---
title: Sepsis Recognition and Bundles
description: A comprehensive clinical reference on the diagnosis, risk assessment, and evidence-based management of sepsis.
keywords: [sepsis, septic shock, SIRS, qSOFA, SOFA, antibiotics, vasopressors, fluid resuscitation]
category: clinical
---

## Sepsis Definition and Diagnostic Criteria

Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection. The updated Sepsis-3 definition requires the presence of an infection plus an increase in the Sequential Organ Failure Assessment (SOFA) score of 2 points or more. Septic shock is a subset of sepsis in which the underlying circulatory, cellular, and metabolic abnormalities are profound enough to substantially increase mortality.

The systemic inflammatory response syndrome (SIRS) criteria, which include fever/hypothermia, tachycardia, tachypnea, and abnormal white blood cell count, are no longer recommended for sepsis diagnosis. Instead, the quick SOFA (qSOFA) score, which assesses respiratory rate, mental status, and systolic blood pressure, can be used to identify patients at high risk of poor outcomes. A qSOFA score of 2 or more should prompt further evaluation for organ dysfunction.

## Risk Factors and Clinical Presentation

Sepsis can occur in response to bacterial, viral, fungal, or parasitic infections. Common risk factors include advanced age, immunosuppression, indwelling devices, recent surgery, and chronic medical conditions such as diabetes, liver disease, and end-stage renal disease. Symptoms may include fever, chills, hypotension, tachycardia, altered mental status, and signs of organ dysfunction (e.g., oliguria, hypoxemia, elevated lactate).

Initial laboratory evaluation should include complete blood count, comprehensive metabolic panel, lactate, and cultures (blood, urine, respiratory, and other sites as clinically indicated). Imaging studies may be necessary to identify the source of infection. Procalcitonin can be used as an adjunct to support the diagnosis of sepsis, particularly in distinguishing bacterial from viral infections.

## Sepsis Risk Stratification

The SOFA score is used to assess the degree of organ dysfunction in sepsis. A SOFA score of 2 or more indicates organ dysfunction, and a score of 4 or more is associated with a mortality risk of approximately 30%. The quick SOFA (qSOFA) score, which includes respiratory rate, systolic blood pressure, and altered mental status, can be used as a rapid bedside tool to identify patients at high risk of poor outcomes.

Other risk stratification tools include the Sepsis-related Organ Failure Assessment (SIRS) criteria, the Confusion, Urea, Respiratory rate, Blood pressure, and Age ≥65 (CURB-65) score for pneumonia, and the Wells score for suspected pulmonary embolism. These tools can help guide the intensity of monitoring and management.

## Sepsis Management Bundles

The Surviving Sepsis Campaign recommends the following evidence-based sepsis management bundles:

1. **Initial Resuscitation Bundle** (to be completed within 3 hours):
   - Measure lactate level
   - Obtain blood cultures prior to antibiotic administration
   - Administer broad-spectrum antibiotics
   - Provide 30 mL/kg crystalloid for hypotension or lactate ≥4 mmol/L

2. **Sepsis Management Bundle** (to be completed within 6 hours):
   - Reassess volume status and tissue perfusion
   - Apply vasopressors if hypotensive during or after fluid resuscitation to maintain MAP ≥65 mmHg
   - Remeasure lactate if initial lactate was elevated

3. **Ongoing Care Bundle** (to be completed within 12 hours):
   - Monitor urine output
   - Maintain glucose control (target 140-180 mg/dL)
   - Perform intermittent or continuous renal replacement therapy if indicated
   - Provide low-dose corticosteroids for septic shock if adequate fluid resuscitation and vasopressors are unable to restore hemodynamic stability

Adherence to these bundles has been associated with improved patient outcomes. Appropriate antibiotic selection, based on the suspected source of infection and local resistance patterns, is crucial. Broad-spectrum antibiotics should be initiated promptly, and de-escalation to more targeted therapy should occur when culture results become available.

## Fluid Resuscitation and Vasopressor Management

Aggressive fluid resuscitation is a key initial intervention for patients with sepsis-induced hypoperfusion. Crystalloids, such as normal saline or Ringer's lactate, are the preferred first-line fluids. The initial fluid challenge should be 30 mL/kg of crystalloid administered over the first 3 hours.

If hypotension persists despite adequate fluid resuscitation, vasopressor therapy should be initiated. Norepinephrine is the first-line vasopressor of choice, with a target mean arterial pressure (MAP) of 65 mmHg or higher. Vasopressin can be added as a second-line agent, and dobutamine may be considered in patients with evidence of myocardial dysfunction.

Fluid administration should be guided by dynamic measures of fluid responsiveness, such as passive leg raise or fluid challenge tests, to avoid over-resuscitation. Fluid management should be titrated to maintain adequate organ perfusion while avoiding fluid overload, which can lead to complications such as acute respiratory distress syndrome (ARDS).

## Adjunctive Therapies and Supportive Care

In addition to antimicrobial therapy and hemodynamic support, various adjunctive therapies may be considered in the management of sepsis:

- Corticosteroids: Low-dose hydrocortisone (200 mg/day) may be used in patients with septic shock who require vasopressor support despite adequate fluid resuscitation.
- Activated protein C: The use of recombinant human activated protein C (drotrecogin alfa) is no longer recommended due to lack of proven benefit and increased bleeding risk.
- Immunomodulatory therapies: The use of intravenous immunoglobulin (IVIG) or granulocyte colony-stimulating factor (G-CSF) is not routinely recommended.
- Supportive care: Mechanical ventilation, renal replacement therapy, and glucose control are important components of comprehensive sepsis management.

Continuous monitoring of the patient's clinical status, hemodynamics, and organ function is essential. Close collaboration between critical care providers, infectious disease specialists, and other multidisciplinary team members is crucial for optimizing sepsis management and improving patient outcomes.