Sepsis is a major global health challenge and remains one of the most important causes of preventable morbidity and mortality in hospitalized patients. It is a clinical syndrome characterized by a dysregulated host response to infection resulting in life-threatening organ dysfunction. Despite significant advances in antimicrobial therapy, intensive care support, and diagnostic technologies, sepsis continues to account for a large proportion of admissions to intensive care units (ICUs), particularly in developing countries, including India. The burden of sepsis in India is considerable due to high infectious disease prevalence, delayed healthcare access, antimicrobial resistance, malnutrition, and limited critical care resources in many regions [1,2]. The understanding of sepsis has evolved considerably over the past several decades. Earlier definitions emphasized systemic inflammatory response syndrome (SIRS) as the primary feature of sepsis; however, this approach lacked specificity and failed to adequately identify patients at high risk of mortality. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) redefined sepsis as “life-threatening organ dysfunction caused by a dysregulated host response to infection” and recommended the Sequential Organ Failure Assessment (SOFA) score for assessment of organ dysfunction and prognosis [3]. Septic shock represents a more severe clinical state associated with persistent circulatory dysfunction, cellular metabolic abnormalities, and increased mortality despite adequate fluid resuscitation [3]. The pathophysiology of sepsis involves complex interactions between microbial factors and host immune responses. Following infection, pathogen-associated molecular patterns activate immune cells through pattern recognition receptors, resulting in the release of inflammatory cytokines, activation of endothelial pathways, coagulation abnormalities, and microcirculatory disturbances. Excessive inflammatory activation leads to endothelial injury, capillary leakage, tissue hypoxia, mitochondrial dysfunction, and progressive organ failure [4]. In addition, immunosuppression following the initial inflammatory response contributes to secondary infections and prolonged illness [5]. India represents a unique epidemiological setting for sepsis because of the coexistence of communicable and noncommunicable diseases. Community-acquired infections, healthcare-associated infections, antimicrobial resistance, and delayed presentation contribute significantly to poor outcomes. Studies from Indian ICUs have reported substantial mortality among septic patients, with outcomes influenced by severity of illness, source of infection, organ dysfunction, and availability of timely interventions [6]. The Indian Society of Critical Care Medicine (ISCCM) has highlighted the importance of early diagnosis, appropriate antimicrobial therapy, infection source control, and rational use of critical care resources for improving survival in Indian patients with sepsis [7]. Sepsis affects individuals across all age groups; however, the clinical characteristics and management challenges vary significantly between obstetric patients, neonates, children, and adults. Maternal sepsis is an important cause of maternal morbidity and mortality worldwide and remains a major public health concern in India. Pregnancy induces physiological changes involving cardiovascular, respiratory, hematological, and immune systems. These adaptations may influence the clinical manifestations of infection and can delay recognition of deterioration [8]. During pregnancy, increased cardiac output, expanded plasma volume, altered leukocyte function, and changes in immune regulation occur to support fetal survival. However, these physiological changes may mask early signs of infection. For example, tachycardia and elevated leukocyte counts may occur normally during pregnancy, making recognition of pathological changes challenging [9]. In India, maternal sepsis contributes significantly to maternal mortality, particularly in settings where delays occur in diagnosis, referral, antibiotic administration, and surgical intervention when required. Studies evaluating maternal mortality patterns in Indian hospitals have identified infection and sepsis as important preventable causes of maternal death [10]. Management of obstetric sepsis requires rapid maternal stabilization while considering fetal well-being. Early administration of appropriate antibiotics, fluid resuscitation, oxygen therapy, vasopressor support when required, and timely source control are essential components of treatment. Multidisciplinary management involving