People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.
For people aged 16 or over in the community and in custodial settings, grade risk of severe illness or death from sepsis using the person's:
history
physical examination results and
criteria based on age (for people aged 16 or over who are not and have not recently been pregnant, see table 3: criteria for stratification of risk from sepsis in people aged 16 or over who are in the community or in a custodial setting. [2016, amended 2024]
Recognise that people aged 16 or over with suspected sepsis in the community and in custodial settings are at:
high risk of severe illness or death from sepsis if they meet any of the high risk criteria in table 3: criteria for stratification of risk from sepsis in people aged 16 or over who are in the community or in a custodial setting
moderate to high risk of severe illness or death from sepsis if they meet any of the moderate to high risk criteria in table 3: criteria for stratification of risk from sepsis in people aged 16 or over who are in the community or in a custodial setting. [2016, amended 2024]
If people aged 16 or over with suspected sepsis in the community and in custodial settings do not meet any high or moderate to high risk criteria, see them as being at low risk of severe illness or death from sepsis. [2016, amended 2024]
In people aged 16 or over, grade risk of severe illness or death from sepsis using the person's:
history
physical examination results (especially symptoms and signs of infection – in line with the recommendations on when to suspect sepsis) and
NEWS2 score.
Interpret the NEWS2 scores within the context of the persons' underlying physiology and comorbidities. [2024]
When evaluating the risk of severe illness or death from sepsis in people aged 16 or over with suspected or confirmed infection, use clinical judgement to interpret the NEWS2 score and recognise that:
a score of 7 or more suggests high risk of severe illness or death from sepsis
a score of 5 or 6 suggests a moderate risk of severe illness or death from sepsis
a score of 1 to 4 suggests a low risk of severe illness or death from sepsis
a score of 0 suggests a very low risk of severe illness or death from sepsis
if a single parameter contributes 3 points to their NEWS2 score, request a high-priority review by a clinician with core competencies in the care of acutely ill patients (FY2 or above), for a definite decision on the person's level of risk of severe illness or death from sepsis. [2024]
Consider evaluating the person's risk of severe illness or death from sepsis as being higher than suggested by their NEWS2 score alone if any of the following is present:
mottled or ashen appearance
non-blanching petechial or purpuric rash
cyanosis of skin, lips or tongue. [2024]
Consider evaluating the person's risk of severe illness or death from sepsis as being higher than suggested by their NEWS2 score alone if there is cause for concern because of deterioration or lack of improvement of the person's condition since:
any previous NEWS2 score was calculated
any interventions have taken place.
This should include taking into account any NEWS2 score calculated or intervention carried out before initial assessment in the emergency department. [2024]
For a short explanation of why the committee made the 2024 recommendations and how they might affect practice, see the rationale and impact section on evaluating risk level in people with suspected sepsis.
Full details of the evidence and the committee's discussion are in evidence review A: stratifying risk of severe illness or death from sepsis.
Recalculate the NEWS2 score and re-evaluate risk of sepsis periodically, in line with the AoMRC statement on the initial antimicrobial treatment of sepsis (2022):
every 30 minutes, for those at high risk of severe illness or death from sepsis
every hour, for those at moderate risk of severe illness or death from sepsis
every 4 to 6 hours, for those at low risk of severe illness or death from sepsis
when standard observations are carried out, in line with local protocol, for those at very low risk of severe illness or death from sepsis. [2024]
If there is deterioration or an unexpected change in the person's condition, recalculate the NEWS2 score and re-evaluate their risk of sepsis. [2024]
For a short explanation of why the committee made the 2024 recommendations and how they might affect practice, see the rationale and impact section on evaluating risk level in people with suspected sepsis.
Full details of the evidence and the committee's discussion are in evidence review A: stratifying risk of severe illness or death from sepsis.
If they meet any high risk criteria, refer people aged 16 or over with suspected sepsis in the community and in custodial settings for emergency medical care (see table 3: criteria for stratification of risk from sepsis in people aged 16 or over who are in the community or in a custodial setting).
Use the most appropriate means of transport (usually 999 ambulance).
