Sepsis Recognition: The Unwell Patient with Infection
How to tell when a patient presenting with infection may be developing sepsis, and when to seek urgent medical help without delay.
Why this matters
Sepsis is a major cause of preventable death and serious illness in the UK. It is not an infection itself but a life-threatening condition in which the body's response to infection begins to damage its own tissues and organs. Community pharmacists are often the first healthcare contact for someone who feels unwell with an infection, and recognising deterioration early can be critical.
Sepsis does not always follow the expected pattern. It can occur with a high temperature, a low temperature, or sometimes a normal temperature, particularly in older adults and immunocompromised patients. Rigors (episodes of severe uncontrollable shaking chills) can be an early marker of significant systemic infection. A patient who appears far more unwell than their reported symptoms would suggest should prompt concern regardless of whether all classic features are present.
People at particularly high risk include older adults, pregnant women, people with poorly controlled diabetes, those recently discharged from hospital, and those whose immune system is suppressed. This includes patients receiving chemotherapy, certain biological medicines that suppress immune function, such as TNF inhibitors, long-term corticosteroids, transplant recipients, and people without a functioning spleen (including those who have had a splenectomy). These patients can deteriorate rapidly and should be assessed promptly even when symptoms initially appear mild.
Community pharmacists do not need to diagnose sepsis. The role is to recognise when a patient with infection appears significantly unwell, identify red flags, and arrange urgent medical assessment without delay. Sepsis is not diagnosed in pharmacy: it is recognised and escalated.
Red flags vs more likely benign
| Feature | More likely benign | Red flag ⚠ |
|---|---|---|
| Temperature | Mild fever with otherwise reassuring features | Very high or abnormally low temperature, especially alongside other signs of serious illness. A normal temperature does not exclude sepsis, particularly in older adults and immunocompromised patients |
| Heart rate | Mild increase during illness | Persistent or unexplained tachycardia: palpitations, racing heart, or a heartbeat that remains markedly fast beyond what would be expected for the degree of fever |
| Breathing | Normal rate and effort | Fast, laboured, shallow breathing, or difficulty speaking in full sentences |
| Mental state | Alert and orientated | New confusion, drowsiness, difficulty staying awake, agitation, unusual behaviour, or reduced responsiveness |
| Rigors | Mild shivering with fever | Severe uncontrollable shaking chills: a potentially important marker of significant systemic infection |
| Skin appearance | Warm and well perfused | Mottled, pale, blue-tinged, cold, or clammy skin |
| Urine output | Normal | Passing significantly less urine than normal, or not passing urine for many hours |
| Overall appearance | Unwell but communicating and functioning | Appears seriously unwell or is deteriorating rapidly, particularly if this seems out of proportion to reported symptoms |
| Rash | None, or blanching viral rash | Non-blanching rash anywhere on the body |
If observations are available
Abnormal observations can support concern for sepsis. Particular concern should be raised by:
- Elevated or noticeably increasing respiratory rate (above 20 breaths per minute is a broadly used threshold, but rate of change and increased effort matter more than any single number)
- Oxygen saturation below the patient's normal level, or below 95% where baseline is unknown
- Systolic blood pressure below 100 mmHg
- Persistent or unexplained tachycardia, particularly when accompanied by other abnormal observations
- Temperature above 38°C or below 36°C (a normal temperature does not exclude sepsis)
- New confusion, drowsiness, or reduced responsiveness
The presence of multiple abnormal observations in a patient with suspected infection should prompt urgent escalation. NEWS2 may support assessment where used locally, but must never replace clinical judgement. If clinical concern remains high despite the absence of classic red flags, arrange urgent medical assessment. Trust your instinct: a patient who appears significantly more unwell than expected should be escalated even if observations are not markedly abnormal.
🛑 SEPSIS: Pharmacy Recognition Framework
Use this framework when a patient with infection appears more than mildly unwell.
Looks much worse than expected. Trust your instinct: appearance before observations.
Confusion, difficulty staying awake, reduced urine output, or breathlessness at rest.
Persistent tachycardia, low blood pressure, elevated or increasing respiratory rate, or rigors.
Mottled, pale, blue-tinged, or clammy skin. Non-blanching rash anywhere on the body.
High-risk group: older adult, immunocompromised, pregnant, recent surgery, recent hospital discharge, or invasive device.
999 if critically unwell. Same-day GP or 111 if concerning but stable. Do not leave the patient alone while awaiting help.
Key Questions to Ask
The following questions help assess severity and identify high-risk patients. Any concerning answer should lower the threshold for urgent escalation.
- How long have symptoms been worsening? Rapid deterioration over hours is more concerning than gradual progression over days.
- Are they drinking fluids and passing urine normally? Not passing urine for many hours suggests possible organ involvement.
- Any new confusion, difficulty staying awake, or unusual behaviour?
- Any severe shaking chills (rigors)?
- Any breathlessness at rest or difficulty speaking in full sentences?
- Recent surgery, hospital admission, or an invasive device such as a urinary catheter?
- Are they taking immunosuppressant medicines, chemotherapy, biological therapies, or long-term steroids?
- Are they pregnant?
Trust your instinct. If a patient appears significantly more unwell than expected for a routine infection, arrange urgent assessment even if classic sepsis features are not yet obvious.
What to do in pharmacy
Key takeaways
- Sepsis is not diagnosed in pharmacy: it is recognised and escalated. If a patient with infection appears seriously unwell, arrange urgent assessment without delay.
- Confusion, rigors, rapid breathing, mottled skin, reduced urine output, or a non-blanching rash alongside infection are important warning signs. Sepsis can occur at a normal temperature, particularly in older adults and immunocompromised patients.
- Trust your instinct. A patient who appears significantly more unwell than expected should be escalated even if individual observations are not markedly abnormal. Clinical judgement always overrides a number.
- High-risk groups include older adults, immunocompromised patients (chemotherapy, biologics, steroids, transplant, splenectomy), pregnant women, those with poorly controlled diabetes, and those recently discharged from hospital.