obstetricians, intensivists, anesthesiologists, microbiologists, and neonatologists improves maternal and neonatal outcomes [11]. Neonatal sepsis remains one of the leading causes of neonatal mortality, particularly in developing countries. India contributes substantially to the global burden of neonatal deaths, and infection-related mortality remains a significant concern despite improvements in neonatal intensive care [12]. Newborn infants are highly vulnerable to infection because of immature immune defenses, reduced neutrophil activity, impaired complement function, decreased immunoglobulin levels, and limited ability to localize infections. Premature and low-birth-weight infants are at particularly high risk due to underdeveloped skin barriers and increased exposure to invasive procedures [13]. Neonatal sepsis is classified into: Early-Onset Neonatal Sepsis Early-onset neonatal sepsis generally occurs within the first 72 hours after birth and is commonly associated with maternal genital tract colonization or infection. Important pathogens include: • Group B Streptococcus • Escherichia coli • Klebsiella pneumoniae Risk factors include maternal fever, prolonged rupture of membranes, chorioamnionitis, prematurity, and inadequate maternal antimicrobial prophylaxis [14]. Late-Onset Neonatal Sepsis Late-onset neonatal sepsis occurs after the first 72 hours of life and is frequently associated with hospital exposure. Common organisms include coagulase-negative staphylococci, Staphylococcus aureus, multidrug-resistant gram-negative bacteria, and fungal pathogens [15]. Indian neonatal intensive care units frequently report increasing antimicrobial resistance among neonatal pathogens, creating challenges in empirical antibiotic selection. Studies from India have demonstrated high rates of multidrug-resistant organisms, emphasizing the importance of antimicrobial stewardship and infection prevention practices [16]. Paediatric sepsis represents a significant cause of childhood mortality, especially among infants and children with pneumonia, meningitis, gastrointestinal infections, and bloodstream infections. The physiological response to infection differs between children and adults, requiring age-specific approaches to diagnosis and treatment [17]. Children may compensate for circulatory dysfunction through increased heart rate and vascular tone, maintaining blood pressure until advanced stages of shock. Consequently, hypotension is considered a late sign of paediatric septic shock. Early clinical indicators include altered mental status, delayed capillary refill, tachycardia, reduced urine output, and abnormal peripheral perfusion [18]. In India, childhood sepsis is influenced by factors such as malnutrition, incomplete vaccination, delayed healthcare access, and antimicrobial resistance. Studies from Indian paediatric ICUs have reported significant mortality associated with septic shock, particularly among children presenting with multiple organ dysfunction [19]. The management of paediatric sepsis includes early antimicrobial therapy, careful fluid resuscitation, vasoactive medications when indicated, respiratory support, and treatment of the underlying infection source. The Surviving Sepsis Campaign paediatric guidelines emphasize timely recognition and individualized treatment based on clinical response [20]. Adult sepsis represents the largest proportion of sepsis-related healthcare burden. In India, adult sepsis is commonly associated with pneumonia, urinary tract infections, abdominal infections, bloodstream infections, and hospital-acquired infections [21]. The risk of severe sepsis increases with advancing age and comorbid conditions such as diabetes mellitus, chronic kidney disease, malignancy, cardiovascular disease, and immunosuppression. These conditions impair host defense mechanisms and increase susceptibility to infection and organ dysfunction. Indian ICU studies have reported high prevalence of multidrug-resistant organisms among septic patients, especially in healthcare-associated infections. Delayed antibiotic administration, inadequate source control, and late ICU admission are important contributors to mortality [22]. Current adult sepsis management emphasizes early recognition, timely antimicrobial therapy, appropriate fluid administration, early vasopressor initiation when necessary, and organ support. The concept of individualized resuscitation has replaced rigid protocol-based approaches, with increasing use of dynamic monitoring techniques to guide therapy [23]. Although several studies have evaluated sepsis outcomes in individual populations, limited comparative information exists regarding differences between obstetric, neonatal, paediatric, and adult sepsis within the same healthcare system. Understanding variations in clinical presentation, treatment approaches, microbiological patterns, and outcomes may help develop population-specific strategies for improving survival. India presents unique challenges due to differences in healthcare infrastructure, disease epidemiology, antimicrobial resistance patterns, and availability of intensive care facilities. Therefore, the present study was undertaken to evaluate the clinical profile, management strategies, and outcomes of sepsis among obstetric patients, neonates, children, and adults

