Trajectories of sepsis survivors in Australia: A scoping review

Abstract

Introduction:

Sepsis poses a substantial global health threat, accounting for approximately 20% of all deaths worldwide. In Australia, available reports indicate a rising incidence, with over 84,000 hospital admissions each year. Although in-hospital survival has improved, many survivors continue to experience long-term physical, psychological, cognitive, and health-related quality-of-life (HRQoL) challenges, collectively known as post-sepsis syndrome (PSS). However, research examining these long-term outcome trajectories remains fragmented and has not been comprehensively synthesised. This scoping review aims to map current evidence, clarify key concepts, and identify gaps in knowledge regarding PSS and related post-sepsis outcomes within the Australian context.

Methods:

A scoping review was carried out in accordance with the updated methodological framework provided by the Joanna Briggs Institute (JBI). A comprehensive search across multiple databases was conducted, including both peer-reviewed and grey literature. Two reviewers independently screened and extracted data. Narrative thematic analysis was employed to identify key themes and knowledge gaps. Reporting followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) checklist, and the review protocol was published on the Open Science Framework (OSF): https://doi.org/10.17605/osf.io/xhzfq.

Result:

Eighteen studies, primarily observational cohort designs, investigated outcomes among a total of 542,599 sepsis survivors. Less than half (39%) of the studies provide nationwide data. Six key themes emerged: long-term mortality risk, hospital readmissions, reduced HRQoL, long-term physical impairments, cognitive dysfunction, and mental health challenges. The most frequently reported outcomes were elevated post-hospital mortality and reduced HRQoL. Notably, 1-year mortality rates ranged from 12.5% to 36.9%. HRQoL was consistently impaired across all domains when compared to the general population. Despite ongoing needs in survivors, post-discharge rehabilitation and support services were reported to be inadequate

Conclusion and recommendations:

This scoping review shows that sepsis survivors in Australia experience multidimensional long-term complications and increased mortality risk. Stakeholders need to provide greater emphasis on the development of tailored post-sepsis care models and follow-up strategies to improve life after experiencing sepsis. Moreover, methodological limitations in the existing literature—including inconsistent case definitions, limited outcome measurement, short follow-up, and insufficient exploration of factors—highlight the need for robust, longitudinal research to strengthen evidence bases.

Keywords

sepsis sepsis survivors post-sepsis syndrome long-term trajectories Australia

Introduction

Sepsis constitutes life-threatening organ dysfunction precipitated by a dysregulated host response to infection.¹ The World Health Organisation (WHO) identifies sepsis as a major global health threat.² In 2017, an estimated 49 million people worldwide developed sepsis, and approximately 11 million died, accounting for nearly 20% of global mortality.³ In Australia, recent reports show a rising incidence of sepsis,^4,5 with more than 84,000 hospitalisations recorded in 2022–23—substantially higher than earlier estimates of approximately 55,000 cases.³ Cumulatively, this rising incidence has resulted in over 936,000 sepsis-related hospitalisations over the 10-year period from 2013–14 to 2022–23.⁶ In contrast to this increasing hospitalisation rate, advancements in sepsis management have led to improvements in in-hospital survival.^7,8 Correspondingly, the trend of sepsis mortality in Australia is decreasing.^4,9 However, hospital discharge marks the beginning—not the end—of recovery trajectories for sepsis survivors.¹⁰

Evidence showed that sepsis survivors often face a range of long-term complications collectively referred to as post-sepsis syndrome (PSS).^11,12 Although there is no universally accepted definition, PSS is widely described as an evolving, multifaceted condition encompassing persistent physical, medical, psychological, cognitive, and health-related quality of life (HRQOL) impairments that may last from weeks to decades following hospital discharge.^11
–13 While approximately half of survivors recover fully within 2 years,^7,14 a substantial proportion continue to experience ongoing complications, including recurrent infections, chronic pain, fatigue, disabling muscles, ongoing organ dysfunction, poor concentration, difficulty in intellectual functions, and mental health disorders, that puts survivors at increased risk of rehospitalisation, mortality, and diminished HRQoL.^11,12,15 For instance, a systematic review of epidemiological studies reported that 16.1% of sepsis survivors die within 1 year,¹⁶ and other studies have shown that 5-year mortality rates range from 43.8% to 62.1%.^17
–20 Besides, sepsis survivors also face recurrent hospital readmission, with 18%–26% returning within 30 days^21
–27, 30%–40% within 90 days,^22,28 and over 40% within 1 year of survival.^11,22,29 Physical symptoms like fatigue,¹³ chronic pain,^13,30 and gastrointestinal issues¹³ were also commonly experienced by sepsis survivors. Notably, chronic pain affects 14%–77% of ICU survivors, including sepsis patients, during the first year after discharge.^31,32

Furthermore, sepsis survivors face an elevated risk of chronic conditions, particularly cardiovascular, pulmonary, liver, and renal diseases. Cardiovascular disease is now widely recognised as both a risk factor and a potential consequence of sepsis.^33,34 Accordingly, a systematic review and meta-analysis study reported a higher rate of cardiovascular events among sepsis survivors compared to non-septic controls, with an incidence of myocardial infarction, stroke, and heart failure ranging from 3% to 9% and corresponding hazard ratios of 1.77, 1.67, and 1.65, respectively.³⁴ The kidney is also one of the commonest organs affected in sepsis patients. Sepsis-associated acute kidney injury (S-AKI) occurs in approximately two-thirds of septic shock patients,³⁵ with a quarter requiring renal replacement therapy.³⁶ S-AKI, in turn, increases the risk of permanent kidney damage, causing chronic kidney diseases (CKD) in survivors.³⁷

Additionally, cognitive impairments such as memory loss, attention deficits, poor concentration, and executive dysfunction are also common among sepsis survivors,^12,38 with an estimated prevalence of 12.5%–21%.³⁹ Similarly, sepsis survival is linked to a higher chance of all causes of dementia.⁴⁰ The long-term effects of sepsis significantly compromise survivors’ HRQoL,^12,41 with a growing body of global literature showing that HRQoL remains impaired for months to years following recovery.^41
–44

