Sepsis: workup and management

Suspected sepsis: life-threatening organ dysfunction from infection. The 2026 Surviving Sepsis Campaign ties antibiotic timing to how likely sepsis or shock is. Cultures, lactate, prompt antibiotics, fluids for hypoperfusion, norepinephrine to MAP ≥65 and early source control.

Working diagnosis Adult · US guidelines Draft · awaiting physician review

Tailor to a patient with AI Bedside calculators Report an error

01Orient

What's new in the evidence

Surviving Sepsis Campaign 2026: antibiotics immediately (ideally within 1 hour) for possible shock or probable/definite sepsis; for possible sepsis without shock, a rapid workup and antibiotics within 3 hours if concern persists
De-escalate once a pathogen and susceptibilities are known; de-escalation is suggested even when cultures are negative
BALANCE (2025): 7 days was noninferior to 14 days for most bloodstream infections (not S. aureus, fungemia, severe immunosuppression or prosthetic material)
SCCM 2024 corticosteroid focused update: hydrocortisone suggested for septic shock
CLOVERS (2023): restrictive vs liberal fluids after initial resuscitation made no mortality difference

Differential diagnoses

Pneumonia
Urinary tract infection or pyelonephritis
Intra-abdominal infection (cholangitis, perforation, abscess)
Skin and soft tissue, including necrotizing fasciitis
Line or device infection; endocarditis
Meningitis
Non-infectious mimics: PE, pancreatitis, adrenal crisis, drug reaction, transfusion reaction

02Assess

Risk scores and decision tools

SOFA (organ dysfunction) and qSOFA as a warning sign only
Lactate (≥2 mmol/L abnormal; ≥4 mmol/L triggers 30 mL/kg)
NEWS2 for deterioration on the ward
Capillary refill time as a perfusion target

Key history questions

Localizing symptoms: cough, dysuria, abdominal pain, headache, rash
Immunosuppression, chemotherapy, splenectomy
Indwelling lines, catheters, prosthetic valves or joints
Recent hospitalization or antibiotics; MRSA or resistant organism history
Recent travel, injection drug use

Examination findings

Vitals, mental status, capillary refill, mottling
Full skin check including back and lines
Chest, abdomen, meningism, joints
New murmur

03Investigate

Initial investigations

Two sets of blood cultures before antibiotics (without delaying them)
Lactate
CBC, BMP, LFTs, coagulation
Urinalysis and urine culture
Chest X-ray

Advanced investigations

Targeted imaging for source (CT abdomen, ultrasound for cholangitis)
Procalcitonin as an adjunct
Echocardiogram for suspected endocarditis
Lumbar puncture if meningitis suspected

04Treat

Immediate management

Antibiotics within 1 hour for possible shock or probable sepsis; within 3 hours after rapid evaluation when sepsis is only possible and there is no shock
≥30 mL/kg balanced crystalloid within 3 hours for hypotension or lactate ≥4 mmol/L, reassessing after each bolus
Norepinephrine to MAP ≥65 mmHg if hypotension persists (peripheral start is acceptable)
Source control as early as possible (drain, debride, remove infected lines)

First-line treatment

Empiric choice by source and local antibiogram; MRSA cover only with risk factors; no empiric antifungals for most patients
Narrow antibiotics once cultures and sensitivities return
Duration: 7 days for most uncomplicated bacteremia after source control (BALANCE); longer for S. aureus, endocarditis, bone or undrained infection
Balanced crystalloid preferred over saline for large volumes

Second-line treatment

Hydrocortisone 200 mg/day if ongoing vasopressor requirement
Vasopressin as second vasopressor

Specialist referrals

ICU for septic shock or rising lactate
Surgery or interventional radiology for source control
Infectious diseases for resistant organisms or endocarditis

05Disposition

Admission criteria

Any organ dysfunction (qSOFA ≥2 is a warning sign, not a rule-out)
Hypotension or lactate ≥2
Immunosuppression with fever

Safe discharge criteria

No organ dysfunction, normal lactate
Clear source treatable with oral antibiotics
Tolerating oral intake and has follow-up

Follow-up timing

Primary care within 1 week; culture results followed up

Patient instructions

Complete the antibiotic course
Return for confusion, breathlessness, or reduced urine

Monitoring

Repeat lactate within 2-4 h if raised
Urine output target ≥0.5 mL/kg/h
Daily review of antibiotic need and duration

Clinical pearls and pitfalls

A normal temperature does not exclude sepsis, especially in older adults
Re-examine after each fluid bolus for overload

RefGuidelines and landmark evidence

GuidelineSurviving Sepsis Campaign – International Guidelines for Management of Sepsis and Septic Shock (2026)PublisherPubMed
TrialBALANCE: 7 vs 14 days of antibiotics for bloodstream infection (2025)PublisherPubMed
GuidelineSCCM – Focused Update on Corticosteroids in Sepsis, ARDS and CAP (2024)PublisherPubMed
GuidelineSurviving Sepsis Campaign – International Guidelines for Management of Sepsis and Septic Shock (2021)PublisherPubMed
TrialCLOVERS: restrictive vs liberal fluids in sepsis-induced hypotension (2023)Free full textPubMed
TrialADRENAL: hydrocortisone in septic shock (2018)PublisherPubMed

For education only. Typical adult starting points; confirm doses against renal function, allergies, interactions and your institution's protocols. Not a substitute for clinical judgment or senior review.