Case — 67-year-old man with cough, purulent expectoration, fever, tachypnoea, tachycardia and hypotension

Immediate recognition and triage. Cough with purulent sputum and fever indicate pneumonia; tachypnoea, tachycardia and hypotension indicate sepsis with shock. Apply ABCDE, secure two large-bore cannulae, attach monitoring and calculate CURB-65 — this patient already scores for age ≥ 65, respiratory rate ≥ 30 and systolic BP < 90, giving a high score that mandates admission to a high-dependency or intensive care area.

The first hour — resuscitation bundle. Oxygen to a target of 94–98% (88–92% if there is known chronic CO 2 retention); blood cultures before antibiotics; measure serum lactate; intravenous broad-spectrum antibiotics within one hour; balanced crystalloid 30 mL/kg given in aliquots with reassessment; and early noradrenaline through a peripheral or central line if the mean arterial pressure remains below 65 mmHg despite fluids. In the older patient give fluid in 250–500 mL boluses with repeated reassessment, because rapid loading precipitates pulmonary oedema in unrecognised diastolic dysfunction. Insert a urinary catheter for hourly output.

Investigations. Chest radiograph (consolidation; look for effusion or cavitation); arterial blood gas with lactate; full blood count, CRP or procalcitonin, urea, electrolytes, creatinine, liver function, glucose, coagulation profile; blood cultures × 2 and sputum Gram stain and culture; urinary pneumococcal and Legionella antigen; respiratory viral PCR including influenza and COVID-19; sputum for AFB/CBNAAT in the Indian setting; ECG and troponin (type 2 myocardial infarction and new atrial fibrillation are common); bedside echocardiography and lung ultrasound. Add CT chest ± CT pulmonary angiogram if the radiograph is normal or pulmonary embolism is possible.

Antibiotic therapy. Empirical cover for severe CAP: intravenous ceftriaxone or amoxicillin-clavulanate (or piperacillin-tazobactam) PLUS a macrolide (azithromycin/clarithromycin) or a respiratory fluoroquinolone (levofloxacin). Add antipseudomonal cover if there is bronchiectasis, structural lung disease or recent β-lactam/fluoroquinolone use within three months; add anaerobic cover if aspiration is suspected; add oseltamivir during influenza season. Adjust doses for renal function, then de-escalate and switch to oral therapy at 48–72 hours once stable.

Ongoing organ support and monitoring. Target MAP ≥ 65 mmHg, adequate urine output and falling lactate. Escalate respiratory support stepwise — controlled oxygen → high-flow nasal oxygen → non-invasive ventilation (pH < 7.35) → intubation. Add vasopressin if noradrenaline requirement is high; give hydrocortisone in refractory shock. Watch for acute kidney injury, delirium, hyperglycaemia, gastrointestinal bleeding and pressure sores; provide VTE prophylaxis, early enteral nutrition, glycaemic control and early mobilisation. Reassess formally at 48 hours.

Complications and goals of care. Look for parapneumonic effusion and empyema, lung abscess, ARDS, acute kidney injury, atrial fibrillation, myocardial infarction and multi-organ failure. If the patient does not improve, consider resistant organism, tuberculosis, empyema requiring drainage, pulmonary embolism or an underlying lung cancer. In parallel, undertake early discussion of goals of care, ceilings of treatment and resuscitation status with the patient and family, and involve palliative care if the trajectory is poor. Plan vaccination and smoking cessation before discharge.

CAPE COD trial (NEJM 2023) — in adults admitted to intensive care with severe community-acquired pneumonia, intravenous hydrocortisone 200 mg per day started within 24 hours reduced 28-day mortality. Adjunctive corticosteroids are therefore now recommended in severe CAP (excluding influenza and suspected aspergillosis). Contemporary sepsis practice has also shifted to balanced crystalloids rather than saline, restrictive fluid strategy with early vasopressors (including peripheral noradrenaline), and dynamic assessment of fluid responsiveness rather than fixed large-volume loading — all particularly important in the frail older patient.