Sepsis in older adults — Rapid | Doctor’s Passport

Synopsis

Recognise sepsis despite absent fever or non-specific decline, stratify risk using physiology and clinical concern, deliver time-critical source, antimicrobial and circulatory care, and prevent treatment complications in frailty and organ impairment.

Sepsis is life-threatening organ dysfunction from a dysregulated response to infection; fever and leukocytosis are neither required nor sufficient.
Older adults may present with delirium, falls, reduced mobility, poor intake or incontinence, so compare with the stable baseline.
First-line assessment uses ABCDE, glucose, NEWS2, lactate where indicated, focused source examination and clinical concern under NICE NG253.
High-risk features require immediate senior review, blood tests and cultures, source-appropriate IV antibiotics within one hour and escalation planning.
Do not delay antibiotics for cultures, imaging or transfer when the high-risk treatment threshold is met; obtain samples first only when this causes no material delay.
Use current local empirical antimicrobial guidance informed by source, allergy, renal function, previous cultures, recent antibiotics and healthcare exposure.
For high-risk circulatory compromise, NICE uses 250 mL isotonic crystalloid boluses over 10 to 15 minutes with reassessment and caution in cardiac or renal disease.
Source control—draining obstruction or abscess, removing an infected device or operating on perforation—is as important as antimicrobial selection.
Review antibiotics at 48 to 72 hours using cultures, imaging, response and diagnosis; narrow, switch route or stop when appropriate.
After stabilisation, address delirium, swallowing, pressure, nutrition, mobility, medicine accumulation and post-sepsis rehabilitation.

Key red flags

New systolic hypotension, lactate elevation, mottling, cyanosis or delayed capillary refill suggests impaired perfusion and high risk.

New oxygen need, respiratory distress or rapidly increasing respiratory rate requires immediate support and source assessment.

Reduced consciousness, new delirium, seizure or sudden functional collapse can be an older adult's principal sepsis manifestation.

Oliguria, acute kidney injury, thrombocytopenia or deranged coagulation indicates evolving organ dysfunction.

Neutropenia, immunosuppression, recent surgery, indwelling device or suspected obstruction lowers the threshold for urgent specialist source control.

Pain out of proportion, crepitus, meningism, purpura or a hot prosthetic joint suggests a source needing immediate specialist intervention.

High-risk perfusion pattern

Hypotension, mottling, prolonged refill, oliguria or raised lactate indicates threatened organ perfusion.

Obstructed urinary source

Sepsis with flank pain, hydronephrosis or anuria requires urgent drainage rather than antibiotics alone.

Deep soft-tissue source

Pain out of proportion, rapidly spreading change, crepitus or bullae suggests necrotising infection.

Investigation priorities

NEWS2 and serial physiologyFirst stepFirst line

Risk-stratify and detect deterioration first line.

Management branches

First-line sepsis sequenceRisk-stratify and treat on the clock

Infection is suspected with new physiological, cognitive or functional deterioration.

Use ABCDE, glucose, NEWS2, lactate and source examination and assign current NICE risk with senior concern included.
Obtain cultures and organ tests without delaying source-appropriate IV antimicrobials within the high-risk treatment window.
Support oxygenation and circulation, identify source-control need and escalate persistent organ dysfunction to critical care.

Key medicines

Isotonic crystalloid for sepsis hypoperfusionGive 250 mL intravenously over 10 to 15 minutes, reassess immediately and repeat 250 mL aliquots only while benefit remains, following the current NICE ceiling and senior-review requirements.Use sodium 130 to 154 mmol/L crystalloid; reassess for pulmonary oedema after every bolus and involve senior or critical care early in heart, kidney or respiratory disease.

Empirical intravenous antimicrobial therapyGive the complete source-specific loading and maintenance regimen from the current local adult sepsis guideline within one hour for high-risk sepsis, adjusting subsequent doses for weight, allergy, renal or hepatic function and dialysis.Obtain cultures first only if this does not delay treatment; review at 48 to 72 hours, narrow by results and avoid continuing broad therapy for colonisation or an unsupported diagnosis.

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