More importantly, the impact of PSS extends to families, caregivers, health care providers, and policymakers.⁴⁴ For example, sepsis survivors had higher healthcare costs and healthcare utilisation compared to individuals without sepsis.^11,45

In this context, PSS has emerged as a significant global public health priority and a complex clinical challenge due to its enduring and multidimensional impact on sepsis survivors.^11,12,46 Although PSS shares some similarities with post-intensive care syndrome (PICS)— which refers to new or worsening physical, cognitive, or mental health impairments following ICU admission of critical illnesses⁴⁷—important distinctions exist. PSS affects only sepsis survivors, including those who were not admitted to the ICU, whereas PICS is limited to critically ill patients who required ICU admission.¹¹ As such, a thorough understanding of PSS and its associated outcomes warrants focussed investigation from clinicians and researchers. In Australia, although sepsis incidence is rising and in-hospital mortality rate is declining, research on post-sepsis outcomes remains fragmented, and no comprehensive synthesis currently maps the scope, quality, and gaps in the existing evidence base. To address this, the present study aims to conduct a scoping review to summarise current knowledge on PSS and related long-term outcomes, clarify concepts, and highlight gaps to inform future research and policy development. The Supplemental Material (Item S1) further illustrates the rationale for the scoping review.

Methods and materials

A scoping review was carried out in accordance with the updated methodological framework provided by the Joanna Briggs Institute (JBI).⁴⁸ Given the broad and complex nature of post-sepsis syndrome (PSS), the heterogeneity of the evidence, and the objective of mapping findings from the existing literature, a scoping review approach was deemed appropriate. A review protocol was developed and registered with the Open Science Framework: https://doi.org/10.17605/OSF.IO/XHZFQ. We also followed the EQUATOR Network’s reporting guidelines, specifically the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR), to ensure transparent and comprehensive reporting (Supplemental Material, Item S2).

Inclusion and exclusion criteria

Eligible studies for the scoping review were selected based on the Population, Concept, and Context (PCC) framework. The detailed inclusion and exclusion criteria are provided in the Supplemental Material (Item S3).

Search strategy

To identify relevant literature for the scoping review, a comprehensive search strategy was created for each database in consultation with a research librarian and appraised using the Peer Review of Electronic Search Strategies (PRESS) 2015 checklist.^49,50 Both published and grey literature were searched to minimise publication bias. Published literature was identified from several online databases, including MEDLINE (Ovid), CINHAL Complete (EBSCOhost), Web of Science (Clarivate), and Scopus (Elsevier) from inception to June 2025. A composite of keywords and Medical Subject Heading (MeSH) terms was used to construct the search strategy. Boolean logic and proximity operators (AND, OR, NOT) were applied to connect the search terms and enhance the searching strategy. The key search terms for the review include sepsis, severe sepsis, septic shock, sepsis survivorship outcomes, long-term outcomes, post-sepsis syndrome, and Australia (Supplemental File, Item S4).

Evidence selection and screening

All identified articles were imported to Covidence software for deduplication and screening. Duplicates were automatically identified and manually verified before removal. The remaining unique records were reviewed in two phases. First, the title and abstract were screened for inclusion by two reviewers (BB, AM). Then, the full text was also reviewed by both reviewers, with discrepancies resolved through discussion. The study selection process was charted using a PRISMA flow diagram.

Data extraction and quality assessment

A bespoke data-charting form was developed, piloted on five studies, and refined before use. Data extraction was performed by the primary author (BB) with the extracted data validated for its completeness, consistency, and accuracy by the other authors (DC, JS, and AM). Extracted information included study characteristics, participant socio-demographic details, and detailed outcome findings (Supplemental File, Item S5).

Although optional for scoping reviews, JBI critical appraisal checklists were applied according to enhanced transparency in evidence interpretation.⁵¹ We used a diverse JBI checklist according to the study design, and most included studies (14, 78%) were assessed as high quality (Supplemental file, Item S6).

Data processing, analysis, and reporting

Basic descriptive statistics—including frequencies, means, and proportions—were used to summarise key characteristics of the included studies, such as study setting, study design, population demographics, and outcome measures. A narrative thematic analysis was then employed. Data were organised thematically through a hybrid deductive–inductive approach, using the Shankar-Hari et al. PSS conceptual framework.¹⁵ Findings are presented through narrative summaries, tables, and visual tools such as charts

Ethical considerations

As the study involves the synthesis of publicly available data and does not involve human participants, ethics approval was not required.

Results

Overview of the studies

The systematic search retrieved 2533 citations from 4 databases: MEDLINE (n = 678), Scopus (n = 1085), CINAHL (n = 234), and Web of Science (n = 536). An additional 67 records were recovered through grey literature sources: Google, Google Scholar, Trove, and ProQuest Thesis and Dissertations. In total, 2600 references were imported into Covidence for deduplication and screening. After removing 694 duplicates, 1906 unique titles and abstracts were screened, followed by full-text review. Eighteen (18) studies met the inclusion criteria. The PRISMA flow diagram presents the detailed selection process (Figure 1).

Figure 1.

The PRISMA flow diagram of the scoping review of trajectories of sepsis survivors in Australia, 2025.

Socio-demographic characteristics of study participants

Of the 18 studies, only 14 peer-reviewed articles reported participant-level sociodemographic data; the 4 grey literature documents (standards and reports) did not provide such details.^52
–55 Collectively, these 14 studies included 542,599 individuals. The smallest sample size was 39 participants in a qualitative study⁵⁶; the largest was 264,678 in cohort studies conducted in New South Wales.^57,58 In the included studies, the mean age of participants was generally above 40,^{56,57,59
–69} ranging from 46.9⁶⁴ to 65.5 years.⁶¹ Male participants predominated in the majority (10/14) of studies^{57,58,60,61,64
–69} (Supplemental File, Item S5).

