Sepsis & the Deteriorating Adult
Last Update 1st September 2026
Sepsis & the Deteriorating Adult
Recognition
Sepsis is life-threatening organ dysfunction caused by a dysregulated host response to infection. Consider it in any patient with acute illness or clinical deterioration that could be due to infection.
No screening tool rules sepsis out. The Surviving Sepsis Campaign recommends against qSOFA as a single screening tool, or relying on any one tool alone. Suspicion plus a full set of observations is the assessment.
Presentation varies by age, which is where sepsis is missed:
- Older people often have none of the classic signs. Fever, a raised white cell count and a raised CRP are all less likely. Hypothermia, delirium and falls in a frail person are more likely.
- Children may show only lethargy, irritability, poor feeding or temperature instability. Hypotension is not required to diagnose septic shock in a child.
Assessment
A full set of observations on every patient where sepsis is on the differential:
- Respiratory rate
- Oxygen saturation
- Heart rate
- Systolic blood pressure
- Temperature
- Altered mentation, behaviour change or delirium
- Poor peripheral perfusion, cool peripheries, delayed capillary refill or mottled skin
- Blood lactate
- In pregnancy, fetal monitoring by CTG
Lactate. Measure venous lactate where doing so will not delay urgent care. Levels above 2 mmol/L are associated with worse outcomes, and falling levels correlate with reduced mortality. It is not diagnostic on its own and should not be the sole endpoint of resuscitation, but it belongs in decision-making for any acutely deteriorating patient. Point-of-care lactate is especially useful in rural and remote settings and in Aboriginal medical services, where critical care is not close by.
A rising lactate should prompt a rethink: source control has not been achieved, or there is a second pathology such as mesenteric ischaemia or cardiogenic shock worsening with fluid.
Red flags
- Family or carer concern — a well-demonstrated warning sign, particularly for an older relative, a child or an infant
- Re-presentation for acute care with signs of infection, or an indwelling medical device
- Clinical deterioration despite treatment
- Recent surgery or burns
- Cancer treatment or immunosuppression
Maintain a high index of suspicion in Aboriginal and Torres Strait Islander patients, who experience higher rates of sepsis.
Finding the source
Examine for the source: chest, urine, skin and soft tissue, abdomen, meninges, indwelling lines and catheters, recent surgical sites, joints.
Ask what makes a resistant or atypical organism more likely: a previous resistant culture, broad-spectrum IV antibiotics in the past 90 days, at least five days in hospital in the past 90 days, severe immunosuppression, travel, or animal and bushland exposure.
Investigate to the level your setting allows — blood cultures before antibiotics where that does not delay them, FBE, UEC, LFTs, coagulation studies, cultures from the suspected source, and imaging directed at the likely site.
Immediate management
Sepsis is a time-critical medical emergency; treatment and resuscitation begin immediately.
- Organ dysfunction present: appropriate antimicrobials within 60 minutes, and as soon as possible if there is shock.
- No shock, diagnosis uncertain: rapidly investigate alternative diagnoses, but if concern for infection persists, start antimicrobials no later than three hours from initial clinical review.
- Do not wait for blood results in a patient who is clearly unwell, and do not withhold antimicrobials while awaiting microbiology.
Fluid resuscitation: at least 30 mL/kg of IV crystalloid within the first three hours for sepsis-induced hypoperfusion or septic shock, using balanced crystalloid in preference to saline. Reassess with dynamic measures and capillary refill rather than a fixed volume alone. Where vasopressors are needed, the initial mean arterial pressure target is 65 mmHg.
Antimicrobial choice is individualised to the suspected source, comorbidities and prior cultures, following local or eTG empirical regimens. Arrange infectious diseases or clinical microbiology advice if the choice is uncertain, and note that antimicrobial therapy is reviewed within 48 hours of the first dose.
Referral
In primary care, suspected sepsis means referral to hospital as soon as possible. If diagnosing or managing sepsis is outside your scope of practice, immediate referral is the correct action.
Call an ambulance, and call the receiving hospital. Notify them of the suspected sepsis diagnosis and of anything already started. Resuscitation should begin, and antimicrobials may need to be given, before transfer — including by the ambulance service.
In a smaller hospital or remote service, activate the local sepsis pathway. Any clinician can activate it. The principles are recognise, resuscitate, refer, review. Escalate immediately, involve the on-call clinician, and prioritise consultation with retrieval services early — consider transfer time when deciding what must be given before the patient leaves.
The patient should be assessed by a clinician experienced in sepsis, in person where possible or by telehealth where 24-hour critical care support is not available, and that clinician should stay involved through the first 48 hours. Patients deteriorate despite initial treatment, so response to treatment is monitored, not assumed.
After sepsis
The GP is usually the coordinator of care after discharge. Post-sepsis morbidity is substantial and under-recognised.
- Confirm the patient has, understands and can afford any ongoing antimicrobials, and knows the duration and why it matters.
- Discuss the effects on cognitive, social and emotional wellbeing — fatigue and anxiety in particular — with the patient and their family.
- Coordinate rehabilitation and allied health input, and refer Aboriginal and Torres Strait Islander patients to culturally safe services.
- Address future risk: infection prevention, the effect of their medical history on future infection risk, and keeping immunisations up to date.
Where a patient has died from sepsis, the family should be offered the chance to discuss what happened, with open disclosure and referral to support organisations such as the Australian Sepsis Network.