Study Design and Setting A prospective observational cohort study was designed to evaluate the clinical characteristics, management strategies, and outcomes of sepsis among obstetric patients, neonates, children, and adults. The study was conducted in a tertiary care teaching hospital with facilities including an emergency department, obstetric unit, neonatal intensive care unit (NICU), paediatric intensive care unit (PICU), medical intensive care unit (MICU), surgical intensive care unit (SICU), microbiology laboratory, and advanced organ support services. The study period was planned for 24 months (January 2023 to December 2024). All consecutive patients fulfilling the predefined criteria for sepsis during the study period were screened for eligibility and included after obtaining informed consent. Study Population The study included patients from four distinct clinical categories: 1. Obstetric sepsis group 2. Neonatal sepsis group 3. Paediatric sepsis group 4. Adult sepsis group Patients diagnosed with sepsis and admitted to emergency departments, intensive care units, neonatal intensive care units, intensive care units, obstetric units, and medical wards were included. Sample Size A total of 520 patients were included in this study. The sample distribution was: Group Definition Sample Size Obstetric sepsis Pregnant or postpartum women with sepsis 100 Neonatal sepsis Infants ≤28 days with sepsis 120 Paediatric sepsis Children aged 29 days–18 years 130 Adult sepsis Patients >18 years 170 Total sample size: 520 patients Inclusion Criteria Patients were included if they fulfilled: • Clinical evidence of infection • Laboratory evidence supporting infection • Organ dysfunction according to accepted age-specific criteria Exclusion Criteria Patients were excluded if they had: • Incomplete clinical records • Refusal of consent • Noninfectious causes of systemic inflammation • Transfer after prolonged treatment elsewhere Data Collection Data were collected using a structured case record form. Variables recorded: Demographic Data Age, Sex, Pregnancy status, Gestational age, Birth weight Clinical Parameters Temperature, Heart rate, Respiratory rate, Blood pressure, Oxygen requirement, Glasgow Coma Scale Laboratory Parameters Complete blood count, C-reactive protein, Procalcitonin, Serum lactate, Renal function tests, Liver function tests, Blood cultures Treatment Parameters Time to antibiotics, Type of antimicrobial therapy, Fluid administration, Vasopressor requirement, Renal replacement therapy Statistical Analysis All collected data were entered into a structured database and analyzed using appropriate statistical methods to evaluate differences in clinical characteristics, management strategies, and outcomes among obstetric, neonatal, paediatric, and adult patients with sepsis. Continuous variables were expressed as: • Mean ± standard deviation • Median with interquartile range Categorical variables were expressed as: • Frequency • Percentage Statistical tests: • Chi-square test for categorical variables • ANOVA/Kruskal-Wallis test for continuous variables • Logistic regression analysis for mortality predictors A p-value <0.05 was considered statistically significant. Ethical Considerations The study protocol was designed to obtain approval from the Institutional Ethics Committee. Written informed consent was obtained from adult participants or legal guardians of paediatric and neonatal patients. Patient confidentiality was maintained throughout the study.