Characteristics and key PSS outcome findings of the included studies

Regarding the key PSS and related long-term outcome findings of the included studies, six key outcome themes were identified. Post-hospital mortality was the most frequently reported outcome (11 studies; 11 studies),^{57,58,60
–68} followed by HRQoL.^{57,59,60,62,67
–69} Conversely, the physical and cognitive sequelae of PSS were infrequently addressed: two studies quantified pain^56,57; two assessed fatigues^54,56; and four studies explored cognitive dysfunctions.^52,54,56,60 Figure 2 further illustrates the domains of post-sepsis syndromes that were reported by Australian literature (Figure 2).

Figure 2.

Diagrammatic presentation of trajectories of sepsis survivors in Australia, 2025.

Long-term mortality risks in sepsis survivors

Post-ICU or hospital mortality in sepsis survivors has been reported across 11 Australian studies. Nevertheless, follow-up intervals and mortality ascertainment windows were heterogeneous, ranging from 90 days^58,62,63 to 11 years.⁶⁶ Most studies assessed outcomes at 6 months^60,62,68 and 1 year post-discharge,^58,63,64,67 while only two studies extended follow-up to 5 years or more.^61,66 Across studies, the mortality rates at 90 days, 6 months, and 1 year ranged from 20%–24%, 22.6%–35.5%, and 12.5%–36.9%, respectively.^{58,60
–63,68} While international evidence suggests that excess mortality may persist for a decade or longer,^70,71 longer-horizon data were sparse in Australia. A multicentre clinical trial reported survival rate of 60.9% at 2 years of the post-sepsis period,⁵⁷ whereas another population-based cohort study estimated a 5-year crude survival of 77.6%.⁶⁴ Furthermore, the only decade-long evidence indicated that, after 9.6 years of follow-up, post-hospital mortality was 45% for community-acquired sepsis and 42% for nosocomial sepsis.⁶¹

The review also divulged that, across the included studies, long-term survival among sepsis survivors was frequently reported to be poorer than that of comparator groups, including the general population and non-sepsis ICU patients.⁶⁶

Evidence on the determinants of long-term mortality after sepsis is limited and inconsistent. Findings related to sex are mixed, with some studies reporting higher 90-day mortality (25.3% vs 22.5%; p < 0.001) and 1 year mortality (39.3% vs 33.7%; p < 0.001) among male survivors,^63,64 whereas a prospective multicentre trial found no significant sex-based difference in 1-year mortality.⁶⁷ The role of ethnicity also remained debatable. One study reported higher long-term mortality among Indigenous Australians,⁶⁴ while others show comparable rates.^58,65 Notably, even when mortality rates are similar, a study conducted in northern Queensland concluded that Indigenous Australians died at a significantly younger age than non-Indigenous patients (58 vs 70 years: p < 0.0001).⁶⁵ Other factors more consistently associated with increased long-term mortality include older age, higher comorbidity burden, and greater severity of sepsis^61,64 (Supplemental File, Item S5, and Table 1).

Table 1.

Showing key findings, evidence gaps, and future directions on the post-discharge mortality status of sepsis survivors in Australia.

Domains	Follow-up periods	Evidence bases	Key findings	Critical appraisal notes
Short-term mortality	90- days mortality	Three studies (two multicentre and one single-centre)^58,62,63	20%–24%	Consistent estimates but all retrospectives; risk of selection bias and inclusion of individuals aged >45 limits generalisability
Intermediate mortality	Six-months	Three multicenter studies (one-nested cohort, one RCT and one prospective^60,62,68	22.6% – 35.5%	Heterogeneous follow-up methods; incomplete adjustment for comorbidity
Intermediate mortality	One- year	Four prospective cohort studies (two multicenter and two single center^58,63,64,67	12.5%–36.9%	Registry linkage quality variable; sepsis definitions inconsistent with the latest guidelines
Long-term mortality	Two-year survival rate	One multicenter RCT study⁵⁷	60.9% survived at 2 years.	Trial not powered for survivorship; follow-up attrition 7%.
	Five-years survival rate	One single -center prospective cohort study⁶⁴	77.6 % survived at 5 years	Single-center studies affect the validity; the sepsis definition is outdated.
	9.6 years post -hospital mortality	One single centre retrospective study⁶¹	Mortality rate ranges from 19.3% to 45%.	Retrospective, use of dated 1992 sepsis definition limits generalisability
Predictors and effect modifiers of long-term mortality	Sex	Three prospective cohort studies^63,64,67	Higher mortality in males,^63,64 whereas no difference is observed in another RCT⁶⁷	Conflicting evidence is observed.
	Age, comorbidity, organ dysfunction	Two single -centre studies (one retrospective and one prospective)^61,64	Higher mortality with older age, higher Charlson Comorbidity Index, organ failure patients	Findings were generated from a single-centre study, and confounding effect modifiers were not controlled.
	Ethnicity	Three studies, two single-centre retrospective and one multi-centre prospective study^58,64,65	Evidences on the long-term mortality of Indigenous Australians compared to non-Indigenous Australians were inconsistent.	Evidence generated by retrospective or registry-based cohorts with a risk of recall and misclassification bias and use of an inconsistent case definition of sepsis might affect the validity of the result. One study only includes participants aged >45%
Methodological quality	Study design	Five prospective^{58,60,63,64,67}, Three retrospective one nested cohort 62 and two RCT studies^57,68		There might be misclassification and recall bias in retrospective studies
Methodological quality	Follow-up period	The follow-up period to report post-discharge mortality varied from 90 days to 11 years		Affects the external generalisability of studies

