Sepsis is a life-threatening condition caused by a dysregulated host response to infection, leading to organ dysfunction and, if untreated, progression to septic shock and death.¹ It remains a major cause of hospital admission, intensive care utilization, and preventable mortality worldwide despite advances in antimicrobial therapy and critical care.² Early recognition and timely management are essential to improve survival and reduce complications. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) redefined sepsis as life-threatening organ dysfunction caused by infection and septic shock as a subset of sepsis associated with profound circulatory and metabolic abnormalities and increased mortality. These definitions are currently recommended for both clinical practice and research.³ Globally, sepsis affects approximately 49 million people each year and is responsible for nearly 11 million deaths, accounting for almost one-fifth of all global deaths. The burden is considerably higher in low- and middle-income countries due to delayed presentation, limited healthcare resources, antimicrobial resistance, and inadequate critical care services.⁴  The emergency department (ED) plays a crucial role in the early identification and management of patients with sepsis.⁵ Prompt administration of broad-spectrum antibiotics, intravenous fluids, source control, and haemodynamic stabilization have been shown to improve outcomes. International guidelines recommend early implementation of evidence-based sepsis bundles to reduce morbidity and mortality^.6 Several factors influence the prognosis of patients with sepsis, including advanced age, diabetes mellitus, hypertension, chronic kidney disease, malignancy, source of infection, septic shock, and the need for mechanical ventilation or vasopressor support. Identification of these high-risk factors is important for timely intervention and improved clinical decision-making. ⁷˒⁸

In Pakistan, infectious diseases remain a common cause of emergency department visits and hospital admissions. ⁹ However, local evidence regarding the clinical characteristics and outcomes of sepsis and septic shock in emergency departments is limited. ¹⁰ Most available studies have focused on intensive care, leaving a gap in emergency department. Therefore, this study aimed to determine the clinical characteristics and outcomes of adult patients with sepsis and septic shock presenting to the Emergency Department of Liaquat University Hospital, Hyderabad.

Study Design and Setting: A retrospective study was conducted in the Emergency Department of Liaquat University Hospital (LUH), Hyderabad, Pakistan. Liaquat University Hospital is a tertiary care teaching hospital affiliated with Liaquat University of Medical and Health Sciences (LUMHS) and serves as one of the major referral healthcare facilities in Sindh Province. The Emergency Department provides round-the-clock emergency medical and surgical services to patients referred from Hyderabad and neighboring districts. The department manages a large number of critically ill patients, including those presenting with severe infections, sepsis, and septic shock. Study Duration: Paper-based medical records of eligible patients with sepsis and septic shock admitted between June 2025 and December 2025 were retrospectively reviewed. Study Population: The study population comprised all adult patients aged 18 years and above who were diagnosed with sepsis or septic shock during their emergency department visit between June 2025 and December 2025. Eligible patients were identified through emergency department registers, admission records, discharge summaries, and paper-based medical records. Sample size calculation: All eligible paper-based medical records of adult patients with sepsis and septic shock meeting the predefined inclusion criteria between June 2025 and December 2025 were included. Therefore, no formal sample size calculation was performed. Eligibility Criteria: Adult patients aged 18 years and above who were diagnosed with sepsis or septic shock during their emergency department visit between June 2025 and December 2025 were included. Only patients with complete medical records containing sufficient demographic, clinical, laboratory, treatment, and outcome information were included. Those Patients presenting with traumatic injuries without evidence of infection, patients referred from another hospital after receiving definitive sepsis management, those who left against medical advice before completion of the initial assessment, and records with substantial missing clinical or outcome data were excluded from the analysis. Data Collection Procedure: Data were collected retrospectively using a structured data extraction form developed based on the study objectives, relevant literature, and routinely documented medical record variables. Medical records were reviewed manually by the investigators, and all eligible cases were screened according to the predefined inclusion and exclusion criteria. Information was extracted from emergency department records, inpatient files, nursing notes, laboratory reports, medication charts, intensive care unit records, and discharge summaries. To ensure consistency, all variables were collected using standardized operational definitions. Patient confidentiality was maintained by assigning a unique study identification number to each record, and no personal identifiers were entered into the study database. Study Variables and Outcome Measures: Data were extracted using a structured data extraction form developed for this study. The collected variables included demographic characteristics (age, gender, marital status, residence, and referral source), clinical characteristics (source of infection, comorbidities, presenting vital signs), laboratory findings (complete blood count, serum creatinine, serum lactate, blood culture, and other available investigations), and treatment-related variables such as intravenous fluid resuscitation, antibiotic therapy, vasopressor use, mechanical ventilation, oxygen therapy, and intensive care unit (ICU) admission. The primary outcome of the study was in-hospital mortality. Secondary outcomes included ICU admission, requirement for mechanical ventilation, vasopressor use, length of hospital stay, length of ICU stay, discharge status, and referral to another healthcare facility, where applicable. Data Management and Statistical Analysis: Data were entered and analyzed using the Statistical Package for Social Sciences (SPSS) version 26.0. Continuous variables were presented as mean ± standard deviation or median (interquartile range), while categorical variables were expressed as frequencies and percentages. Group comparisons were performed using the independent sample t-test or Mann–Whitney U test for continuous variables and the Chi-square test or Fisher's exact test for categorical variables. Multivariable binary logistic regression analysis was performed to identify factors associated with in-hospital mortality. A p-value of <0.05 was considered statistically significant. Ethical Considerations: Ethical approval was obtained from the Ethics Review Committee (ERC) of Liaquat University of Medical and Health Sciences (LUMHS), Jamshoro. Administrative permission was obtained from the Medical Superintendent, Head of the Emergency Department of Liaquat University Hospital, Hyderabad. Patient confidentiality was maintained by removing all personal identifiers, and the data were used solely for research purposes.

