What is the treatment for septicemia?

Treatment for Septicemia

The treatment of septicemia requires immediate administration of broad-spectrum intravenous antimicrobials within one hour of recognition, along with aggressive fluid resuscitation using crystalloids at 30 mL/kg, and source control measures implemented as soon as possible. 1

Initial Resuscitation and Antimicrobial Therapy

Antimicrobial Therapy

• Administer IV antimicrobials within 1 hour of sepsis recognition 1
• Use empiric broad-spectrum therapy covering all likely pathogens 1
• Initial antimicrobial options:
  • For ICU patients with severe sepsis: Anti-pseudomonal beta-lactams (cefepime, carbapenems like meropenem, or piperacillin-tazobactam) 2
  • Consider combination therapy for septic shock using at least two antibiotics of different classes aimed at the most likely pathogens 1
• Obtain appropriate cultures before starting antibiotics (blood cultures, samples from suspected infection sites) 1
• De-escalate antimicrobial therapy within the first few days based on clinical improvement and culture results 1
• Duration of therapy: 7-10 days for most serious infections 1

Fluid Resuscitation

• Initial fluid challenge: minimum 30 mL/kg of crystalloids (portion may be albumin) 1
• Continue fluid administration as long as hemodynamic improvement occurs 1
• Target adequate tissue perfusion as the principal endpoint of resuscitation 1
• Use crystalloids as first-choice fluid; avoid hydroxyethyl starches 1
• Consider albumin when patients require substantial amounts of crystalloids 1

Vasopressors and Inotropic Support

Vasopressors

• Initiate if fluid resuscitation fails to restore MAP ≥65 mmHg 1
• Norepinephrine is the first-choice vasopressor 1
• Consider adding vasopressin (up to 0.03 U/min) or epinephrine to raise MAP or decrease norepinephrine dosage 1
• Use dopamine only in selected patients with low risk of tachyarrhythmias or with bradycardia 1
• Place arterial catheter as soon as practical for patients requiring vasopressors 1

Inotropic Support

• Add dobutamine when there is evidence of persistent hypoperfusion despite adequate fluid loading and vasopressor use 1
• Target improvements in ScvO₂ and reduction in lactate levels 1
• Combination of dobutamine and norepinephrine is recommended as first-line treatment for low cardiac output with hypotension 1

Source Control

• Identify the anatomic source of infection as rapidly as possible 1
• Implement source control intervention as soon as medically and logistically practical 1
• Use the least physiologically disruptive approach (e.g., percutaneous rather than surgical drainage) 1
• Remove intravascular access devices that are possible sources of sepsis promptly 1

Adjunctive Therapies

Corticosteroids

• Consider IV hydrocortisone (200-300 mg/day) only if adequate fluid resuscitation and vasopressor therapy cannot restore hemodynamic stability 1
• Taper corticosteroids when vasopressors are no longer required 1

Blood Products

• Transfuse RBCs when hemoglobin decreases to <7.0 g/dL (target 7.0-9.0 g/dL) once tissue hypoperfusion has resolved 1
• Do not use fresh frozen plasma to correct laboratory clotting abnormalities unless bleeding or invasive procedures are planned 1
• Administer platelets prophylactically when counts are <10,000/mm³ without bleeding or <20,000/mm³ with significant bleeding risk 1

Respiratory Support

• Apply oxygen to achieve saturation >90% 1
• Place patients in semi-recumbent position (head of bed raised 30-45°) 1
• For patients with ARDS, use low tidal volume ventilation (6 mL/kg predicted body weight) 1
• Consider prone positioning for severe refractory hypoxemia (PaO₂/FiO₂ ≤100 mmHg) 1

Common Pitfalls and Caveats

1. Delayed antimicrobial therapy: Each hour delay in appropriate antibiotic administration significantly increases mortality 3

2. Inadequate fluid resuscitation: Insufficient early fluid administration leads to persistent tissue hypoperfusion and increased organ dysfunction 3

3. Failure to identify and control infection source: Uncontrolled sources lead to persistent infection despite appropriate antibiotics 1

4. Over-reliance on static hemodynamic parameters: Use dynamic variables to guide fluid responsiveness when possible 4

5. Prolonged broad-spectrum antibiotics: Failure to de-escalate antibiotics increases risk of resistance and secondary infections 1

6. Overlooking immunosuppression in later stages: Many septic patients develop immune dysfunction in later stages, leading to secondary infections 5

7. Inappropriate vasopressor selection: Using vasopressors without adequate fluid resuscitation can worsen tissue perfusion 1

By following this evidence-based approach to septicemia management with prompt recognition, early antimicrobial therapy, aggressive fluid resuscitation, appropriate vasopressor support, and source control, patient outcomes can be significantly improved.