Emergency care requires facilities for resuscitation to be available and, depending on local services, may be an emergency department or medical admissions unit. [2016, amended 2024]
For people at high risk of severe illness or death from sepsis who are in an acute mental health setting, follow local emergency protocols on treatment and ambulance transfer. [2024]
For a short explanation of why the committee made this recommendation and how it might affect practice, see the rationale and impact section on when to transfer immediately: people in mental health settings.
Full details of the evidence and the committee's discussion are in evidence review C: early management of suspected sepsis (except antibiotic therapy) in the NEWS2 population, in acute hospital settings.
Ambulance crews should consider a time-critical transfer and pre-alerting the hospital for people aged 16 or over with suspected or confirmed infection who either have consecutive NEWS2 scores of 5 or above or show cause for significant clinical concern. [2024]
When deciding whether a time-critical transfer and pre-alerting the hospital is needed for someone aged 16 or over with consecutive NEWS2 scores of 5 or above and suspected or confirmed infection, take into account:
local guidelines and protocols in relation to clinician scope of practice
agreements on transfer to hospital
advance care planning
end of life care planning. [2024]
For a short explanation of why the committee made the 2024 recommendations and how they might affect practice, see the rationale and impact section on transfer by ambulance for people with consecutive NEWS2 scores of 5 or above.
Full details of the evidence and the committee's discussion are in evidence review B: managing and treating suspected sepsis in acute hospital settings; antibiotic treatment in people with suspected sepsis.
In remote and rural locations where transfer time to emergency department is routinely more than 1 hour, ensure GPs have mechanisms in place to give antibiotics to people with high risk criteria in pre-hospital settings. For high risk criteria, see table 3: criteria for stratification of risk from sepsis in people aged 16 or over who are in the community or in a custodial setting. [2016, amended 2024]
In remote and rural locations where combined transfer and handover times to emergency department are greater than 1 hour:
ambulance services should consider whether they need to put mechanisms in place to be able to give antibiotics to people at high risk of severe illness or death from sepsis if antibiotics have not been given before by a GP (see recommendation 1.11.4 on evaluating risk of severe illness or death from sepsis).
paramedics who are thinking about giving antibiotics should follow local guidelines. [2016, amended 2024]
See also the recommendations on choice of antibiotic therapy.
For a short explanation of why the committee made the 2024 recommendations and how they might affect practice, see the rationale and impact section on managing suspected sepsis in acute hospital settings: when to count time from (time zero).
Full details of the evidence and the committee's discussion are in evidence review B: managing and treating suspected sepsis in acute hospital settings; antibiotic treatment in people with suspected sepsis.
In the community and in custodial settings, assess people aged 16 or over with suspected sepsis who meet any moderate to high risk criteria (as per table 3: criteria for stratification of risk from sepsis in people aged 16 or over who are in the community or in a custodial setting) to:
make a definitive diagnosis of their condition
decide whether their condition can be treated safely outside hospital.
If a definitive diagnosis is not reached or the person's condition cannot be treated safely outside an acute hospital setting, refer them urgently for emergency care. [2016, amended 2024]
In the community and in custodial settings, provide information about the following to people aged 16 or over with suspected sepsis who do not meet any high risk or moderate to high risk criteria:
symptoms to monitor and
how to access medical care if they are concerned.
Also see information at discharge for people assessed for suspected sepsis, but not diagnosed with sepsis. [2016, amended 2024]
In acute mental health settings, assess people aged 16 or over who are at moderate risk of severe illness and death from sepsis (see recommendation 1.11.4 on evaluating risk of severe illness or death from sepsis) to:
make a definitive diagnosis of their condition
decide whether their condition can be treated safely outside hospital.
If a definitive diagnosis is not reached or the person's condition cannot be treated safely outside an acute hospital setting, follow local emergency protocols on treatment and ambulance transfer. [2016, amended 2024]
In acute mental health settings, provide information about the following to people aged 16 or over who are at low or very low risk of sepsis:
symptoms to monitor and
how to access medical care if they are concerned.
