Sepsis: recognition, diagnosis and early management

Why this is important

The lack of robust UK based epidemiological studies on the incidence and outcomes from sepsis have been clear throughout the guideline development process. A large epidemiological study to collect information about where sepsis is being treated, patient interventions and patient outcomes would provide population based statistics on epidemiology of sepsis which are necessary to support evaluation of interventions, planning of services and service redesign. The mortality and morbidity and service complexity associated with severe infection and sepsis, and the need to use broad spectrum antimicrobials to treat sepsis, justifies the cost required to set up such a study.

Why this is important

Implementation of NICE's guideline on sepsis will be a challenge to the NHS. A robust evaluation of how NHS service providers adhere to the recommended care processes needs to be carried out over the next 5 years.

A complex evaluation is needed to understand the effect of guidelines on services and on patient outcomes. Evaluation should include assessment of costs and cost effectiveness, the use of a universal audit tool for sepsis patient care that includes evaluation of pre-hospital and secondary care and monitoring of broad spectrum antibiotic use, development of multi-resistant organisms and incidence of antibiotic-related infection such as C. difficile.

Why this is important

There is an urgent clinical need for accurate biomarkers of serious bacterial infection (SBI) which provide early diagnosis of SBI, and prompt clinical interventions to improve outcomes. The current tests used in the NHS (white cell count and C-reactive protein) are non-specific and not sensitive enough. Biomarker-guided initiation and termination of antibiotic therapy might be an effective strategy to reduce unnecessary antibiotic use and help prevent further multidrug resistance. The NICE diagnostics guidance on procalcitonin for diagnosing and monitoring sepsis has shown there is not enough evidence in this area.

Why this is important

Delay in detecting and treating sepsis increases mortality. Early detection and appropriate management will reduce morbidity and mortality and will reduce NHS costs by reducing critical care admissions, inappropriate antimicrobial use and length of hospital stay. No high quality data exist on the validation or use of early warning scores in pre-hospital settings or in the emergency department settings. The use of scores might improve communication between pre-hospital settings and hospital settings and allow recognition of people who need more urgent assessment.

Why this is important

In primary care and emergency departments people with suspected sepsis are often seen by relatively inexperienced doctors. Many of these people will be in low and medium risk groups but evidence is lacking as to who can be sent home safely and who needs intravenous or oral antibiotics. The consequences of getting the decision making wrong can be catastrophic and therefore many patients are potentially over-investigated and admitted inappropriately. Current guidance is dependent on use of individual variables informed by low quality evidence.