Suspected sepsis on the ward (adult)
Adult inpatient with suspected infection and new deterioration.
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Internal MedicineEmergency
Sepsis Recognition and Initial Ward Management (SSC 2026)
Sepsis Recognition and Initial Ward Management (SSC 2026): Suspected sepsis on the ward (adult) → Check first: child, pregnancy, neutropenia, meningitis...
Pathway Overview
18 steps
Algorithm Steps
18 total
01Start 02Warning Check first: child, pregnancy, neutropenia, meningitis, necrotising infection
These patients need a different pathway or faster action.
- Child, or pregnant or recently pregnant: use the paediatric or maternal sepsis pathway
- Neutropenia or on chemotherapy: antibiotics within 30 min (febrile neutropenia regimen)
- Suspected meningitis or necrotising fasciitis: special regimen (special infections step); emergency surgery for necrotising fasciitis
03Action Screen and recognise sepsis
Screen with NEWS2, MEWS, SIRS or your local tool. Do not use qSOFA as the only screen.
- SIRS (2 or more): temp above 38 or below 36 °C; HR above 90/min; RR above 20/min; WCC above 12 or below 4 x10^9/L
- Sepsis: infection plus new organ dysfunction (acute SOFA rise of 2 or more)
- Septic shock: vasopressor needed for MAP 65 mmHg or more, and lactate above 2 mmol/L, despite adequate fluids
- No single test rules sepsis in or out. Beta-blockers or a pacemaker can hide a raised HR
- Call for senior review, or a rapid response call if criteria are met
04Action Start now: first-hour actions
Sepsis is an emergency. Do all of these in parallel. Do not wait for results.
- Hypotensive or lactate raised: start a 500 mL IV fluid bolus now; smaller boluses in heart failure or dialysis (see fluid step)
- Two sets of blood cultures before antibiotics, if this does not delay them
- Measure lactate (venous is acceptable) and capillary refill time
- On long-term corticosteroids or known adrenal insufficiency: hydrocortisone 100 mg IV now, then 50 mg IV 6-hourly
- Bloods: FBC, UEC, LFTs, coagulation, glucose; samples from the likely source
- Oxygen if needed: SpO2 92–96% (88–92% if at risk of CO2 retention)
- Review goals of care and advance care plan; discuss with the patient and family
05Action IV antibiotics: within 1 h if shock or probable sepsis
Check penicillin allergy first. Follow local antimicrobial policy. Regimens below are Australian (Therapeutic Guidelines-based), adult, CrCl above 50 mL/min.
- Shock, or probable or definite sepsis: give immediately, ideally within 1 h
- Possible sepsis without shock: rapid assessment; if infection is still likely, give within 3 h
- Unknown source: gentamicin IV PLUS flucloxacillin 2 g IV 4-hourly
- Non-severe penicillin allergy (e.g. rash): cefazolin 2 g IV 6-hourly in place of flucloxacillin
- Severe penicillin allergy (anaphylaxis, or severe skin reaction such as SJS/TEN or DRESS): vancomycin IV in place of flucloxacillin
- Gentamicin contraindicated (e.g. myasthenia gravis, past aminoglycoside ototoxicity): use local policy or ID advice
- Add vancomycin IV if MRSA is suspected or if septic shock
- High risk of multidrug-resistant organism: meropenem 1 g IV 8-hourly PLUS vancomycin IV
- Known source, neutropenia, meningitis or necrotising fasciitis: use the source-specific regimen (special infections step, Therapeutic Guidelines or local policy)
- Beta-lactams: give by prolonged infusion after the loading dose
06Action Antibiotic doses: gentamicin and vancomycin (adult)
Renal impairment: gentamicin as a single dose only if CrCl below 40 mL/min; adjust other doses.
- Gentamicin: 4–5 mg/kg IV once (ideal or adjusted body weight); up to 7 mg/kg in septic shock
- Vancomycin: load 25–30 mg/kg IV (max 2.5 g), then 15–20 mg/kg (max 2 g) IV 12-hourly; actual body weight
- Review empirical gentamicin and all empirical therapy by 48 h
07Action Special infections: neutropenia, meningitis, necrotising fasciitis (adult)
Check penicillin allergy first. Do not delay antibiotics for tests. Doses for CrCl above 50 mL/min.
- Febrile neutropenia: piperacillin-tazobactam 4.5 g IV 6-hourly, within 30 min
- Neutropenia and penicillin allergy: non-severe, cefepime 2 g IV 8-hourly; anaphylaxis, meropenem 1 g IV 8-hourly; SJS/TEN or DRESS, expert advice
- Neutropenia with septic shock: consider adding gentamicin; MDRO risk: meropenem 1 g IV 8-hourly instead
- Meningitis: ceftriaxone 2 g IV 12-hourly PLUS dexamethasone 10 mg IV 6-hourly for 4 days, first dose before or with the antibiotic
- Meningitis with Listeria risk (immunocompromised, over 50 years, alcohol misuse, pregnant): add benzylpenicillin 2.4 g IV 4-hourly
- Meningitis: add vancomycin IV if otitis, sinusitis, recent beta-lactam or LP not possible; add aciclovir IV if encephalitis is possible
- Meningitis and life-threatening penicillin allergy: moxifloxacin 400 mg IV 24-hourly; ID advice for Listeria cover
- Necrotising fasciitis (any allergy status): meropenem 1 g IV 8-hourly PLUS vancomycin IV PLUS clindamycin 600 mg IV 8-hourly; emergency surgery
08Decision Hypotension or raised lactate?
