General MedicineTier 1Approach to a presentation

Undifferentiated presentations - fever and sepsis

Red flags

qSOFA >=2 (RR>=22, SBP<=100, altered mentation) - screens for higher mortality risk outside ICU
Lactate >2 mmol/L - now treated as actionable, not just >=4
Hypotension unresponsive to initial fluid bolus - septic shock, needs vasopressors
Non-blanching rash + fever - meningococcaemia until excluded
Neutropenic fever (temp >=38 with neutrophils <0.5) - medical emergency, antibiotics within 1h
Fever + new focal neurology - meningitis/encephalitis/abscess
Returned traveller with fever - malaria until excluded

By source (find it before broad-spectrum blind treatment)

Respiratory, urinary, intra-abdominal/biliary, skin/soft tissue, CNS, line-associated, endocarditis

Fever without an obvious source

Occult UTI/pyelonephritis, endocarditis, intra-abdominal collection, drug fever, malignancy (esp. lymphoma - Pel-Ebstein pattern), CTD flare, thyroid storm, transfusion reaction

By host

Neutropenic: gram-negatives (Pseudomonas), gram-positives (line-related) - empirical broad cover immediately
Returned traveller: malaria, dengue, typhoid, rickettsial disease
Post-splenectomy/asplenic: overwhelming pyococcal sepsis (encapsulated organisms - Strep pneumoniae, Hib, meningococcus)
IVDU: endocarditis (right-sided), epidural abscess

Non-infective mimics

Drug fever, malignancy, thyroid storm, serotonin syndrome/NMS, pulmonary embolism, pancreatitis

Onset, rigors, associated localising symptoms (cough, dysuria, abdominal pain, headache/neck stiffness)
Immunosuppression, recent hospitalisation/surgery/instrumentation, indwelling devices/lines
Travel history, animal/tick exposure, sick contacts
Comorbidities affecting physiological reserve (age, diabetes, cirrhosis, renal failure)

Full vital signs incl. RR (most sensitive early deterioration sign, often ignored)
Source hunt: chest, abdomen, skin/wounds/lines, urine, joints, meninges (neck stiffness, photophobia)
Perfusion - cap refill, mottling, urine output
Signs of endocarditis (murmur, splinters, Osler nodes/Janeway lesions) if unexplained fever + bacteraemia

Blood cultures x2 before antibiotics (but do not delay antibiotics for this if septic shock)
FBE, UEC, LFT, CRP, lactate (trend, not single value)
Urine MCS, CXR, source-directed imaging (CT abdomen/pelvis, echo if endocarditis suspected)
Coagulation profile if DIC suspected

1. Recognise and risk-stratify

qSOFA/SOFA at presentation; escalate care for septic shock (hypotension + lactate >2 despite fluids)

2. Sepsis six / hour-1 bundle

Antibiotics within 1 hour of septic shock recognition (broad-spectrum, source-directed, de-escalate on cultures)
Blood cultures before antibiotics where feasible without delay
IV fluids - individualised rather than fixed-volume; reassess with lactate clearance and dynamic markers rather than continuing to fixed lactate normalisation
Oxygen if hypoxic, source control (drain abscess, remove infected line) as soon as identified
Vasopressors (noradrenaline first-line) if fluid-refractory hypotension

3. Source-specific

De-escalate antibiotics once organism/sensitivities known
Source control is as important as antibiotics - imaging-guided or surgical drainage where indicated

Normal blood pressure does not exclude septic shock - young/compensated patients maintain BP until late, then decompensate suddenly
Lactate 2-4 mmol/L ("intermediate") is now recognised as prognostically significant, not "normal enough" to ignore
Antibiotics before cultures is correct in septic shock - do not delay treatment chasing perfect specimens
Neutropenic fever needs antibiotics within the hour regardless of how well the patient looks
A single normal-looking observation set does not exclude evolving sepsis - trend, don't snapshot

1. Screen fast, treat faster

"qSOFA and lactate guide my urgency; septic shock gets antibiotics within the hour."

2. Source control matters as much as the antibiotic

"I'm always asking what needs to be drained or removed, not just what needs to be covered."

3. Trend the lactate, don't chase a single number

"An intermediate lactate that isn't clearing is still telling me something important."

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