A total of 320 adult patients diagnosed with sepsis or septic shock were included in the study. Demographic characteristics, clinical profile, laboratory findings, management practices, clinical outcomes, and factors associated with in-hospital mortality were analyzed. The demographic characteristics of the study participants are presented in Table 1. The mean age of the patients was 58.7 ± 16.4 years, and the majority belonged to the 60–79 years age group (36.9%). Male patients constituted 58.8% of the study population. Most participants were married (80.9%), resided in urban areas (66.9%), and presented directly to the emergency department (64.1%).

Table 1. Demographic Characteristics Patients with Sepsis and Septic Shock

Baseline clinical characteristics of the study participants are summarized in Table 2. Sepsis was diagnosed in 74.4% of patients, whereas 25.6% presented with septic shock. Diabetes mellitus (44.1%) and hypertension (41.3%) were the most common comorbidities, followed by ischemic heart disease (13.8%) and chronic kidney disease (12.2%), as shown in Table 2.

Table 2. Baseline Clinical Characteristics

The clinical presentation and laboratory findings of patients at emergency department admission are shown in Table 3. The mean body temperature was 38.5 ± 1.1°C, heart rate was 108 ± 22 beats/min, and respiratory rate was 25 ± 6 breaths/min. The median Glasgow Coma Scale score was 14 (IQR: 12–15). The mean white blood cell count was 16.8 ± 7.4 ×10⁹/L, while 28.8% of patients had positive blood cultures and 40.0% had a Quick Sequential Organ Failure Assessment qSOFA score of ≥2, as presented in Table 3.

Table 3. Clinical Presentation and Laboratory Findings

The distribution of infection sources and emergency department management is presented in Table 4. Respiratory tract infection was the most common source of infection (39.4%), followed by urinary tract infection (24.4%) and intra-abdominal infection (13.1%). Most patients received intravenous fluids (96.3%) and empirical antibiotic therapy (93.8%) in the emergency department. Vasopressor support, mechanical ventilation, and ICU admission were required in 23.8%, 16.9%, and 25.3% of patients, respectively, as shown in Table 4.

Table 4. Source of Infection and Emergency Department Management

Clinical outcomes of the study participants are summarized in Table 5. The median hospital stay was 7 days (IQR: 4–11), while the median ICU stay was 4 days (IQR: 2–8). Overall, 81.9% of patients were discharged alive, whereas the in-hospital mortality rate was 15.0%. A small proportion of patients left against medical advice (2.2%) or were referred to another healthcare facility (0.9%), as presented in Table 5.

Table 5. Clinical Outcomes

A comparison between survivors and non-survivors is presented in Table 6. Non-survivors were significantly older and had higher proportions of septic shock, diabetes mellitus, chronic kidney disease, mechanical ventilation, vasopressor use, and ICU admission compared with survivors. All these variables showed statistically significant associations with in-hospital mortality, as shown in Table 6.