SBP below 90 mmHg or MAP below 65 mmHg, or lactate above 2 mmol/L.
- If Yes
09Action Hypotension or raised lactate: IV fluid boluses
Balanced crystalloid (e.g. Hartmann's). Heart failure, dialysis or fluid overload: smaller boluses and early ICU review.
- Give a 500 mL bolus rapidly; reassess after each bolus
- Hypotension or lactate 4 mmol/L or more: at least 30 mL/kg within the first 3 h, if tolerated
- BMI above 30 kg/m2: use adjusted or ideal body weight for mL/kg
- Do not run antibiotics in the same line as Hartmann's; flush before and after
- Do not use starches or gelatin
10Action After fluids: reassess response
Decide on more fluid by response, not by a fixed volume.
- Check BP, HR, RR, mental state, capillary refill and urine output (aim 0.5 mL/kg/h or more)
- Lactate raised: repeat within 2 h; aim for a fall, not normalisation
- Use dynamic tests (e.g. passive leg raise) where available
- Signs of fluid overload (crackles, rising oxygen need): stop fluids
11Decision Still hypotensive after fluids?
MAP below 65 mmHg despite initial fluids. If not: continue reassessment and close monitoring.
- If Yes
12Action Persistent hypotension (septic shock): noradrenaline, ICU now
Emergency ICU review. Noradrenaline is first line. Unstable shock: start it with fluids, not after.
- Start noradrenaline via a peripheral line if needed; do not wait for a central line
- Target MAP 65 mmHg (60–65 mmHg if aged 65 years or over)
- Noradrenaline dose rising: add vasopressin; then adrenaline if MAP still low (ICU)
- Ongoing need: hydrocortisone 50 mg IV 6-hourly when noradrenaline is 0.25 microgram/kg/min or more for at least 4 h
- Doses and dilutions: local ICU protocol
13Action Find and control the source
All patients. Source control ideally within 6 h of diagnosis. Necrotising soft tissue infection: emergency surgery now.
- Examine, then image by likely source (e.g. chest X-ray, urine, CT abdomen)
- Drain abscesses; debride infected tissue
- Remove infected lines and devices
- Early surgical, radiology and infectious diseases input
14Decision Needs ICU?
Vasopressors, ventilation or high oxygen need, severe organ failure, or deterioration despite treatment.
- If Yes
15Action Needs ICU: admit within 6 h
Refer to ICU now. Hand over sepsis timings and treatment given.
16Outcome Daily review: de-escalate and plan
Reassess the diagnosis and antibiotics every day.
- Other cause found: stop empirical antibiotics
- Cultures and susceptibilities back: narrow or stop antibiotics
- Source controlled: shorter courses are preferred
- Discuss goals of care within 72 h
If No17Action Stays on ward: senior plan and escalation criteria
Document the escalation plan and observation frequency.
- Clear escalation criteria and senior review
- Repeat lactate and observations as above
- Early warning score rising: escalate
- Path rejoins step 16Shared downstream outcome
If No- Path rejoins step 13Shared downstream outcome
If No18Action No hypotension, lactate 2 mmol/L or less: close monitoring
Treat the infection and watch for deterioration.
- Observations every 30 min for 2 h, then hourly for at least 4 h
- Escalate if RR rises, SBP below 100 mmHg, urine output below 0.5 mL/kg/h or consciousness falls
- If hypotension develops or lactate rises: go to fluid boluses and reassess
- Path rejoins step 13Shared downstream outcome
Guideline Source
Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2026
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Adults only. Not for children or pregnancy: use paediatric or maternal sepsis pathways.
- Antibiotic regimens are Australian adult doses for CrCl above 50 mL/min; follow local antimicrobial policy and adjust for renal function.
- Fluid volumes must be individualised (heart failure, dialysis, frailty).
- Lactate can rise for non-infective reasons; interpret it in context.
Contraindicated Populations
pediatricneonatal
Applicable Regions
AUUSEU
AU: Empirical antibiotics follow the Safer Care Victoria Adult Sepsis Pathway (Jan 2025), adapted from Therapeutic Guidelines: Antibiotic. Check the current eTG and local policy. ACSQHC Sepsis Clinical Care Standard applies. eTG (March 2025) allows less frequent flucloxacillin and cefazolin dosing in sepsis without shock or ICU need; the more frequent doses shown suit shock.
EU: Antibiotic regimens shown are Australian. Use your national and local antimicrobial policy.
US: Antibiotic regimens shown are Australian. Use your local antimicrobial policy and antibiogram.
Version 2Next review: 2027-09-30
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Related Resources
Frequently Asked Questions
What is the Sepsis Recognition and Initial Ward Management (SSC 2026)?
The Sepsis Recognition and Initial Ward Management (SSC 2026) is a emergency clinical algorithm for Internal Medicine. It provides a structured decision tree to guide clinical decision-making, based on Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2026.
What guideline is the Sepsis Recognition and Initial Ward Management (SSC 2026) based on?
This algorithm is based on Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2026 (DOI: 10.1097/CCM.0000000000007075).
What are the limitations of the Sepsis Recognition and Initial Ward Management (SSC 2026)?
Known limitations include: Adults only. Not for children or pregnancy: use paediatric or maternal sepsis pathways.; Antibiotic regimens are Australian adult doses for CrCl above 50 mL/min; follow local antimicrobial policy and adjust for renal function.; Fluid volumes must be individualised (heart failure, dialysis, frailty).; Lactate can rise for non-infective reasons; interpret it in context.. Individual patient factors may require deviation from these recommendations.
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