Also see information at discharge for people assessed for suspected sepsis, but not diagnosed with sepsis. [2016, amended 2024]
For a short explanation of why the committee made the 2024 recommendations and how they might affect practice, see the rationale and impact section on managing suspected sepsis outside acute hospital settings: if immediate transfer is not required.
Full details of the evidence and the committee's discussion are in evidence review B: managing and treating suspected sepsis in acute hospital settings; antibiotic treatment in people with suspected sepsis.
For people in hospital who have suspected infections:
start looking for the source of infection (see the section on finding and controlling the source of infection)
take microbiological and blood samples before giving an antimicrobial.
See the UK standards for microbiology investigations. [2016, amended 2024]
In January 2024, we updated the recommendations in this section to incorporate use of NEWS2.
We did not review the evidence on other aspects of management. Evidence for tests and interventions recommended in this section was last reviewed in 2016. We are currently reviewing the evidence and will consider making new recommendations or updating existing recommendations on:
rapid antigen testing
indicators of organ hypoperfusion
intravenous fluid therapy
vasopressors.
This update is expected to publish in 2025. See the update page for more information.
A person is at high risk of severe illness or death from sepsis if they have suspected or confirmed infection and a NEWS2 score of 7 or above.
A person is also at high risk of severe illness or death from sepsis if they have suspected or confirmed infection, a NEWS2 score below 7, and:
a single parameter contributes 3 points to their NEWS2 score and a medical review has confirmed that they are at high risk (see recommendation 1.11.4 on evaluating risk of severe illness or death from sepsis) or
there are any other clinical reasons for concern (see recommendations 1.11.6 and 1.11.7 on taking causes for clinical concern into account when evaluating risk of severe illness or death from sepsis).
For people aged 16 or over who are at high risk of severe illness or death from sepsis:
arrange for a clinician with core competencies in the care of acutely ill patients (FY2 level or above) to urgently assess the person's condition and think about alternative diagnoses to sepsis
carry out a venous blood test, including for:
blood gas, including glucose and lactate measurement
blood culture
full blood count
C-reactive protein
urea and electrolytes
creatinine
liver function tests
a clotting screen
give antibiotics in line with recommendation 1.13.3 and the recommendations on choice of antibiotic therapy
refer to the senior clinical decision maker as soon as possible
use
clinical judgement to decide whether to discuss with a consultant.
[2024]
For a short explanation of why the committee made the 2024 recommendation and how it might affect practice, see the rationale and impact section on managing suspected sepsis in acute hospital settings: high and moderate risk of severe illness or death from sepsis.
Full details of the evidence and the committee's discussion are in evidence review C: early management of suspected sepsis (except antibiotic therapy) in the NEWS2 population, in acute hospital settings.
Give people aged 16 or over who are at high risk of severe illness or death from sepsis broad-spectrum intravenous antibiotic treatment, within 1 hour of calculating the person's NEWS2 score on initial assessment in the emergency department or on ward deterioration. Only give antibiotics if they have not been given before for this episode of sepsis (see recommendations 1.12.7 and 1.12.8 on managing the condition while awaiting transfer).
Also see the recommendations on finding and controlling the source of infection and choice of antibiotic therapy. [2024]
For a short explanation of why the committee made the 2024 recommendation and how it might affect practice, see the rationale and impact section on managing suspected sepsis: type and timing of antibiotics.
Full details of the evidence and the committee's discussion are in evidence review B: managing and treating suspected sepsis in acute hospital settings; antibiotic treatment in people with suspected sepsis.
For people aged 16 or over with a high risk of severe illness or death from sepsis and either lactate over 2 mmol/litre or systolic blood pressure less than 90 mmHg, give intravenous fluid bolus without delay (within 1 hour of identifying that they are at high risk) in line with recommendations on intravenous fluids for people with suspected sepsis. [2024]
For people aged 16 or over with a high risk of severe illness or death from sepsis and lactate of 2 mmol/litre or lower, consider giving an intravenous fluid bolus (in line with recommendations on intravenous fluids for people with suspected sepsis). [2024]
Recalculate the NEWS2 score periodically, in line with the recommendations on when to recalculate a NEWS2 score. [2024]
If a person aged 16 years or over who is at high risk of severe illness or death from sepsis does not respond within 1 hour of any intervention:
ensure the senior clinical decision maker attends in person and
refer to or discuss with a critical care specialist or team and
inform the responsible consultant. [2024]
For a short explanation of why the committee made the 2024 recommendations and how they might affect practice, see the rationale and impact section on managing suspected sepsis in acute hospital settings: high and moderate risk of severe illness or death from sepsis.
