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Written on 20th May 2022 by

The Academy of Medical Royal Colleges has published new guidance on when antibiotic treatment should be started for patients with suspected sepsis. The new guidance recommends that different maximum time deadlines for starting antibiotics should apply, depending on the severity of the patient’s illness and whether they have confirmed or merely suspected sepsis

The extended three-hour deadline in less unwell patients with suspected sepsis is designed to allow healthcare staff time to investigate and accurately identify the source of infection so that they can prescribe the correct antibiotic for the infection. The aim is to reduce the use of broad spectrum (general/non-specific) antibiotics in patients who are waiting for a confirmed diagnosis of sepsis infection to address the growing threat of antibiotic resistance.

What is sepsis?

Sepsis is a life-threatening complication of serious infection. The most severe forms of sepsis, affecting the organs, the blood supply to the tissues or when the blood pressure drops dangerously low (septic shock) are medical emergencies.

Around 245,000 people in the UK are affected by sepsis each year.  Five people die from sepsis every hour in the UK, an annual total of around 48,000 deaths.  40% of sepsis survivors are left with permanent, life-changing after-effects. Sepsis is often treatable if caught early but can develop very quickly, with devastating consequences for the patient. Early diagnosis and antibiotic treatment are the key to successful recovery from sepsis.

What does the Academy of Medical Royal Colleges say about existing treatments for sepsis?

According to the Academy, timely correct treatment for sepsis means that:

  • The person must be seen by a healthcare professional, such as a doctor, nurse or paramedic. They point out that in the early stages of sepsis, people often don’t think they are unwell enough to need medical help.

  • Healthcare professionals must recognise that the person has a potentially serious illness and that it could be sepsis. This can be challenging as early signs of sepsis can be mild and appear similar to other illnesses.
  • The patient must be transferred promptly to an acute hospital.
  • The clinical team must provide basic support for the person if needed, such as giving extra fluid to increase blood pressure or oxygen to assist breathing. They must also perform tests to see why the person is ill.
  • If an infection is thought to be the cause of the illness, or tests show that that this is the case, antibiotics must be given promptly and then changed or stopped later on when more test results are available.

They emphasise the importance of choosing the right antibiotic to treat sepsis, but where test results do not identify the microbe which is causing the infection or are not available quickly, patients who might have sepsis are often given broad spectrum antibiotics which cover a range of possible microbes. Existing national guidelines say these should be given intravenously within one hour of diagnosis, and can later be stopped or changed depending on the test results.  

The Academy is concerned that whilst giving antibiotics within one hour is appropriate for those who are very unwell with sepsis, others who are less ill or are subsequently found not to have sepsis infection may be given the wrong antibiotics or antibiotics they do not need. Unnecessary use of antibiotics increases the risk that the microbes which cause infection become resistant, so that antibiotics no longer work. The World Health Organisation currently recognises antimicrobial resistance as a major global threat.

The Academy says that many national and international emergency and intensive care and infectious diseases organisations believe it is better to investigate and find the right treatment for patients who are less sick, than to rush to give them broad spectrum antibiotics within one hour. The Academy recommend that national guidance should be changed to give healthcare staff more time to assess, investigate and treat patients with suspected sepsis, and suggest that in these cases the deadline for starting antibiotic treatment should be extended to three hours. They believe that this will result in more accurate treatment, with better patient outcomes and less antimicrobial resistance.

What does the new guidance say about starting antibiotic treatment for sepsis?

The Academy’s recommendations include:

  • Healthcare professionals should recognise and treat the most severely ill patients with sepsis within one hour, and those who are less ill and suspected to have sepsis should be assessed and treated within a maximum of three hours.

  • Patients with suspected sepsis should be assessed using an updated National Early Warning Score (NEWS), which gives a score to their vital signs which then determines the speed and seniority of clinical response.
  • The NEWS assessment should be used to supplement the doctor’s clinical judgement to identify patients with suspected sepsis who are critically ill and need treatment quickly.
  • An equivalent Paediatric Early Warning Score (PEWS) is being trialled for children.
  • These suggested times are not to allow hospitals to delay assessment and treatment, but give healthcare professionals some more time to find out what the best treatment is for that person. If a decision is made to give antibiotics there should not be any avoidable delay.
  • Urgency of treatment of adult and paediatric patients with suspected sepsis should be based on updated NEWS and PEWS scores, combined with clinical and laboratory assessments of severity, urgency and probability of infection.
  • Healthcare professionals must not simply rely on the NEWS score but must also use their own judgement and consider other factors, such as where a patient has other high risk factors.
  • Where there are additional concerns about the patient’s serious infective diagnosis, such as with conditions such as necrotising fasciitis, meningitis, or conditions which make the patient more vulnerable to sepsis, level of severity and required action should be upgraded according to patient need.
  • The patient may need other urgent management to provide organ-system support or provide pain relief.
  • Broad-spectrum antimicrobials (including antibiotics, antifungal and antiviral treatments) should be reserved for patients with severe illness or who are at higher-risk.
  • Where broad-spectrum antimicrobials are given their appropriateness should be reviewed within 48 – 72 hours.
  • Senior clinical input, including from microbiology or infectious disease physicians, should be sought if the patient is not improving.
  • The times stated in the guidance are maximum periods, not targets. The aim is not to delay treatment, but to allow sufficient time to make an informed clinical judgement.
  • The guidance does not remove the need for professional judgement from doctors and nurses about the best way to care for people with sepsis, or the duty of care from the wider healthcare system.
  • The new guidance should be audited and checked within hospitals to confirm they do improve care for people with sepsis.

In addition to the general recommendations, where the patient is a child, the guidance also included:

  • Parental concern should always be taken seriously, and clinical decisions made in partnership with the parents.
  • The importance of first looking at the child to see if they appear unwell, independent of any other formal assessments. If the child appears unwell, action should be taken regardless of the score on the PEWS system.
  • Other urgent management, such as correcting hypoglycaemia or giving pain relief may be necessary.

The Academy recommended that the NHS, NHS Improvement, the Department of Health and Social Care, and The National Institute for Health and Care Excellence (NICE) consider reviewing and revising their current sepsis triage guidance.

What does UK Sepsis Trust say about the new guidance

The UK Sepsis Trust, which is currently celebrating its 10th anniversary year, welcomed the publication of the new guidelines. 

Dr Ron Daniels, CEO of the UK Sepsis Trust said, “Ten years ago, when the UK Sepsis Trust was established, sepsis was not a term widely understood outside of intensive care units. Increased awareness of, and education around, the grave dangers of sepsis over the last decade have culminated in the important new guidance published today… To equip those working tirelessly on the frontline to recognise and manage sepsis decisively and responsibly, the Trust is delighted to support implementation of the guidelines via our resources and tools which will help stop this life-threatening condition in its tracks.”

To support implementation of the guidance, the UK Sepsis Trust is launching updated tools and guidance to help healthcare professionals treat patients with sepsis. These include:

  • A new edition of the UK Sepsis Trust’s ‘The Sepsis Manual’, a free educational tool for healthcare professionals which includes the Trust’s ‘Sepsis Six’ treatment pathway;
  • Clinical screening and action tools which comply with the new guidelines, to guide clinical decision-making;
  • Ongoing work to develop a series of e-learning modules to help healthcare professionals and the public understand, identify, and manage sepsis.

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