags
- Hypotension (SBP <90 or MAP <65).
- Altered mental status.
- Tachypnea (RR >22) or Respiratory distress.
- Tachycardia (>100 bpm).
- Signs of poor perfusion (mottled skin, cold extremities, low urine output).
- Elevated lactate (>2 mmol/L).
Signs and symptoms
- Signs of Infection: Fever or Hypothermia, Chills/Rigors, Symptoms related to source (e.g., cough/dyspnea for pneumonia, dysuria for UTI, abdominal pain, wound infection).
- Signs of Organ Dysfunction (SIRS criteria components / SOFA score elements):
- - Temperature: >38°C or <36°C.
- - Heart Rate: >90 bpm (tachycardia).
- - Respiratory Rate: >20 breaths/min or PaCO2 <32 mmHg (tachypnea).
- - White Blood Cell Count: >12,000/mm³, <4,000/mm³, or >10% immature forms (bands).
- - Altered Mental Status: Confusion, agitation, lethargy, coma.
- - Hypotension: Systolic BP <90-100 mmHg, MAP <65-70 mmHg, or significant drop from baseline.
- - Signs of Poor Perfusion: Mottled skin, cold extremities, delayed capillary refill (>3 sec), decreased urine output (oliguria <0.5 ml/kg/hr).
- - Hyperglycaemia: (in absence of diabetes).
- - Elevated Lactate: Indicates tissue hypoperfusion.
- Septic Shock: Sepsis with persistent hypotension requiring vasopressors to maintain MAP ≥65 mmHg AND serum lactate >2 mmol/L despite adequate volume resuscitation.
Risk factors
- Extremes of age (infants, elderly).
- Immunosuppression (HIV, cancer, chemotherapy, chronic steroids, transplant).
- Chronic diseases (Diabetes, COPD, kidney disease, liver disease, heart failure).
- Recent surgery or invasive procedures.
- Indwelling catheters or devices (IV lines, urinary catheters, drains).
- Hospitalization / ICU stay.
- Malnutrition.
- Alcoholism.
- Splenectomy.
Diagnosis
Clinical assessment
Clinical diagnosis based on suspected or confirmed infection PLUS evidence of organ dysfunction (using criteria like SIRS, qSOFA, or SOFA score components). Identify potential source of infection.
Differential diagnosis
- Non-infectious SIRS (e.g., pancreatitis, trauma, burns).
- Cardiogenic shock.
- Hypovolemic shock.
- Anaphylaxis.
- Pulmonary embolism.
- Adrenal crisis.
- Drug overdose/toxicity.
Investigations
- Identify Source: Chest X-ray, Urinalysis & Culture, Abdominal imaging (US/CT), Wound swabs/cultures, LP (if meningitis suspected).
- Blood Cultures: Essential. Obtain at least 2 sets from different sites BEFORE starting antibiotics.
- Laboratory Tests:
- - FBC with differential.
- - Lactate level (venous or arterial).
- - Renal function tests (Urea, Creatinine) & Electrolytes.
- - Liver function tests (LFTs).
- - Coagulation studies (INR, aPTT, Fibrinogen, D-dimer - for DIC).
- - Blood Glucose.
- - C-Reactive Protein (CRP) / Procalcitonin (inflammatory markers).
- - Arterial Blood Gas (ABG) - assess oxygenation, ventilation, acid-base status.
Diagnostic criteria
Suspected/confirmed infection + signs of organ dysfunction (e.g., meeting SIRS criteria + infection = sepsis; qSOFA score >=2; SOFA score increase >=2).
Management
Non-pharmacological management
- Early Recognition and Resuscitation (Sepsis Bundles - time critical):
- 1. Measure Lactate Level.
- 2. Obtain Blood Cultures before antibiotics.
- 3. Administer Broad-Spectrum Antibiotics promptly (within 1 hour).
- 4. Rapid administration of 30 ml/kg crystalloid IV fluid for hypotension or lactate ≥4 mmol/L.
- 5. Apply Vasopressors if hypotensive during or after fluid resuscitation to maintain MAP ≥65 mmHg.
- Source Control: Identify and manage the source of infection urgently (e.g., drain abscess, remove infected line, surgical debridement).
- Supportive Care (Hospital/ICU):
- - Oxygen therapy (maintain SpO2 >92-94%).
- - Mechanical ventilation if respiratory failure/ARDS.
- - Monitor vital signs, urine output (catheterize), mental status frequently.
- - Glycaemic control (target <180 mg/dL).
- - DVT prophylaxis (e.g., LMWH).
- - Stress ulcer prophylaxis.
- - Nutritional support.
Pharmacological treatment
- Broad-Spectrum IV Antibiotics (Empirical): Start within 1 hour of recognition. Choice depends on suspected source, local resistance patterns, patient factors.
- - UCG Recommendation (Unknown focus): Gentamicin IV (Adult: 7mg/kg Q24H or 1.5-2mg/kg Q8H; Child: 3.5-4mg/kg Q8H) PLUS Cloxacillin IV (Adult: 2g Q4-6H; Child: 50mg/kg Q4-6H) OR Chloramphenicol IV (Adult: 750mg Q6H).
- - Alternative: Ceftriaxone IV (Child: 50mg/kg Q8H).
- - De-escalate/Tailor Therapy: Narrow antibiotic coverage once culture/sensitivity results available.
- Vasopressors (for Septic Shock): (ICU/RR)
- - First line: Norepinephrine (5-20 mcg/min infusion).
- - Add Vasopressin or Epinephrine if needed.
- Inotropes: Consider Dobutamine if myocardial dysfunction present.
- Corticosteroids: Consider IV Hydrocortisone (e.g., 200mg/day) ONLY for refractory septic shock unresponsive to fluids and vasopressors (controversial, specialist use).
Monitoring
Continuous monitoring of vital signs (HR, BP, MAP, RR, SpO2, Temp). Monitor urine output hourly. Monitor lactate clearance. Monitor mental status. Monitor organ function (renal, liver, coagulation). Reassess volume status and perfusion frequently.
Complications
- Septic shock.
- Acute Respiratory Distress Syndrome (ARDS).
- Acute Kidney Injury (AKI).
- Disseminated Intravascular Coagulation (DIC).
- Multiple Organ Dysfunction Syndrome (MODS).
- Critical illness polyneuropathy/myopathy.
- Long-term cognitive impairment.
- Death.
Prevention
- Vaccination against relevant pathogens (Pneumococcus, Hib, Influenza).
- Prompt diagnosis and treatment of localized infections.
- Aseptic techniques for invasive procedures.
- Good infection prevention and control practices in healthcare settings.
- Appropriate antibiotic stewardship.
Patient education
- Explanation of sepsis as a severe body response to infection.
- Need for urgent hospital treatment (fluids, antibiotics, oxygen, monitoring).
- Importance of identifying infection source.
- Potential seriousness and complications.
- Information for family regarding prognosis and care needs.
Uganda-specific notes
Sepsis is a major cause of mortality. Early recognition based on clinical signs (qSOFA may be useful) and prompt initiation of fluids and broad-spectrum antibiotics (Gentamicin + Cloxacillin/Ceftriaxone common) is critical. Blood cultures and lactate measurement often unavailable. Management of septic shock challenging due to limited ICU resources.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 2, Section 2.1.7, 2.1.7.1 (Neonatal), 2.1.7.2 (Septic Shock)