Full details of the evidence and the committee's discussion are in evidence review C: early management of suspected sepsis (except antibiotic therapy) in the NEWS2 population, in acute hospital settings.
A person is at moderate risk of severe illness or death from sepsis if they have suspected or confirmed infection and a NEWS2 score of 5 or 6.
A person is also at moderate risk of severe illness or death from sepsis if they have suspected or confirmed infection, a NEWS2 score below 5, and:
a single parameter contributes 3 points to their NEWS2 score, and a medical review has confirmed that they are at moderate risk (see recommendation 1.11.4 on evaluating risk of severe illness or death from sepsis) or
there are any other clinical reasons for concern (see recommendations 1.11.6 and 1.11.7 on taking causes for clinical concern into account when evaluating risk of severe illness or death from sepsis).
For people aged 16 or over with moderate risk of severe illness or death from sepsis:
carry out a venous blood test, including for:
blood gas, including glucose and lactate measurement
blood culture
full blood count
C-reactive protein
urea and electrolytes
creatinine
liver function tests
a clotting screen
arrange for a clinician with core competencies in the care of acutely ill patients (FY2 level or above) to review the person's condition and venous lactate results within 1 hour of the person being assessed as at moderate risk. [2024]
For a short explanation of why the committee made the 2024 recommendation and how it might affect practice, see the rationale and impact section on managing suspected sepsis in acute hospital settings: high and moderate risk of severe illness or death from sepsis.
Full details of the evidence and the committee's discussion are in evidence review C: early management of suspected sepsis (except antibiotic therapy) in the NEWS2 population, in acute hospital settings.
For people at moderate risk of severe illness or death from sepsis, a clinician with core competencies in the care of acutely ill patients (FY2 level or above) should consider:
deferring administration of a broad-spectrum antibiotic treatment for up to 3 hours after calculating the person's first NEWS2 score on initial assessment in the emergency department or on ward deterioration and
using this time to gather information for a more specific diagnosis (see recommendations on finding and controlling the source of infection and choice of antibiotic therapy)
discussing with a senior clinical decision maker.
Once a decision is made to give antibiotics, do not delay administration any further. [2024]
For someone with a NEWS2 score of 5 or 6 and a single parameter contributing 3 points to their total NEWS2 score, use clinical judgement to determine the likely cause of the 3 points in one parameter. If the likely cause is:
the current infection, manage as high risk and give broad-spectrum antibiotic treatment in line with recommendation 1.13.3
something else (such as a pre-existing condition), manage as moderate risk and follow recommendation 1.13.9. [2024]
For a short explanation of why the committee made the 2024 recommendations and how they might affect practice, see the rationale and impact section on managing suspected sepsis: type and timing of antibiotics.
Full details of the evidence and the committee's discussion are in evidence review B: managing and treating suspected sepsis in acute hospital settings; antibiotic treatment in people with suspected sepsis.
For people aged 16 or over at moderate risk of severe illness or death from sepsis:
recalculate the NEWS2 score periodically, in line with the recommendations on when to recalculate a NEWS2 score
if there is deterioration or no improvement, escalate care to a clinician with core competencies in the care of acutely ill patients (FY2 level or above). [2024]
For people aged 16 or over with a moderate risk of severe illness or death from sepsis and either lactate over 2 mmol/litre or evidence of acute kidney injury, treat their condition as if they were at high risk of severe illness or death from sepsis.
For definition of acute kidney injury, see NICE's guideline on acute kidney injury. [2024]
For a short explanation of why the committee made the 2024 recommendations and how they might affect practice, see the rationale and impact section on managing suspected sepsis in acute hospital settings: high and moderate risk of severe illness or death from sepsis.
