If septic, start the Sepsis Six within 1 hour: antibiotics and fluids without delay after cultures. Escalate to senior or critical care if lactate above 2 persists or blood pressure does not respond.
Severity: CURB-65 (1 point each)
- Confusion (new; AMT 8 or less)
- Urea above 7 mmol/L
- Respiratory rate 30 or more
- BP: systolic below 90 or diastolic 60 or less
- Age 65 or older
Empirical antibiotics (check local policy)
- CURB 0 to 1: amoxicillin oral (doxycycline or clarithromycin if penicillin allergic)
- CURB 2: amoxicillin plus a macrolide
- CURB 3 to 5: co-amoxiclav (or a cephalosporin) plus a macrolide, IV; discuss critical care
- Review and de-escalate on cultures at 48 to 72 h
CURB-65 0 to 1 (low)
- About 1 to 3% mortality
- Often suitable for home or short stay
- Oral antibiotics
CURB-65 2 (moderate)
- About 9% mortality
- Admit or hospital-supervised care
- Dual antibiotics, review oxygen
CURB-65 3 to 5 (high)
- 15 to 40% mortality
- Severe: assess for critical care
- IV antibiotics within 1 h if septic
Sepsis Six within 1 hour (if septic)
1
1. Take bloods
Blood cultures (before antibiotics if no delay), lactate, FBC, U&E, CRP, glucose. Chest X-ray.
Blood cultures (before antibiotics if no delay), lactate, FBC, U&E, CRP, glucose. Chest X-ray.
↓
2
2. Give oxygen and antibiotics
Oxygen to target saturations (94 to 98%, or 88 to 92% if COPD risk). IV broad-spectrum antibiotics per local policy.
Oxygen to target saturations (94 to 98%, or 88 to 92% if COPD risk). IV broad-spectrum antibiotics per local policy.
↓
3
3. Give fluids
500 mL crystalloid bolus over 15 min if hypotensive or lactate above 2; reassess and repeat. Care in frailty and heart failure.
500 mL crystalloid bolus over 15 min if hypotensive or lactate above 2; reassess and repeat. Care in frailty and heart failure.
↓
4
4. Monitor and escalate
Urine output, repeat lactate, NEWS2. Escalate to senior or critical care if not responding or lactate above 4.
Urine output, repeat lactate, NEWS2. Escalate to senior or critical care if not responding or lactate above 4.
Source and extra cover
- Drain a parapneumonic effusion or empyema
- Legionella and pneumococcal urinary antigen if severe
- Cover Pseudomonas if severe COPD or bronchiectasis
- Test and treat flu or COVID if suspected
Pitfalls
- Delaying antibiotics in sepsis
- Over-filling frail or heart failure patients
- Missing aspiration or TB risk
- Not reviewing or de-escalating at 48 to 72 h
MedPrep - www.medprep.uk - Educational revision aid only. Not clinical guidance. Doses are adult examples; check the BNF, current guidelines and local policy, and seek senior advice. Nov 2026