From the Guidelines
The initial management of sepsis and severe sepsis focuses on early recognition and prompt intervention, with administration of broad-spectrum antibiotics within one hour of recognition and intravenous fluid resuscitation with crystalloids (typically 30 ml/kg) for patients with hypotension or elevated lactate levels, as recommended by the Surviving Sepsis Campaign guidelines 1. For both conditions, the first steps include:
- Obtaining blood cultures before starting antibiotics
- Administering broad-spectrum antibiotics within one hour of recognition
- Providing intravenous fluid resuscitation with crystalloids (typically 30 ml/kg) for patients with hypotension or elevated lactate levels Additional measures for severe sepsis, which involves organ dysfunction, include:
- Vasopressors (norepinephrine as first-line at 0.05-0.5 mcg/kg/min) if fluid resuscitation fails to restore adequate blood pressure, with a target mean arterial pressure of ≥65 mmHg 1
- Lactate levels should be measured and monitored, with a goal of normalizing elevated levels
- Source control through drainage of infected fluid collections or removal of infected devices should be performed as soon as possible
- Oxygen therapy should be provided to maintain oxygen saturation above 94% These interventions are critical as sepsis represents a dysregulated host response to infection that can rapidly progress to multi-organ failure and death, with mortality increasing significantly with each hour of delayed appropriate antibiotic therapy and hemodynamic stabilization 1. Key recommendations from the Surviving Sepsis Campaign guidelines include:
- Early quantitative resuscitation of the septic patient during the first 6 hours after recognition
- Blood cultures before antibiotic therapy
- Administration of broad-spectrum antimicrobials therapy within 1 hour of the recognition of septic shock and severe sepsis without septic shock
- Initial fluid resuscitation with crystalloid and consideration of the addition of albumin in patients who continue to require substantial amounts of crystalloid to maintain adequate mean arterial pressure.
From the Research
Initial Management of Sepsis vs Severe Sepsis
The initial management of sepsis and severe sepsis involves several key steps, including:
- Respiratory stabilization
- Aggressive fluid resuscitation
- Vasopressor therapy when fluid resuscitation fails to restore adequate mean arterial pressure and organ perfusion
- Early antibiotic therapy, which should be given within one hour of suspected sepsis 2
- Blood product therapy may be required in some cases to correct coagulopathy and anemia, and to improve the central venous oxygen saturation
- Insulin therapy may be required to maintain serum glucose levels less than 180 mg per dL
- Initiation of low-dose corticosteroids may further improve survival in patients with septic shock that does not respond to vasopressor therapy 2
Antibiotic Therapy
The choice of antibiotic therapy is crucial in the management of sepsis and severe sepsis. Studies have compared the effectiveness of different antibiotics, such as meropenem and piperacillin-tazobactam, in the treatment of sepsis and septic shock 3, 4. The results of these studies suggest that meropenem may have a lower mortality rate and improved clinical outcomes compared to piperacillin-tazobactam.
Guidelines and Recommendations
The management of sepsis and severe sepsis is guided by several recommendations and guidelines, including the Surviving Sepsis Campaign Guidelines and the National Severe Sepsis and Septic Shock Early Management Bundle (SEP-1) measure 5, 6. These guidelines emphasize the importance of early recognition and diagnosis of sepsis, as well as the need for prompt and effective treatment to prevent the transition into septic shock. The Infectious Diseases Society of America (IDSA) has also recommended revisions to the SEP-1 measure to reduce the risk of antibiotic overuse and improve the focus on evidence-based elements 5.