MICA · FIRST-LINE LEARNING NOTES
Understand, prioritise and organise follow-up
Assess acute infection through the likely source, severity, background risks and trajectory; fever and biomarkers alone are insufficient.
Detect infection with organ compromise
Look for new confusion, breathlessness, poor perfusion, hypotension, reduced urine output or rapid deterioration. Sepsis can occur without fever, particularly in older or immunocompromised adults. Ask about chemotherapy, immunosuppression, recent procedures, invasive devices and previous resistant infection. Suspected febrile neutropenia or meningitis needs a specific urgent pathway. Clinical judgement remains essential even when a severity score appears low.
[1][2]Connect source, patient factors and tests
Document timing, respiratory, urinary, gastrointestinal, skin or neurological symptoms, and relevant travel or exposures. Obtain complete vital signs and examine for a source. Tailor microbiology, laboratory testing and imaging to the hypothesis and severity rather than ordering indiscriminately. In suspected pneumonia, clinical impact and comorbidities inform referral; confirmation and monitoring depend on the care setting.
[3][2]An infectious focus must fit the examination and clinical course. Distinguish microbiological confirmation from colonisation and contamination; a positive culture does not automatically explain every symptom. In respiratory infection, reassess respiratory rate, oxygenation, blood pressure and fluid intake. Severity scores supplement judgement without replacing assessment for organ failure or barriers to follow-up.
[3][2]Combine timely treatment and antimicrobial stewardship
Probable sepsis, shock or other severe features requires immediate hospital referral and appropriate treatment without awaiting all results. Obtain useful samples early when this does not delay urgent care. Outside severe illness, assess bacterial probability and competing diagnoses before prescribing. Antibiotic choice depends on source, allergies, renal function and local resistance; some sources require a specialist procedure for control.
[4][2]- Look for an infection requiring drainage or another intervention rather than only a change in antibiotics.
- With sepsis features, expedite care without waiting for every microbiological result.
- At review, reconcile clinical response and results; reconsider diagnosis, treatment and suitability for outpatient care.
Review response and the diagnosis
Set a review interval appropriate to risk and explain symptoms requiring immediate return. Review microbiology, tolerance and clinical progress to confirm, adapt or medically discontinue treatment that is no longer justified. Failure to improve should prompt assessment for complications, uncontrolled source, resistance or a noninfectious diagnosis. After severe infection, consider fatigue, functional ability and rehabilitation needs; a normal biomarker does not define recovery.
[4][3]A learning situation
FICTIONAL CASE · SELF-REFLECTION WITHOUT A SCORE
A 79-year-old man presents with weakness and cough for two days. There is no clear fever. His daughter reports unusual confusion and reduced intake; he is breathing faster than usual.
Does the absence of fever justify a diagnosis of minor infection?
Read the reasoning
No. Confusion and altered breathing may signal severe illness. Obtain all vital signs, assess perfusion and oxygenation, and look for a source, including pneumonia. Suspected sepsis warrants urgent referral; waiting for an inflammatory marker must not delay that decision. Also assess noninfectious causes of confusion.
References and scope
- Suspected sepsis in people aged 16 or over — NG253, Could this be sepsis? ↗
- Suspected sepsis in people aged 16 or over: recognition, assessment and early management — NG253, Managing suspected sepsis ↗
- Pneumonia: diagnosis and management — NG250, Recommendations ↗
- Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2026 — recommendations ↗
Original educational synthesis for adult first-line practice. International references must be interpreted with the clinical setting and local care pathways. Independent human scientific review remains to be confirmed.