Table 6. Comparison Between Survivors and Non-Survivors

Multivariable logistic regression analysis was performed to identify independent predictors of in-hospital mortality. As shown in Table 7, increasing age was independently associated with a higher risk of in-hospital mortality (AOR=1.03; 95% CI: 1.01–1.05; p=0.002). Patients presenting with septic shock had nearly five times higher odds of mortality (AOR=4.86; 95% CI: 2.41–9.82; p<0.001). Chronic kidney disease (AOR=2.64; 95% CI: 1.31–5.29; p=0.006), diabetes mellitus (AOR=1.72; 95% CI: 1.01–2.95; p=0.046), mechanical ventilation (AOR=5.21; 95% CI: 2.54–10.68; p<0.001), and vasopressor use (AOR=3.79; 95% CI: 1.92–7.48; p<0.001) were also identified as significant independent predictors of in-hospital mortality.

Table 7. Multivariable Logistic Regression for In-Hospital Mortality

The present retrospective study evaluated the clinical characteristics and outcomes of adult patients with sepsis and septic shock presenting to the Emergency Department of Liaquat University Hospital, Hyderabad. The findings showed that sepsis constituted a substantial burden among emergency admissions, with nearly one-quarter of patients presenting with septic shock. Respiratory tract infection was the most common source of infection, while diabetes mellitus and hypertension were the predominant comorbidities. Although most patients received early fluid resuscitation and empirical antibiotic therapy, a considerable proportion required ICU admission, mechanical ventilation, and vasopressor support. The overall in-hospital mortality was 15.0%, with increasing age, septic shock, chronic kidney disease, mechanical ventilation, and vasopressor use identified as independent predictors of mortality. The mean age of patients in the present study was 58.7 years, and males accounted for 58.8% of the study population. Older age was significantly associated with in-hospital mortality. Similar findings have been reported in the United Kingdom by Sabir et al., who observed that patients presenting with suspected sepsis were predominantly elderly, with increasing age associated with poorer clinical outcomes.⁸ Likewise, the Global Burden of Disease study reported that sepsis-related mortality increases markedly with advancing age because of immune-senescence, multiple chronic illnesses, and reduced physiological reserve.¹¹ Similar age and gender distributions have also been reported in studies from India and China, where male predominance and older age were common among hospitalized patients with sepsis.¹²˒¹³ In the present study, 25.6% of patients presented with septic shock, and mortality was significantly higher among these patients than among those with sepsis alone. Septic shock remained one of the strongest independent predictors of in-hospital mortality. These findings are consistent with the multinational systematic review by Vincent et al., which identified septic shock as a major determinant of mortality across Europe and North America.¹⁴ Similarly, Cecconi et al. reported that circulatory failure, persistent hypotension, and tissue hypoperfusion associated with septic shock substantially increase the risk of multiple organ dysfunction and death despite advances in critical care management.¹⁵ A multicentre observational study from China also demonstrated significantly higher mortality among patients with septic shock compared with uncomplicated sepsis.¹⁶ Diabetes mellitus and hypertension were the most frequently documented comorbidities in this study, while chronic kidney disease showed a significant association with mortality. These findings are biologically plausible because chronic diseases impair immune function, increase susceptibility to severe infection, and reduce the physiological reserve needed to recover from sepsis. Previous studies have consistently identified diabetes mellitus and chronic kidney disease as important predictors of adverse outcomes among patients with sepsis.¹⁷ Similar observations have been reported from South Asian populations, where the growing burden of non-communicable diseases has contributed to increased severity of infectious illnesses and poorer hospital outcomes.18 Respiratory tract infection was identified as the leading source of infection, followed by urinary tract and intra-abdominal infections. This finding is consistent with several international studies in which pneumonia remained the most common source of sepsis requiring emergency department or intensive care admission.19 A retrospective multicentre study conducted in Europe similarly reported respiratory infections as the predominant source of sepsis, followed by urinary tract infections.17 Comparable findings have also been described in regional studies from South Asia, highlighting the continued burden of lower respiratory tract infections among adults presenting with severe sepsis.18 Mechanical ventilation and vasopressor therapy were strong predictors of mortality in the present study. These interventions generally reflect severe respiratory and circulatory failure rather than being direct causes of death. Previous studies have consistently demonstrated that patients requiring organ support are more likely to develop multiple organ dysfunction syndrome and experience higher in-hospital mortality.¹⁵˒20 Early identification of high-risk patients and timely implementation of evidence-based sepsis management bundles may therefore improve survival and reduce disease-related mortality. This study provides preliminary local evidence regarding the burden of sepsis and septic shock in a tertiary care emergency department in Pakistan. The findings may assist emergency physicians, nurses, hospital administrators, and policymakers in strengthening institutional sepsis protocols, improving resource allocation, and enhancing the quality of emergency care. Strengths The study included adult patients presenting to a high-volume tertiary care emergency department, providing valuable information regarding the clinical profile and outcomes of sepsis in routine clinical practice. The retrospective design enabled evaluation of a broad range of demographic, clinical, laboratory, management, and outcome variables using routinely available hospital records. Limitations The retrospective nature of the study limited data collection to information available in medical records, and some variables may have been incompletely documented. Being a single-centre study, the findings may not be generalizable to all healthcare settings in Pakistan. In addition, variations in clinical documentation and missing laboratory investigations may have influenced the completeness of data. Future multi-Centre prospective studies with standardized data collection are recommended to validate these findings and provide more comprehensive evidence regarding sepsis epidemiology and outcomes in Pakistan.

