Suspected sepsis in people aged 16 or over: recognition, assessment and early management

What this guideline says

GMJ summary

This NICE guideline (NG253, November 2025, updated September 2026) provides comprehensive recommendations for recognising, assessing and managing suspected sepsis in people aged 16 or over across community, custodial, ambulance, acute hospital and acute mental health settings. It introduces a risk-stratification framework based on the National Early Warning Score 2 (NEWS2) in acute settings, with four risk bands: very low (NEWS2=0), low (1–4), medium (5–6) and high (≥7), each linked to specific timeframes for clinical review and antibiotic administration.

Key interventions include: broad-spectrum intravenous antibiotics within 1 hour for high-risk patients (NEWS2 ≥7), within 3 hours for medium-risk (NEWS2 5–6), and within 6 hours for low-risk (NEWS2 1–4); intravenous fluid resuscitation with isotonic crystalloids in 250 ml boluses (up to 1,000 ml total) for high-risk patients; and escalation pathways involving clinicians with core competencies in acute care (FY2 or above). The guideline emphasises clinical judgement when interpreting NEWS2 scores, particularly for patients with single parameters contributing 3 points, baseline physiological variations, or signs such as mottled/ashen appearance or non-blanching rash.

The 2026 update adds procalcitonin testing as a consideration for medium- and high-risk patients where results are available within an acceptable timeframe. The guideline also addresses antimicrobial stewardship by recommending deferral of broad-spectrum antibiotics in lower-risk groups to allow time for source identification, transfer arrangements for remote/rural settings where combined transfer and handover times exceed 1 hour, and specific management for neutropenic sepsis. Information and support recommendations emphasise shared decision-making, safety-netting advice at discharge, and awareness of groups most vulnerable to sepsis including people aged ≥75, those from ethnic minorities, people with frailty, immunosuppression, communication challenges, or social deprivation.

Key points

For clinicians — doses and thresholds as stated in the guideline

1. Use NEWS2 score to stratify risk in acute hospital, mental health and ambulance settings: very low (0), low (1–4), medium (5–6), high (≥7); recalculate every 30 min (high risk), hourly (medium), 4–6 hourly (low), or per local protocol (very low).
2. Give intravenous broad-spectrum antibiotics within 1 hour (high risk), 3 hours (medium risk), or 6 hours (low risk) of first NEWS2 score on initial emergency department assessment or ward deterioration; do not delay once decision to give is made.
3. In community/custodial settings, use table 1 criteria: high-risk includes objective altered mental state, respiratory rate ≥25/min, systolic BP ≤90 mmHg or >40 mmHg below normal, heart rate >130/min, no urine in 18 hours, mottled/ashen/cyanotic appearance, or non-blanching rash; medium-risk includes respiratory rate 21–24/min, systolic BP 91–100 mmHg, heart rate 91–130/min, no urine 12–18 hours, tympanic temperature <36°C, or signs of surgical site infection.
4. Give intravenous fluid bolus of 250 ml isotonic crystalloid (Hartmann's or 0.9% saline) over 10–15 minutes to high-risk patients; reassess after each bolus; give further 250 ml boluses up to 1,000 ml total; seek senior advice if no improvement after 1,000 ml.
5. For medium-risk patients with lactate >2 mmol/litre or acute kidney injury, manage as high risk; consider fluids after clinical assessment for medium-risk patients without hypoperfusion.
6. Consider procalcitonin testing for medium- and high-risk patients where results are available within an acceptable timeframe to assist clinical decision-making.
7. Transfer immediately to acute hospital if high-risk criteria met in community/custodial settings (999 ambulance); pre-alert secondary care; in remote/rural areas where combined transfer and handover >1 hour, GPs should have mechanisms to give antibiotics pre-hospital.
8. Escalate to senior clinical decision maker if high-risk patient does not respond within 1 hour of any intervention; refer to or discuss with critical care; inform responsible consultant; for medium-risk patients arrange clinician with core competencies (FY2+) review within 1 hour; escalate if deterioration or no improvement.

Criteria for stratification of risk of severe illness or death from sepsis in people aged 16 or above in community or custodial settings (Table 1)

Table extracted from the guideline

Source: National Institute for Health and Care Excellence (UK), Suspected sepsis in people aged 16 or over: recognition, assessment and early management. Reproduced in summary form.

What changed in this edition

Versus the previous edition

• September 2026: added recommendations on considering procalcitonin testing for medium- and high-risk patients (1.8.2, 1.8.16); aligned risk-level labelling with NEWS2 terminology.
• January 2026: amended terminology from 'learning difficulties' to 'learning disabilities' throughout.
• November 2025: split the all-age sepsis guideline into three separate guidelines (under 16s, 16 and over, pregnant/recently pregnant); reviewed evidence on rapid antigen/PCR testing, indicators of organ hypoperfusion, intravenous fluid therapy, vasopressors, and sepsis risk factors; updated fluid bolus volume from 500 ml to 250 ml; removed human albumin solution from initial resuscitation; added recommendation on recent multiple presentations (1.3.6); clarified escalation criteria and timeframes; updated risk factor categorisation (1.2.1); amended mental health setting recommendations for clarity on facilities and expertise.
• 2024 update: introduced NEWS2-based risk stratification in acute settings (replacing previous lactate-based criteria); adopted AoMRC 2022 statement on antibiotic timing (1, 3, 6 hours by risk level); expanded surgical source control to include radiological interventions; amended neutropenic sepsis definition to include immunosuppressant therapy; clarified time zero as first NEWS2 on ED assessment or ward deterioration; added recommendations on peripheral vasopressor administration; updated escalation pathways to clinicians with core competencies (FY2+); removed discharge recommendations for medium/low-risk during initial management period.

From the guideline

Verbatim

“Give people aged 16 or over who are at high risk of severe illness or death from sepsis broad-spectrum intravenous antibiotic treatment, within 1 hour of calculating the person's NEWS2 score on initial assessment in the emergency department or on ward deterioration.”

Editor’s perspective

Why this matters for Georgia and the region

Applicability

Georgia and the South Caucasus

Questions this guideline answers

Quick answers

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