Hospital re-admissions following surviving sepsis

Five Australian studies have quantified hospital readmissions following survival of an index sepsis admission, with follow-up horizons spanning from 30 days to 2 years.^{52,53,57,58,61} The most comprehensive data come from a report by the ACSQHC, in partnership with the Australian Sepsis Network, which showed that 40% of sepsis survivors were readmitted within 30 days and 75% within 12 months.⁵³ Similarly, Thompson et al. showed that about half and 75% of sepsis survivors were readmitted to the hospital within 90 days and 1 year of the follow-up.⁵⁸ Of those readmitted, 20%–25% returned due to recurrent sepsis episodes.^53,58 Additionally, a multicentre follow-up study in New South Wales found that, over a 2-year period, 71.7% of sepsis survivors were readmitted to the hospital, a rate comparable to that observed in non-sepsis survivors.⁵⁷

Limited evidence exists on what drives readmission risk in sepsis survivors in Australia. A single-centre prospective study revealed that male sepsis survivors had significantly higher odds of readmission within 90 days compared to females (52.5% vs. 50%; p < 0.001).⁶³ With respect to ethnicity, although data remain scarce, Thompson et al. found no significant difference in readmission rates between Indigenous and non-Indigenous patients⁵⁸ (Supplemental File, Item S5 and Table 1 and Table 2).

Table 2.

Showing key findings, evidence gaps, and future directions on hospital readmission status of sepsis survivors in Australia.

Domain	Follow-up period	Evidence base	Key findings	Critical appraisal
Hospital readmission	30 days	A report by ACSQHC with Australian Sepsis Programme (ASP )^52,53	40%	Administrative data, prone to misclassification, may omit readmission to private hospitals
	90 days	One multicentre prospective cohort study⁵⁸	50%	Misclassification of sepsis due to the diagnosis criteria
	12 months	A report ACSQHC with ASP⁵³	75%	Misclassification bias
	2 years	One multicentre RCT study⁵⁷	45.1%	Failure to match important confounders might limit external validity
Recurrent readmission with sepsis	12 months	ACSQHC with ASP⁵⁷ and One prospective cohort study	20%–25%	Lacks stratification by initial illness severity or discharge destination, administrative data, prone to misclassification, may omit readmission to private hospitals
Predictors	Sex	Only one single centreProspective cohort study⁶³	52.5% in males vs. 50%; p < 0.001)	A single centre study, limited to age >45 years only. hormonal factors were not considered
Predictors	Ethnicity	One multicentreprospective study⁵⁸	No significant readmission difference at 90 days and 1-year between Aboriginal and non-Aboriginal (1-year readmission rate was 79.3% in Aboriginal and 72.6% in non-Aboriginal populations (p-value = 0.17).	The cohort included participants aged 45 and above, which may limit external applicability to younger populations. Potential confounding due to unmeasured social determinants and environmental factors
Methodological quality	From 30 days to 2 years	One single centre study, One RCT, and other two are administrative record.^{53,56 –58,63}		Many of the pieces of evidence rely on routinely collected data in which factors and predictors were overlooked.

Poor HRQol outcome in sepsis survivors

Seven studies evaluated HRQoL among Australian sepsis survivors, with follow-up durations ranging from 3 months to 2 years.^{57,59,60,62,67
–69} Most of the studies examined the HRQoL at 6 months.^{57,59,60,62,68,69} The EuroQol-5D (three- or five-level version) was the predominant instrument,^{57,60,62,67
–69} supplemented in some studies by the SF-36 or SF-12v2.^60,62,68,69 In almost all studies, sepsis survivors demonstrated substantial decrements across all HRQoL domains,^{57,59,67
–69} with scores consistently below Australian population norms.^59,67,68 For example, Hammond et al. reported moderate-to-severe HRQoL problems in 15%–30% of survivors.⁶⁹ Severity of sepsis episode influenced outcomes: HRQoL reductions were greater after severe sepsis or septic shock than after uncomplicated sepsis.⁵⁹ Moreover, three studies in the review compared the HRQol with other non-sepsis ICU patients and revealed comparable results.^57,60,68 Physical domains—particularly mobility and the ability to perform usual activities—were the most frequently and markedly impaired components.^57,60,69 Notably, Thompson et al. documented mobility limitations in 37.8%, self-care deficits in 24.7%, and pain in 44.5% of survivors, respectively.⁵⁷

Regarding factors influencing HRQoL, findings on the impact of sociodemographic and clinical variables remain inconclusive. One study found that male sepsis patients experienced lower levels of pain compared to females, which was associated with better HRQol,⁶⁹ while another detected no significant gender differences.⁶⁷ Additionally, although based on a small sample (n = 9), a nested cohort study observed that, 6 months after discharge, Indigenous sepsis patients reported better HRQoL compared to non-Indigenous Australians.⁶² This finding is highly indefinite due to sample size and potential selection bias. Furthermore, a multicentre RCT showed no significant HRQoL differences between patients treated with Early Goal-Directed Therapy (EGDT) and those receiving standard care⁶⁸ (Supplemental File, Item S5 and Table 3).

Table 3.

Showing key findings, evidence gaps, and future directions on the HRQoL trajectories of sepsis survivors in Australia.

