Recommendation 11: The management of the deteriorating adult patient with a suspicion of sepsis within the emergency department and hospital setting should be based on the National Early Warning Score 2 (NEWS2).

The clinical decision support framework developed by AoMRC should be used. The framework provides a severity score based on NEWS2 bands of 0, 1–4, 5–6 and ≥7. This severity score should be interpreted in the light of clinical assessment, rapidity of deterioration, likely diagnosis, immune status and evidence of organ dysfunction.

At time zero, defined as the time of the first NEWS2 assessment on presentation to the emergency department or ward deterioration, the administration of appropriate antimicrobials should be completed within:

• 6 hours of recording a NEWS2 score of 1–4 for patients with possible infection
• 3 hours of recording a NEWS2 score of 5–6 for patients with probable infection, or
• 1 hour of recording a NEWS2 score ≥7 for patients with definite infection.

Consult local antimicrobial policy for empirical therapy.

The Academy of Medical Royal Colleges (AoMRC) 2022 ‘Statement on the initial antimicrobial treatment of sepsis’¹⁷ – endorsed by a wide range of national stakeholders, including the Scottish Antimicrobial Prescribing Group and the Scottish Intensive Care Society and with a number of Scottish representatives in the working group – includes all the available studies on timing of antimicrobials. The paper relates to adult patients presenting with sepsis and septic shock in the emergency department or hospital setting. The AoMRC working group unanimously agreed on changing the timing of the first administration of antimicrobials in the context of sepsis, basing the urgency of treatment on an assessment of illness severity using vital signs summarised where possible by NEWS2 scores. This may affect how the Sepsis Six clinical care bundle is delivered.

The change in timing of initial antimicrobial has the advantages of treating infections based on severity of illness, reducing antimicrobial consumption in those patients who present with a sepsis-like illness but in whom further investigations reveal another primary diagnosis, reducing the use of broad-spectrum antimicrobials and increasing the use of targeted antimicrobials in patients who present with sepsis. Patients who are acutely unwell with septic shock or sepsis with multiorgan failure will still receive timely antimicrobials. The evidence shows that timely antimicrobials related to NEWS scores does not increase mortality or adversely affect outcomes. Economically, the reduced use of broad-spectrum antimicrobials, as well as judicious use of these in stable patients, should result in a reduction in total antimicrobial usage for patients presenting with sepsis in hospital or emergency department. There will, however, be some patients with sepsis who will not show signs of severe illness and who could be disadvantaged in not receiving appropriate timely antimicrobials.

In patients who are documented to be actively dying, the advent of sepsis may be a terminal event and intervention has the potential to be of low benefit or harmful. Decisions for not treating will need to be documented in the medical notes and TEP.

This stratification for the timing of initial antimicrobial based on NEWS2 will allow the prescriber to have more diagnostic information on which to base the choice of antimicrobial so as to target the organism(s) most likely involved.

Good practice point 2: The AoMRC clinical decision support framework should be extended to such instances when the right monitoring of antimicrobials is available within community or primary care.

There is no robust evidence to guide the use of the AoMRC approach within the community or in primary care.