Re: Suspected sepsis: summary of NICE guidance
NICE Guideline 51 addresses identification, risk assessment and immediate management of people with suspected sepsis. It was not commissioned to replace other NICE guidance of specific conditions nor to be a textbook of infectious diseases. In the absence of definitive biomarkers to diagnose sepsis and in the face of many non-specific symptoms, the NICE guideline provides a pragmatic approach to identification, risk assessment and management of suspected sepsis, recognising that at any stage other conditions may be diagnosed and more appropriate management pathways followed.
In relation to the specific scenarios described by Eisenhut:
a) the situation of a specific infection (encephalitis) that would not necessarily be recognised as sepsis should be treated according to the best care pathway for that condition. Any child or adult with symptoms or signs suggestive of encephalitis, but not meeting any high risk sepsis criteria, should be managed with appropriate investigations and treatments. For children under 5 years old, the NICE feverish illness guideline (CG160) can be followed once high risk sepsis is not identified, or for children of any age if encephalitis is strongly suspected then the national best practice consensus guideline Eisenhut references should be used.
b) Lactate was not found by the NICE GDG or others (1) to strongly correlate to the risk of mortality. This is why the NICE guideline uses lactate to guide the immediacy of fluid therapy delivery and further referral rather than being used as an independent risk factor per se. Eisenhut is therefore incorrect in stating that “probably more than 30% of patients with bacteremia would have been missed if a cut-off of 2 mmol/l of lactate was applied” as the NICE guideline does not use lactate as part of the risk assessment.
c) The NICE guideline clearly states that immediate antibiotics should be given where one high risk criterion is present alongside the clinical suspicion of sepsis. This includes cases of UTI, or any suspected infection, where poor peripheral perfusion (evidenced by parameters including heart rate or respiratory rate above the thresholds outlined in the NICE guidance) suggests a high risk of mortality due to sepsis. Rigors themselves were not considered by the GDG to be an independent indicator of risk but are certainly part of the assessment leading to a suspicion of infection. To avoid over-treatment with antibiotics, the guideline allows de-escalation to specific care pathways for identified specific infections. However, non-specific symptoms in the context of one definite high risk criterion and no alternative diagnosis should certainly lead to immediate antibiotic therapy.
(1) Singer M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane D, Bauer M, Bellomo R, Bernard GR, Chiche JD, Coopersmith CM,Hotchkiss RS, Levy MM, Marshall JC, Martin GS, Opal SM, Rubenfeld GD, van der Poll T, Vincent JL, Angus DC. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016 Feb 23;315(8):801-10. doi: 10.1001/jama.2016.0287.
Saul Faust, University of Southampton
Norma O’Flynn, National Guideline Centre
Caroline Keir, National Institute for Health and Care Excellence
Martin Allaby National Institute for Health and Care Excellence
Competing interests: No competing interests