Domain	Follow-up period	Evidence base	Key findings	Critical appraisal
HRQoL	Three-months	One multicentre prospective cohort study⁶⁰	Mobility and personal care deficit	No information on discharge care; proxy response might lead to misclassification bias and limited follow-up time.
	Six-months	Six studies (five multicenter^{57,59,60,62,68,69} and one single-centre prospective cohort study⁵⁹	15%–30% had poor HRQoL, and the EQ-5D-5L Visual Analogue Score (VAS) was 70.8 (from a scale of 0–10), and the mean Utility score was 0.59 (from a scale of 0–1).⁵⁷ Additionally, another study reported that mobility problems occur in 37.8%, self-care deficits in 24.7%, pain in 44.5%, anxiety in 2.4%, Impaired daily activity in 36.9%⁶⁹ HRQoL is significantly reduced compared to the population norms	Lack of baseline HRQoL data, use of inconsistent HRQoL measurement tools, and obtaining information from their proxies might limit the external applicability of the study. Confounders and effect modifiers of poor HRQoL were not controlled.
	Twelve-months	One multicentre prospective cohort study⁶⁷	The HRQoL scores for male and female patients were significantly lower compared to age-matched population norms⁶⁷	Proxy responses might introduce biases. In addition, confounders were not controlled.
Factors influencing HRQoL	Sex	Two multicentre studies (one RCT and one prospective cohort^67,69	Hammond et al. reported males had good HRQoL,⁶⁸ whereas there was no significance difference in HRQoL of male and female survivors⁶⁷	The small sample size by Hammond et al. affects the validity of the study. The proxy response might also lead to a biased estimate in both studies.
	Indigenous	One multicentre nested cohort study⁶²	Aboriginal and Torres Strait Islander patients reported better QoL compared to non-Aboriginal patients⁶²	Small sample sizes limit external validity (nine participants); baseline HRQol was not assessed
	Shock	One multicentre RCT study⁶⁹	Longer time to reverse shock was linked with increased problems with mobility, usual activity, pain, and self-care practices, reducing QoL⁶⁹	No data on post-discharge care which affects the HRQoL,Proxy response affects the validity of the finding
Methodological quality	Retrospective	None	-
	Nested cohort study	One multicentre nested-cohort study⁶²	-	Longitudinal follow-up studies would be the most appropriate to investigate the HRQoL because HRQol is not a rare phenomenon in sepsis survivors
	Prospective studies	Five studies (three RCT) and two prospective cohorts^{57,60,67 –69}	-	Lack of baseline HRQoL to control confounders.

Physical impairments in sepsis survivors

In Australia, physical impairments ranging from loss of mobility and difficulty with daily tasks like bathing and toileting to severe complications like amputations were the other domain of PSS reported in the included studies.^54,56,57,62 Notably, none of the included studies used validated performance-based tools—such as the Six-Minute Walk Test (6MWT), Manual Muscle Testing (MMT), or dynamometry—which are standard measures of physical functioning in critically ill patients. Some studies also relied on proxy respondents or telephone-based assessment tools, which may introduce measurement bias.^57,60 Despite being small, available studies showed that survivors may experience a wide spectrum of physical impairments. Pain and impaired ability to perform daily living activities were among the most frequently reported complaints. Two studies found that 44.5% to 53.5% of survivors experienced chronic pain.^57,62 Impaired activity of daily living also happened in about 36.9% to 47.9% of sepsis survivors.^54,57 Fatigue, muscle weakness, mobility problems, disability, and amputation were also commonly experienced by sepsis survivors in Australia. In this context, an online survey in Queensland detected that fatigue and weak muscles were observed in 91.9% and 62.6% of survivors, respectively.⁵⁴ New disability also occurred in nearly one-third (29%) to 39.6% of sepsis survivors^54,60 (Supplemental File, Item S5, and Table 4).

Table 4.

Showing key findings, evidence gaps, and future directions on the physical functional status of sepsis survivors in Australia.

Domain (physical)	Follow-up period	Evidence bases	Key findings	Critical appraisal
Pain	Survey	One online survey report⁵⁴	53.5% of survivors experienced chronic joint pain	No follow- up, simple descriptive, no control of confounding, prone to bias due to subjective measures of pain
Pain	Two-years	One multicentre prospective RCT⁵⁷	44.5% experience pain	No control of confounding like comorbidities and frailty,
Impaired ADLs	Survey	Online survey⁵⁴	47.9%	No follow-up, no control for confounders, personal reports
Impaired ADLs	Six-months	One multicentre prospective cohort⁶⁰	36.9%	Loss to follow-up (7%) and proxy response limit the reliability of the finding. Use of telephone for assessment might affect accuracy
Fatiguability	Survey	One online survey report⁵⁴	91.9% experience fatiguability.	No follow-up, patients identified using a self-report, and control for confounders.
Muscle weakness	Survey	One online survey report⁵⁴	62.6%experience muscle weakness	No follow-up, no control for confounders, and the muscle strength test is not being used.
Mobility problems	Two-years	One multicentre prospective RCT⁵⁷	37.8% of sepsis survivors experience mobility problems	Data collected from proxies might introduce misclassification bias with no full control of confounders.
Disabilities	Survey	One online survey report⁵⁴	29% develop new disability	Not using a validated tool, patients were identified using a self-report. Measurement of disability based on baseline recall may introduce bias.
Disabilities	Six- months	One multicentre prospective cohort⁶⁰	39.6% develop new disability	Self-reported baseline status introduce bias, loss to follow-up (7%), use of telephone might affect accuracy of findings
Methodological quality	One for 6 month and the other for 2 year	One multicentre RCT and one multicentre prospective cohort study.^57,62		These studies are not initially intended to measure the physical functions; participants not perfectly matched
	One survey	No follow-up period		Triangulation is necessary, with no controlling for confounding.
	Administrative reports or, standards	No follow-up period

Cognitive dysfunction in sepsis survivors

Four studies covered the cognitive aspects of sepsis survivors,^52,54,56,60 whereby two of them were administrative reports or guidelines from ACSQHC.^52,56 Of the four included studies, only one study by Hodgson et al. assessed the cognitive status of survivors using the validated tool, the Montreal Cognitive Assessment tool (MoCA).⁶⁰ The maximum follow-up period to assess cognitive impairment in the included studies spans 6 months.⁶⁰ Accordingly, at 6 months post-discharge, it was found that one-third (29.5%) of survivors had cognitive impairment.⁶⁰ The study also found that the prevalence of cognitive dysfunction among sepsis survivors was consistent with the matched non-sepsis ICU cohort. However, interpretation is limited by the lack of baseline cognitive data and the use of proxy and telephone-based assessment.⁶⁰ In contrast, an online survey conducted in Queensland, in northeastern Australia, reported self-perceived brain fog in 59.6% of respondents and memory loss in 53.5%. Additionally, ACSQHC reports suggest that sepsis survivors in Australia may be at increased risk of long-term cognitive impairments, including memory loss and reduced working memory capacity^52,56 (Supplemental File, Item S5 and Table 5).