Sepsis and septic shock remain important causes of morbidity and mortality among adults presenting to the emergency department of a tertiary care teaching hospital. Older age, septic shock, chronic kidney disease, mechanical ventilation, and vasopressor requirement were associated with poorer clinical outcomes and increased in-hospital mortality. Early recognition, prompt evidence-based management, and timely escalation of care are essential to improve patient outcomes. Further prospective multi-Centre studies are recommended to strengthen the evidence base and support the development of national sepsis management strategies.

1. Raza, H. A., Hashmi, A. P., Khakwani, M. M., Ali, M. H., & Jamil, B. (2023). Review of sepsis in Pakistan: how far have we come?. IJID regions, 10, 108–113. https://doi.org/10.1016/j.ijregi.2023.12.002
2. Seymour, C. W., Liu, V. X., Iwashyna, T. J., Brunkhorst, F. M., Rea, T. D., Scherag, A., Rubenfeld, G., Kahn, J. M., Shankar-Hari, M., Singer, M., Deutschman, C. S., Escobar, G. J., & Angus, D. C. (2026). Assessment of Clinical Criteria for Sepsis: For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA, 315(8), 762–774. https://doi.org/10.1001/jama.2016.0288
3. World Health Organization. Global report on the epidemiology and burden of sepsis: Current evidence, identifying gaps and future directions. Geneva: World Health Organization; 2020. https://www.who.int/publications/i/item/9789240010789
4. Abels, W., Reinhart, K., Neugebauer, E., Wulkotte, E., Toubekis, E., Piedmont, S., Born, S., Rieck, T., Wegwarth, O., Spies, C., Schlattmann, P., Schwarzkopf, D., & Fleischmann-Struzek, C. (2024). Improving prevention and early detection of sepsis among patient groups at risk: Introducing a model for a multimodal information campaign-The SepWiss study protocol. PloS one, 19(7), e0305107. https://doi.org/10.1371/journal.pone.0305107
5. Evans, L., Rhodes, A., Alhazzani, W., Antonelli, M., Coopersmith, C. M., French, C., Machado, F. R., Mcintyre, L., Ostermann, M., Prescott, H. C., Schorr, C., Simpson, S., Wiersinga, W. J., Alshamsi, F., Angus, D. C., Arabi, Y., Azevedo, L., Beale, R., Beilman, G., Belley-Cote, E., … Levy, M. (2021). Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. Critical care medicine, 49(11), e1063–e1143. https://doi.org/10.1097/CCM.0000000000005337
6. Evans, L., Rhodes, A., Alhazzani, W., Antonelli, M., Coopersmith, C. M., French, C., Machado, F. R., Mcintyre, L., Ostermann, M., Prescott, H. C., Schorr, C., Simpson, S., Wiersinga, W. J., Alshamsi, F., Angus, D. C., Arabi, Y., Azevedo, L., Beale, R., Beilman, G., Belley-Cote, E., … Levy, M. (2021). Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive care medicine, 47(11), 1181–1247. https://doi.org/10.1007/s00134-021-06506-y
7. Rudd, K. E., Johnson, S. C., Agesa, K. M., Shackelford, K. A., Tsoi, D., Kievlan, D. R., Colombara, D. V., Ikuta, K. S., Kissoon, N., Finfer, S., Fleischmann-Struzek, C., Machado, F. R., Reinhart, K. K., Rowan, K., Seymour, C. W., Watson, R. S., West, T. E., Marinho, F., Hay, S. I., Lozano, R., … Naghavi, M. (2020). Global, regional, and national sepsis incidence and mortality, 1990-2017: analysis for the Global Burden of Disease Study. Lancet (London, England), 395(10219), 200–211. https://doi.org/10.1016/S0140-6736(19)32989-7