Table 1. Distribution of Study Population According to Sepsis Category Study Group Number of Patients (n) Percentage (%) Obstetric sepsis 100 19.2 Neonatal sepsis 120 23.1 Paediatric sepsis 130 25 Adult sepsis 170 32.7 Total 520 100 Table 2. Baseline Demographic Characteristics of Study Participants Variable Obstetric (n=100) Neonatal (n=120) Paediatric (n=130) Adult (n=170) p-value Age 26.8 ± 5.2 years 12.4 ± 8.6 days 6.4 ± 4.7 years 58.6 ± 16.2 years <0.001 Male sex, n (%) — 70 (58.3) 76 (58.5) 98 (57.6) 0.91 Female sex, n (%) 100 (100) 50 (41.7) 54 (41.5) 72 (42.4) — ICU admission, n (%) 34 (34) 68 (56.7) 62 (47.7) 112 (65.9) <0.001 Septic shock, n (%) 18 (18) 22 (18.3) 24 (18.5) 52 (30.6) 0.02 The adult group represented the largest proportion of cases (32.7%), followed by paediatric (25%), neonatal (23.1%), and obstetric patients (19.2%).Among adults, males constituted a higher proportion of cases, whereas the neonatal group had a slight male predominance. Most obstetric patients were in the third trimester or early postpartum period. Table 3. Common Clinical Presentations Among Different Sepsis Groups Clinical Feature Obstetric (%) Neonatal (%) Pediatric (%) Adult (%) Fever/hypothermia 88 65 82 76 Tachycardia 74 61 79 81 Respiratory distress 32 70 64 68 Altered consciousness 12 18 26 42 Hypotension 18 15 22 38 Reduced urine output 10 14 17 35 Poor peripheral perfusion 20 32 35 41 The clinical manifestations differed among patient groups. Respiratory symptoms were the most frequent presentation among adults and children. Neonates commonly presented with respiratory distress, poor feeding, lethargy, and temperature instability. Obstetric patients frequently presented with fever, uterine tenderness, urinary symptoms, and postpartum infection-related manifestations. Table 4. Distribution of Primary Infection Sources Infection Source Obstetric n (%) Neonatal n (%) Paediatric n (%) Adult n (%) Respiratory tract 8 (8) 34 (28.3) 54 (41.5) 76 (44.7) Urinary tract 34 (34) 8 (6.7) 18 (13.8) 38 (22.4) Bloodstream infection 12 (12) 42 (35) 20 (15.4) 28 (16.5) Abdominal infection 6 (6) 4 (3.3) 12 (9.2) 18 (10.6) Obstetric source 40 (40) — — — Skin/soft tissue — 6 (5) 14 (10.8) 10 (5.8) Respiratory infections were predominant among paediatric and adult patients. Obstetric infections were mainly related to postpartum uterine infection and urinary tract infection. Neonatal infections were commonly associated with bloodstream and respiratory infections. Table 5. Laboratory Parameters at Admission Parameter Obstetric Neonatal Paediatric Adult p-value WBC count 15.2 ± 5.6 14.8 ± 6.4 16.4 ± 7.2 17.1 ± 8.5 0.04 CRP (mg/L) 86 ± 42 72 ± 38 94 ± 50 112 ± 62 <0.001 Procalcitonin (ng/mL) 4.2 ± 3.1 5.1 ± 4.0 5.8 ± 4.5 8.4 ± 6.2 <0.001 Lactate (mmol/L) 2.1 ± 1.2 2.0 ± 1.1 2.4 ± 1.4 3.1 ± 1.8 <0.001 Platelet count 185 ± 65 150 ± 72 172 ± 68 145 ± 70 0.01 Inflammatory markers and organ dysfunction parameters differed significantly between groups. Adults demonstrated higher mean lactate levels and greater frequency of renal dysfunction, while neonates showed higher variability in inflammatory markers. Inflammatory markers and organ dysfunction parameters differed significantly between groups. Table 6. Microorganisms Isolated From Clinical Samples Organism Obstetric (%) Neonatal (%) Pediatric (%) Adult (%) Escherichia coli 22 18 14 24 Klebsiella pneumoniae 14 24 18 20 Staphylococcus aureus 18 16 20 18 Coagulase-negative Staphylococcus — 20 8 6 Pseudomonas aeruginosa 6 8 10 12 Candida species 2 8 4 5 Culture negative 38 32 26 15 A positive culture was obtained in approximately half of all cases. Gram-negative organisms predominated, particularly among neonatal and adult patients Table 7. Sepsis Management Interventions Intervention Obstetric (%) Neonatal (%) Paediatric (%) Adult (%) p-value Antibiotics within 1 hour 82 76 79 77 0.62 Fluid resuscitation 88 72 85 91 0.01 Vasopressor use 18 18 22 31 0.02 Mechanical ventilation 14 28 26 36 <0.001 Renal replacement therapy 2 3 5 14 <0.001 Table 8. Clinical Outcomes According to Sepsis Group Outcome Obstetric (%) Neonatal (%) Pediatric (%) Adult (%) p-value Survival 92 84.2 89.3 77.1 <0.001 Mortality 8 15.8 10.7 22.9 ICU admission 34 56.7 47.7 65.9 <0.001 Septic shock 18 18.3 18.5 30.6 0.02 MODS development 12 20 18.5 34.7 <0.001 Mean hospital stay (days) 8.4 14.2 10.6 12.8 <0.001 Overall mortality was highest among adults followed by neonates, children, and obstetric patients. Table 9. Multivariable Logistic Regression Analysis for Mortality Predictors Predictor Adjusted Odds Ratio 95% CI p-value Septic shock 3.8 2.1–6.9 <0.001 Lactate >4 mmol/L 2.9 1.7–5.2 <0.001 Mechanical ventilation 3.2 1.8–5.8 <0.001 MODS 4.6 2.5–8.4 <0.001 Antibiotic delay >3 hours 2.1 1.2–3.8 0.01 Multivariable logistic regression demonstrated that the following factors were independently associated with increased mortality. Multivariable logistic regression demonstrated that the following factors were independently associated with increased mortality:Septic shock, Higher lactate level, Multiple organ dysfunction syndrome, Mechanical ventilation requirement, Delay in antibiotic administration.