Table 5.

Showing key findings, evidence gaps, and future directions on the cognitive status of sepsis survivors in Australia.

Domain	Follow-up period	Evidence base	Key findings	Critical appraisal
Cognitive impairment/ changes	-	Two administrative reports^52,56	Sepsis survivors had ongoing cognitive changes like memory loss and poor working memory	No empirical evidence in these reports
Cognitive impairment/ changes	Six-months	One multicentre prospective study⁶⁰	29% develop cognitive dysfunctions	The baseline cognitive status is not extensively addressed, introducing bias. Telephone and proxy data might limit accuracy
Memory problems	Survey	One online survey report⁵⁴	53.5% experience memory problems.	Patients were identified using a self-report, which may affect the validity; no attempt to control confounding effect
Brain fog	Survey	One online survey report⁵⁴	59.6% experience brain fog	Self-reports by patients might affect the validity, and confounding effects might intrude on the validity.
Methodological quality	Six-months	One multicentre prospective cohort⁶⁰		Incomplete follow-up and missing data
	Survey	One online survey report⁵⁴		Descriptive data, no methodological rigour
	-	Two administrative reports^52,56		Not supported by latest evidence

Long-term mental health challenges in sepsis survivors

Five studies examined the mental and psychological sequelae experienced by sepsis survivors in Australia.^54
–57,60 The most frequently reported mental health conditions included PTSD, generalised anxiety disorder, and depression. Concerning the outcome, only three studies reported mental health outcomes quantitatively.^54,57,60 Between 20.5 and 57.6% of sepsis survivors encountered anxiety,^54,60 while depression affected 26.0%–51.5% of survivors.^54,57,60 An online survey in Queensland also found that 47.5% of survivors reported losing interest in their usual activities—a common symptom of depression.⁵⁴ Furthermore, a multicentre study found 12.9% of sepsis patients were at risk of PTSD 6 months after hospital discharge.⁶⁰ In addition, a nationwide report by the ACSQHC and the Sepsis Australia Network emphasised that mental health impacts extend beyond survivors themselves, affecting families, friends, and bereaved individuals, many of whom experience ongoing psychological distress and disruptions to daily life and work⁵⁶ (Supplemental File, Item S5 Table 6).

Table 6.

Showing key findings, evidence gaps, and future directions on mental health status of sepsis survivors in Australia.

Domain (mental health)	Follow-up period	Evidence base	Key findings	Critical appraisal
Anxiety	Six-months	One multicentre RCT⁵⁷	42.4%	The outcome is measured using EuroQol-5D-3L (not a more detailed tool)Pre-existing mental health conditions were not accounted for, proxy response might introduce bias, a single measurement might affect validity
	Six-months	One prospective cohort study⁶⁰	20.5%	The study employed a validated tool (Hospital Anxiety and Depression Scale (HADS)).Outcome assessed at a single point in time, overlooking fluctuation. There might be response bias and social desirability bias as the data is collected by telephone.
	Survey	One online survey report⁵⁴	57.6%	No controlling confounding, simply descriptive, no clinical validation for sepsis diagnosis
Depression	Six-months	One prospective cohort study⁶⁰	26.0%	Outcome might fluctuate with time; bias might compromise the external validity of the findings
Depression	Survey	One online survey report⁵⁴	51.5%	It is simply a descriptive study; there is no clinical validation for sepsis diagnosis. patients were identified using a self-report
PTSD	Six-months	One prospective cohort study⁶⁰	12.9%	The lack of pre-ICU mental health status and outcome measurement method might affect the validity of the result
Methodological appraisal	Prospective	Two (one RCT andone observational prospective)^57,60		Lack of pre-ICU baseline data, use of inconsistent measurement tools
	Survey	One online survey report⁵⁴		No rigorous analysis methods were used; effect modifiers and confounders were not controlled. Patients were identified using a self-report.
	Administrative reports	Two^55,56		No rigorous analysis methods, no latest empirical data, and reflexivity (author’s background) are implied but not explicitly discussed.

Discussion

Summary of key findings

Although advances in acute sepsis care have improved survival, life after sepsis has become a significant public health challenge. Many survivors continue to grapple with long-lasting physical, psychological, and cognitive issues, yet these experiences have not been well explored in the Australian context. This scoping review brings together what is currently known about post-sepsis trajectories in Australia, drawing on both peer-reviewed studies and grey literature. The review organises post-sepsis outcomes into six coherent themes: (1) long-term mortality risk, (2) hospital readmissions, (3) reduced health-related quality of life, (4) long-term physical impairments, (5) cognitive dysfunction, and (6) long-term mental health challenges. This thematic structure provides a clear and comprehensive picture of the multidimensional burden faced by sepsis survivors.