8. Sabir, L., Wharton, L., & Goodacre, S. (2022). Retrospective single-centre descriptive study of the characteristics, management and outcomes of adult patients with suspected sepsis in the emergency department. Emergency medicine journal : EMJ, 39(4), 272–278. https://doi.org/10.1136/emermed-2020-211111
9. Vincent JL, Jones G, David S, Olariu E, Cadwell KK. Frequency and mortality of septic shock in Europe and North America: a systematic review and meta-analysis. Crit Care. 2019;23:196.
10. Reinhart K, Daniels R, Kissoon N, Machado FR, Schachter RD, Finfer S. Recognizing sepsis as a global health priority. N Engl J Med. 2017;377(5):414-17.
11. Rudd KE, Johnson SC, Agesa KM, et al. Global, regional, and national sepsis incidence and mortality, 1990–2017. Lancet. 2020;395(10219):200-211.
12. Chatterjee, S., Bhattacharya, M., & Todi, S. K. (2017). Epidemiology of Adult-population Sepsis in India: A Single Center 5 Year Experience. Indian journal of critical care medicine : peer-reviewed, official publication of Indian Society of Critical Care Medicine, 21(9), 573–577. https://doi.org/10.4103/ijccm.IJCCM_240_17
13. Xie, J., Wang, H., Kang, Y., Zhou, L., Liu, Z., Qin, B., Ma, X., Cao, X., Chen, D., Lu, W., Yao, C., Yu, K., Yao, X., Shang, H., Qiu, H., Yang, Y., & CHinese Epidemiological Study of Sepsis (CHESS) Study Investigators (2020). The Epidemiology of Sepsis in Chinese ICUs: A National Cross-Sectional Survey. Critical care medicine, 48(3), e209–e218. https://doi.org/10.1097/CCM.0000000000004155
14. Vincent, J. L., Jones, G., David, S., Olariu, E., & Cadwell, K. K. (2019). Frequency and mortality of septic shock in Europe and North America: a systematic review and meta-analysis. Critical care (London, England), 23(1), 196. https://doi.org/10.1186/s13054-019-2478-6
15. Cecconi, M., Evans, L., Levy, M., & Rhodes, A. (2018). Sepsis and septic shock. Lancet (London, England), 392(10141), 75–87. https://doi.org/10.1016/S0140-6736(18)30696-2
16. Probst, L., Schalk, E., Liebregts, T., Zeremski, V., Tzalavras, A., von Bergwelt-Baildon, M., Hesse, N., Prinz, J., Vehreschild, J. J., Shimabukuro-Vornhagen, A., Eichenauer, D. A., Garcia Borrega, J., Kochanek, M., Böll, B., & Working Party on Intensive Care Medicine in Hematologic and Oncologic Patients (iCHOP) of the German Society of Hematology and Medical Oncology (DGHO) (2019). Prognostic accuracy of SOFA, qSOFA and SIRS criteria in hematological cancer patients: a retrospective multicenter study. Journal of intensive care, 7, 41. https://doi.org/10.1186/s40560-019-0396-y
17. Frydrych, L. M., Bian, G., O'Lone, D. E., Ward, P. A., & Delano, M. J. (2018). Obesity and type 2 diabetes mellitus drive immune dysfunction, infection development, and sepsis mortality. Journal of leukocyte biology, 104(3), 525–534. https://doi.org/10.1002/JLB.5VMR0118-021RR
18. Sarnak, M. J., & Jaber, B. L. (2000). Mortality caused by sepsis in patients with end-stage renal disease compared with the general population. Kidney international, 58(4), 1758–1764. https://doi.org/10.1111/j.1523-1755.2000.00337.x
19. Ghaffar, A., Reddy, K. S., & Singhi, M. (2004). Burden of non-communicable diseases in South Asia. BMJ (Clinical research ed.), 328(7443), 807–810. https://doi.org/10.1136/bmj.328.7443.807
20. Martin-Loeches, I., Rodriguez, A. H., & Torres, A. (2018). New guidelines for hospital-acquired pneumonia/ventilator-associated pneumonia: USA vs. Europe. Current opinion in critical care, 24(5), 347–352. https://doi.org/10.1097/MCC.0000000000000535