Sepsis Management in Adults
In adult patients with sepsis or septic shock, immediately initiate empiric broad-spectrum antimicrobials within 1 hour for septic shock or within 3 hours for sepsis without shock, alongside aggressive fluid resuscitation with 30 mL/kg balanced crystalloids within the first 3 hours, and start norepinephrine if hypotension persists despite fluids to maintain MAP ≥65 mmHg 1, 2.
Recognition and Screening
Use the NEWS2 score or qSOFA (≥2 points) to identify at-risk patients 2. Suspect sepsis in any patient with suspected infection plus any two of:
- Altered mental status
- Respiratory rate >22 breaths/minute
- Systolic blood pressure <100 mmHg 3
Measure serum lactate immediately when sepsis is suspected 2. Septic shock is defined by persistent hypotension requiring vasopressors to maintain MAP ≥65 mmHg AND lactate >2 mmol/L despite adequate fluid resuscitation 2.
Antimicrobial Therapy - The Critical First Step
Obtain at least two sets of blood cultures BEFORE antibiotics, but do not delay antimicrobial administration 2. The timing is non-negotiable:
Initiate empiric broad-spectrum therapy covering all likely pathogens including bacterial, and potentially fungal or viral coverage depending on clinical context 1. Failure to initiate appropriate empiric therapy substantially increases morbidity and mortality 1.
Narrow antimicrobial therapy once pathogen identification and sensitivities are established or adequate clinical improvement is noted 1.
Practical Antimicrobial Delivery
If vascular access is limited, prioritize β-lactams that can be administered as bolus or rapid infusion 1. Consider:
- Intraosseous access for rapid administration in adults 1
- Intramuscular preparations (imipenem/cilastatin, cefepime, ceftriaxone, ertapenem) if vascular access is unavailable 1
- "Stat" orders and premixed antimicrobials to eliminate pharmacy delays 1
Hemodynamic Resuscitation
Administer 30 mL/kg of balanced crystalloids within the first 3 hours 2, 4. This is the initial fluid bolus, not a ceiling.
If hypotension persists after fluid resuscitation, start norepinephrine as the first-line vasopressor to maintain MAP ≥65 mmHg 2, 4. This approach reduces the risk of fluid overload 4.
For refractory shock unresponsive to norepinephrine alone, add vasopressin rather than epinephrine 4. Monitor fluid responsiveness and tolerance continuously to avoid fluid overload 4.
Additional Supportive Measures
Corticosteroids: Consider low-dose hydrocortisone (with fludrocortisone) for patients in septic shock 3. This represents a shift from previous uncertainty, with recent evidence supporting survival benefit in shock states.
Mechanical ventilation: If required, use lung-protective ventilation with tidal volumes of 6 mL/kg (not 10 mL/kg) 4.
Thromboprophylaxis: Administer heparin for venous thromboembolism prevention 4.
Glycemic control: Maintain appropriate glucose levels, though specific targets should be individualized 4.
Quality Improvement Considerations
The 2026 German nationwide quality assurance procedure emphasizes screening rates, antibiotic timing, standardized treatment protocols, and staff training 2. Institutional delays in antimicrobial delivery often stem from:
- Failure to recognize sepsis early
- Inappropriate empiric antimicrobial selection
- Administrative/logistic barriers 1
Address these through defined order sets, improved communication between medical/pharmacy/nursing staff, and ensuring premixed antimicrobials are available for urgent situations 1.
Post-Sepsis Care
Inform survivors early about potential long-term sequelae including post-intensive care syndrome (PICS) 2. Coordinate discharge planning and structured follow-up care 2. This represents an important evolution in sepsis guidelines, recognizing that survival is only the first outcome—quality of life matters equally.
Critical Pitfalls to Avoid
- Never delay antibiotics to obtain cultures—obtain cultures quickly but start antibiotics within the time windows specified
- Do not under-resuscitate fluids initially—30 mL/kg is the starting point, not the maximum
- Do not use epinephrine before trying vasopressin in refractory shock on norepinephrine
- Do not use traditional tidal volumes (10 mL/kg) if mechanical ventilation is needed—use 6 mL/kg