Interpretation of the findings and comparison with other studies

This review highlights that a substantial proportion of sepsis survivors face an elevated risk of long-term mortality compared with the general population.^57,61
–68 In Australia, 1 year post-sepsis mortality ranged from 12.5% to 36.9% across the included studies,^61,63,68 which aligns with international estimates: 22.3% in a French national discharge database analysis⁷² and 15% in an observation cohort study in the United Kingdom.⁷³ Similar trends were also reported in U.S. administrative claims and other settings.^16,74 Factors such as older age, indigenous status, higher comorbidity burden, and greater organ dysfunction appear to increase the risk of post-hospital mortality.⁶⁴ This finding is aligned with evidence from Denmark⁷⁵ and an observational cohort study in the U.K.⁷³ In addition, evidence regarding sex differences in post-hospital mortality remains inconsistent. Notably, two studies reported higher mortality among male survivors.^63,64 This is supported by findings from the U.K.,⁷³ France,⁷⁶ and the U.S.⁷⁷ Proposed biological explanations include X-chromosome–linked gene expression and oestrogen-mediated modulation of immune response and endothelial function protection to reduce severity and mortality risk in females.^78
–80 In contrast, another study in the review reported no sex-based difference in long-term mortality,⁶⁷ possibly due to its methodological approach, which deployed a risk-adjusted analysis by stratifying patients by age groups (premenopausal, <50 years vs. older). A prior systematic review supports this finding, indicating that sex had no clear effect on short-term mortality, while female sex may be linked to lower 1-year mortality (OR = 0.83, 95%CI 0.68–0.98).⁸¹ Moreover, the review identified conflicting results in long-term mortality outcomes in Indigenous versus non-Indigenous population groups. Davis et al.⁶⁴ found higher long-term mortality, while Hargovan et al. reported similar overall mortality.⁶⁵ The higher mortality rates in Aboriginal and Torres Strait Islander people may be attributed to health care access and utilisation disparities, higher alcohol and smoking usage, higher chronic illness burden, and residual confounding.^82,83

Australian sepsis survivors experience high rates of hospital readmission, commonly due to recurrent sepsis. In this review, around 40% are readmitted within 30 days and up to 75% within 12 months of discharge.⁵³ These rates are consistent with international reports: 20%–32% at 30 days, about 40% at 90 days, and more than 40% at 1 year.^{12,21
–26,29,73} This elevated risk could be due to the increased vulnerability to infections and worsening of chronic conditions following sepsis-related immune dysregulation.¹² Although generated from a single piece of evidence, the review also found a higher readmission risk among males; a cohort across three U.S. states reported a similar pattern,²⁵ possibly due to sex-based immune differences.⁷⁹ Readmissions contribute to higher mortality, longer hospital stays, and greater healthcare use and costs, underscoring the need to identify high-risk groups and strengthen post-sepsis follow-up services.⁸⁴

Poor HRQoL is another important concern among sepsis survivors in Australia. This review concluded that HRQoL is substantially impaired after sepsis,^{58,60,61,63,69,70} consistent with findings from global studies.^41–44 Reductions in HRQoL are plausibly driven by persistent inflammation and immune dysregulation, physical limitations, psychological morbidity, and disruptions to social roles.⁸⁵ Conversely, some studies in the review reported that the HRQoL of sepsis survivors is comparable to that of other ICU patients,^57,62,68 supported by international studies.^17,42,86,87 However, prospective studies from Tokyo and the Netherlands reported worse HRQoL among sepsis survivors compared to other ICU cohorts^88,89; a discrepancy might be explained by lower baseline HRQoL in those studies, whereas studies included in this review did not account for pre-sepsis HRQoL, limiting direct comparison. Evidence on determinants of HRQoL remains limited, and findings on sex differences remain debatable. Notably, one study found that males had better HRQoL than females,⁶⁹ consistent with findings from a Chinese case–control study.⁹⁰ This difference may be attributed to lower physical and psychological well-being and less frequent exercise habits among women, which could contribute to reduced HRQoL.⁹¹ Conversely, another cohort study observed no sex-based difference at 12 months.⁶⁷

Although under-explored, this review also divulged that sepsis survivors in Australia also experience significant impairments in physical functioning. Approximately half of survivors reported ongoing pain (44.5%–53.5%),^54,57 consistent with prior investigations in ICU survivor cohorts.^31,92 Persistent pain likely reflects interacting mechanisms, including ongoing inflammation with peripheral and central sensitisation, neuropathic changes related to inflammatory nerve injury, cytokine-mediated alterations in nociception, and sequelae of organ dysfunction and ischaemic injury.^30,93 More than half also experienced some degree of fatigue and exercise intolerance,^54,57 supported by findings from a prospective cohort at Jena University Hospital, Germany.⁹⁴ These outcomes are associated with prolonged ICU stays and immobility, leading to neuromuscular dysfunction and loss of muscle mass and strength.⁹⁵ Additional sequelae include self-care deficits, mobility problems, amputations, and other disabilities.^54,56,57,60 Collectively, these impairments are associated with loss of independence and concentration, increased health care utilisation, and diminished quality of life.⁹⁶

Cognitive dysfunctions are another long-term sequela reported by existing studies in Australia. Consequently, memory loss affected over half of survivors (53.5%),⁵⁴ while nearly one-third (29.5%) showed broader cognitive impairment,⁶⁰ consistent with expert estimates that 25%–50% of severe sepsis survivors experience significant cognitive deficits.^97,98 The proposed mechanisms include cerebral hypoperfusion and ischaemia, blood–brain barrier disruption, neuroinflammation, and neurotransmitter dysregulation.^98,99 In contrast, this finding exceeds those reported in some U.S. cohorts (10.6%–18%),^100,101 likely reflecting differences in socio-demographic attributes of study populations, assessment timing, and measurement tools. For example, one U.S. study enrolled older, non–critically ill septic participants,¹⁰⁰ whereas Australian studies included mechanically ventilated ICU patients with outcomes assessed within 6 months of discharge, a window that may precede full cognitive recovery.

In Australia, sepsis survivors and their families experience substantial mental health burdens, with anxiety and depression affecting roughly 20% to over 50% of individuals.^54,57,60 Estimates are concordant, with reported anxiety prevalences of 32% at 3 months, 40% at 6 months, and 34% at 12–24 months post-sepsis¹⁰² and depression prevalences of 29% at 2–3 months, 34% at 6 months, and 29% at 12–24 months.¹⁰³ Contributing mechanisms include neuroinflammation, cerebrovascular injury, neurotransmitter disturbances, and trauma from the ICU experience.^{12,99,104,105} Difficulty recalling events during the illness and uncertainty about the future may also explain these phenomena.^106,107 Although factors such as advanced age, female sex, prolonged ICU stay, baseline mental health status, and post-discharge supportive service status are associated with adverse psychiatric outcomes,¹⁰⁵ herein, this review could not quantify their association in the Australian context.