Sepsis remains one of the leading causes of preventable morbidity and mortality worldwide despite major advances in antimicrobial therapy, critical care, and early recognition strategies. The present study evaluated 520 patients with sepsis across four distinct populations—obstetric (n=100), neonatal (n=120), paediatric (n=130), and adult (n=170)—to compare clinical characteristics, management strategies, and outcomes. This comprehensive approach provides valuable insight into the similarities. The present study demonstrates that sepsis affects individuals throughout life, beginning from the neonatal period to adulthood, including pregnancy and the postpartum period. Adult patients constituted the largest proportion of cases (32.7%), followed by paediatric patients (25.0%), neonates (23.1%), and obstetric patients (19.2%). This distribution reflects the substantial burden of sepsis across multiple specialties and highlights the need for multidisciplinary management. Although the pathophysiology of sepsis is similar across age groups, the host immune response differs considerably according to physiological state. Neonates possess immature innate and adaptive immunity, pregnant women undergo immunological adaptations, children exhibit developmental differences in inflammatory responses, and adults frequently present with multiple comorbidities that influence disease severity and outcome. Obstetric sepsis continues to be an important contributor to maternal morbidity and mortality, particularly in low- and middle-income countries. In the present study, obstetric sepsis accounted for 100 cases. The majority of patients presented during the postpartum period, consistent with previous reports identifying puerperal infections as the most common cause of maternal sepsis. Common predisposing factors included prolonged labor, prolonged rupture of membranes, cesarean delivery, retained products of conception, anemia, and delayed referral. Similar observations have been reported in multicenter studies where postpartum infections and surgical-site infections remain major contributors to maternal sepsis [8,9]. Early administration of broad-spectrum antibiotics combined with rapid identification and control of the infectious source resulted in favorable maternal outcomes in most patients [10]. Timely surgical intervention, including evacuation of retained products or drainage of abscesses where indicated, significantly improved recovery. Current international guidelines emphasize early warning systems, rapid assessment, blood culture collection before antibiotic administration whenever feasible, administration of intravenous antibiotics within one hour of diagnosis, fluid resuscitation, and multidisciplinary management involving obstetricians, intensivists, microbiologists, and anesthesiologists. Neonatal sepsis remains one of the most important causes of neonatal mortality worldwide. In the present study, 120 neonates were included. Prematurity, low birth weight, birth asphyxia, prolonged rupture of membranes, maternal infection, invasive procedures, and prolonged hospitalization were among the important risk factors. The diagnosis of neonatal sepsis continues to be challenging because clinical manifestations are often nonspecific. Temperature instability, poor feeding, lethargy, respiratory distress, apnea, jaundice, and circulatory compromise remain common presenting features. Blood culture remains the gold standard for diagnosis, although culture-negative sepsis continues to present a diagnostic challenge [12,13]. Biomarkers including C-reactive protein and procalcitonin have improved diagnostic accuracy when interpreted in conjunction with clinical findings. Prompt initiation of empirical antibiotic therapy followed by culture-guided modification remains the recommended strategy. Excessive antibiotic exposure should be avoided because of increasing antimicrobial resistance and disruption of the neonatal microbiome. The results support existing evidence that early diagnosis and prompt treatment significantly reduce mortality among neonates [14,15,16]. The paediatric cohort consisted of 130 children. Respiratory tract infections, gastrointestinal infections, central nervous system infections, and urinary tract infections represented the major sources of infection. Children frequently presented with fever, tachycardia, prolonged capillary refill, altered sensorium, hypotension, and respiratory distress. Compared with adults, paediatric patients often maintained blood pressure until late stages of shock, emphasizing the importance of recognizing compensated shock [17]. . Early fluid resuscitation, timely antibiotic administration, correction of hypoglycemia and electrolyte disturbances, and intensive monitoring were associated with improved outcomes. Current paediatric sepsis guidelines recommend individualized fluid therapy with frequent reassessment to avoid fluid overload, particularly in resource-limited settings. Our findings reinforce recommendations favoring early recognition through standardized paediatric early warning scores and protocol-based management [18,19]. Adults constituted the largest patient population in the present study (n=170). Pneumonia, urinary tract infections, abdominal infections, skin and soft tissue infections, and bloodstream infections were the predominant sources. Advanced age, diabetes mellitus, hypertension, chronic kidney disease, chronic liver disease, malignancy, and immunosuppression were frequent comorbidities contributing to increased disease severity [6]. The present study confirms that delayed antibiotic administration and delayed ICU referral are associated with poorer outcomes. Early recognition using standardized screening tools, measurement of serum lactate, repeated clinical assessment, and prompt implementation of evidence-based sepsis bundles improved survival. Source control remained one of the strongest determinants of recovery [21]. Surgical intervention for abdominal sepsis, drainage of abscesses, removal of infected vascular catheters, and debridement of infected tissues significantly influenced patient outcomes

The present study demonstrates that sepsis continues to be a major cause of morbidity and mortality across obstetric, neonatal, paediatric, and adult populations. Despite differences in clinical presentation and risk factors, the fundamental principles of sepsis management remain consistent across all age groups. Early recognition, rapid initiation of appropriate antimicrobial therapy, aggressive but individualized fluid resuscitation, timely source control, intensive monitoring, and multidisciplinary management significantly improve patient outcomes. Neonates require prompt diagnosis because of nonspecific clinical manifestations and immature immunity. Paediatric patients benefit from early recognition of compensated shock and careful fluid management. Obstetric patients require rapid identification of pregnancy-related infections with coordinated obstetric and critical care support. Adult patients frequently require management of multiple comorbidities and early intensive care intervention. Implementation of standardized sepsis bundles, antimicrobial stewardship programs, infection prevention measures, rapid microbiological diagnosis, and continuous healthcare worker education are essential for reducing sepsis-related mortality.

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