Full details of the evidence and the committee's discussion are in evidence review C: early management of suspected sepsis (except antibiotic therapy) in the NEWS2 population, in acute hospital settings.
A person is at low risk of severe illness or death from sepsis if they have suspected or confirmed infection and a NEWS2 score of 1 to 4 (see recommendation 1.11.4 on evaluating risk of severe illness or death from sepsis) or a NEWS2 score of 0 and cause for clinical concern (see recommendations 1.11.6 and 1.11.7 on taking causes for clinical concern into account when evaluating risk of severe illness or death from sepsis).
For a short explanation of why the committee made the 2024 recommendation and how it might affect practice, see the rationale and impact section on low or very low risk of severe illness or death from sepsis.
Full details of the evidence and the committee's discussion are in evidence review C: early management of suspected sepsis (except antibiotic therapy) in the NEWS2 population, in acute hospital settings.
For people at low risk of severe illness or death from sepsis, request assessment by a clinician with core competencies in the care of acutely ill patients (FY2 level or above) for them to consider:
deferring administration of a broad-spectrum antibiotic treatment for up to 6 hours after calculating the person's first NEWS2 score on initial assessment in the emergency department or on ward deterioration and
using this time to gather information for a more specific diagnosis (see recommendations on finding and controlling the source of infection and choice of antibiotic therapy).
Once a decision is made to give antibiotics, do not delay administration any further. [2024]
For someone with a NEWS2 score of 3 or 4 and a single parameter contributing 3 points to their total NEWS2 score, use clinical judgement to determine the likely cause of the 3 points in one parameter. If the likely cause is:
the current infection, manage as moderate or high risk and:
for moderate risk, give broad-spectrum antibiotic treatment in line with recommendation 1.13.9
for high risk, give broad-spectrum antibiotic treatment in line with recommendation 1.13.3
something else (such as a pre-existing condition), manage as low risk and follow recommendation 1.13.14. [2024]
For a short explanation of why the committee made the 2024 recommendations and how they might affect practice, see the rationale and impact section on managing suspected sepsis: type and timing of antibiotics.
Full details of the evidence and the committee's discussion are in evidence review B: managing and treating suspected sepsis in acute hospital settings; antibiotic treatment in people with suspected sepsis.
For people aged 16 or over at low risk of severe illness or death from sepsis:
recalculate the NEWS2 score periodically, in line with the recommendations on when to recalculate a NEWS2 score
if there is deterioration or no improvement, escalate care to a clinician with core competencies in the care of acutely ill patients (FY2 level or above). [2024]
For a short explanation of why the committee made the 2024 recommendations and how they might affect practice, see the rationale and impact section on low or very low risk of severe illness or death from sepsis.
Full details of the evidence and the committee's discussion are in evidence review C: early management of suspected sepsis (except antibiotic therapy) in the NEWS2 population, in acute hospital settings.
A person is at very low risk of severe illness or death from sepsis if they have suspected or confirmed infection and a NEWS2 score of 0 (see recommendation 1.11.4 on evaluating risk of severe illness or death from sepsis).
For people who are at very low risk of severe illness or death from sepsis:
arrange for review by a registered health practitioner
use clinical judgement to manage their condition and escalate if appropriate
recalculate the NEWS2 score periodically, in line with the recommendations on when to recalculate a NEWS2 score. [2024]
For a short explanation of why the committee made the 2024 recommendation and how it might affect practice, see the rationale and impact section on low or very low risk of severe illness or death from sepsis.
Full details of the evidence and the committee's discussion are in evidence review C: early management of suspected sepsis (except antibiotic therapy) in the NEWS2 population, in acute hospital settings.
Before discharging people who have been assessed for suspected sepsis, provide information on:
the management of their definitive condition (if identified) and
warning signs for sepsis (see information at discharge for people assessed for suspected sepsis). [2024]
For a short explanation of why the committee made the 2024 recommendation and how it might affect practice, see the rationale and impact section on managing suspected sepsis in acute hospital settings: discharge.
Full details of the evidence and the committee's discussion are in evidence review C: early management of suspected sepsis (except antibiotic therapy) in the NEWS2 population, in acute hospital settings.