Evidence gaps of existing studies

Beyond mapping the findings of existing literature, this scoping review identified several important gaps in the Australian evidence base on post-sepsis outcomes. Key domains of post-sepsis syndrome—particularly cognitive, physical, and psychological outcomes—have not been comprehensively explored. Australian evidence on post-sepsis outcomes has prioritised long-term survival over survivors’ well-being. Studies assessing these outcomes frequently relied on proxy or self-reported measures, made limited use of validated assessment tools (e.g., the Montreal Cognitive Assessment [MoCA], Mini-Mental State Examination [MMSE], 6-minute Walk Test [6MWT], Timed Up and Go [TUG], and Short Physical Performance Battery [SPPB]), employed heterogeneous instruments (such as the Hospital Anxiety and Depression Scale [HADS] and European HRQoL measures for mental health assessment), and often involved short follow-up periods, limiting understanding of long-term outcomes.

Secondly, existing studies also insufficiently examine key determinants of long-term sequelae, particularly for the physical, cognitive, and mental health outcomes, and often lack a rigorous analytical approach to control confounders.

Thirdly, use of inconsistent sepsis definitions reduces comparability, interpretability, and generalisability of the findings. Lastly, infrequent assessment of outcomes beyond 1 year potentially underestimates the true burden of post-sepsis sequelae. Reliance on retrospective or cross-sectional designs might introduce misclassification or recall bias, restricting e the robustness of the evidence (Tables 1 –6).

Strengths and limitations

The key strength of this scoping review lies in its rigorous and comprehensive search strategy across multiple databases and grey literature, ensuring broad coverage of existing evidence. Nevertheless, some limitations should be acknowledged. First, data extraction by a single reviewer may introduce interpretation bias. Secondly, the broad scope of the review required prioritising the mapping of diverse themes over in-depth exploration of individual domains. Finally, the absence of stakeholder or consumer consultation—an optional but valuable component of JBI scoping review methodology—may limit the translation of findings into practice, particularly in relation to post-sepsis care needs.

Implications and future directions

Understanding the long-term trajectories and lived experiences of adult sepsis survivors is essential for strengthening post-sepsis care pathways. This scoping review demonstrates that sepsis survivors in Australia experience substantial long-term challenges, including increased mortality and persistent multidimensional sequelae, underlining that sepsis is a life-altering condition rather than a time-limited acute illness. Findings from the included grey literature simultaneously indicate that post-sepsis care remains poorly planned and insufficiently implemented, largely because the health system remains focused on the acute hospital management of illness.^52
–54 For example, an online survey conducted in Queensland reported that 68.7% of respondents felt family circumstances were overlooked at discharge, 57.2% received insufficient guidance on managing post-sepsis syndrome, and 62.2% were not informed about warning signs of deterioration.⁵⁴ Collectively, these findings underscore the need for clinical practice, research, and health system responses to extend beyond hospital discharge. This suggestion is also supported by a national recommendation by Sepsis survivors in Australia, ACSQHC, and the George Institute of Global Health, underscoring that rehabilitation service should commence during hospitalisation, be incorporated into discharge planning and strengthen individualised and structured follow-up service settings^46,55,108

Conclusions and recommendations

The scoping review concluded that sepsis survivors in Australia experience substantial long-term complications and elevated mortality risk. These findings highlight the need for greater stakeholder emphasis on the design of a coordinated, culturally safe, and person-centred rehabilitation service supported by scalable care models, improved awareness, and sustained engagement of survivors, families, and primary care providers. Moreover, inconsistencies in sepsis case definitions, the absence of validated outcome measurement instruments, short follow-up periods, and inadequate exploration and adjustment for key determinants highlight the need for robust, standardised, and well-designed longitudinal studies to better characterise the breadth and depth of PSS outcomes and to inform targeted intervention strategies.

Supplemental Material

sj-docx-1-inc-10.1177_17511437261456097 – Supplemental material for Trajectories of sepsis survivors in Australia: A scoping review

Supplemental material, sj-docx-1-inc-10.1177_17511437261456097 for Trajectories of sepsis survivors in Australia: A scoping review by Berihun Bantie, Anteneh Mengist, Jacqueline H. Stephens and Diane Chamberlain in Journal of the Intensive Care Society

Footnotes

Abbreviations and acronyms

ACSQHC- Australian Commission on Safety and Quality in Health Care; AIHW- Australian Institute of Health and Welfare; AKI- Acute Kidney Injury; CKD- Chronic Kidney Injury; CLD- Chronic Liver Disease; CVD- Cardiovascular Disease; ICU- Intensive Care Unit; OSF- Open Science Framework; PCC- Population, Concept, Context; PSS—Post-Sepsis Syndrome; PTSD - Post-Traumatic Stress Disorder; HRQoL- Health-Related Quality of Life; PRISMA-ScR - Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews; RCT: Randomised Control Trials; U.K.- United Kingdom; U.S.- United States; WHO- World Health Organisation.

ORCID iD

Berihun Bantie

Ethical considerations

As the study involves the synthesis of publicly available data and does not involve human participants, ethics approval was not required. Indeed, the review protocol was registered to ensure transparency and methodological rigor.

Consent to participate

There are no human participants in this article, and informed consent is not required.

Author contributions

BB, DC and JS: contributed to synthesising the research question, developing objectives, designing methodology, drawing conclusion, and preparing the initial draft of the manuscript. BB and AM: involved in study selection, data extraction, analysis, interpretation and preparing the initial draft of the manuscript. All authors entirely read and approved the manuscript.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Open science framework (OSF) registration

The scoping review protocol was registered in the Open Science Framework (OSF) on June 12, 2025, with DOI: .

Data availability statement

The manuscript and its supplementary materials contain all the information used to draw the conclusions. No new datasets were generated for this study.

Supplemental material

Supplemental material for this article is available online.

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