What are the guidelines for managing sepsis?

Sepsis Management Guidelines

Immediate administration of IV antimicrobials within one hour of sepsis recognition is the cornerstone of sepsis management, along with early fluid resuscitation of at least 30 mL/kg of crystalloids within the first 3 hours. 1

Initial Assessment and Management

Diagnosis

• Obtain appropriate microbiologic cultures before starting antimicrobials if no substantial delay (>45 minutes) will occur 1
• Always include at least two sets of blood cultures (both aerobic and anaerobic) 1
• Perform prompt imaging studies to confirm potential infection sources 1

Antimicrobial Therapy

1. Timing:

   • Administer IV antimicrobials within one hour of sepsis or septic shock recognition 1, 2
   • Each hour delay in antibiotic administration increases risk of progression to septic shock by 8% 3

2. Selection:

   • Use empiric broad-spectrum therapy covering all likely pathogens (bacterial, potentially fungal or viral) 1
   • Consider local resistance patterns and patient-specific risk factors for MDR organisms 2
   • For septic shock: Use combination therapy with at least two antibiotics of different classes targeting likely pathogens 1

3. Special Considerations:

   • For Pseudomonas aeruginosa bacteremia: Combine extended-spectrum β-lactam with either aminoglycoside or fluoroquinolone 1
   • For bacteremic pneumococcal infections with septic shock: Combine β-lactam and macrolide 1
   • For suspected fungal infections: Consider 1,3-β-D-glucan assay, mannan and anti-mannan antibody assays 1
   • Initiate antiviral therapy early if viral etiology suspected 1

4. Optimization:

   • Use pharmacokinetic/pharmacodynamic principles to optimize dosing 1, 2
   • Consider extended or continuous infusion of β-lactams in critically ill patients 2

Fluid Resuscitation and Hemodynamic Support

• Administer at least 30 mL/kg of IV crystalloid fluid within first 3 hours 1, 4
• Perform frequent reassessment of hemodynamic status to guide further fluid administration 1, 4
• Target mean arterial pressure (MAP) of 65 mmHg in patients requiring vasopressors 1, 4
• Use norepinephrine as first-choice vasopressor 4
• Consider vasopressin (0.03 U/min) to raise MAP or decrease norepinephrine dosage 4

Ongoing Management

Source Control

• Identify infection source as rapidly as possible 4
• Implement source control interventions (drainage of abscesses, removal of infected devices) as soon as medically and logistically practical 4

Antimicrobial Stewardship

1. De-escalation:

   • Reassess antimicrobial regimen daily 1
   • Narrow therapy once pathogen identification and sensitivities are established 1
   • De-escalate combination therapy within first few days in response to clinical improvement 1

2. Duration:

   • Standard duration: 7-10 days for most serious infections 1, 4
   • Consider longer courses for:
     • Slow clinical response
     • Undrainable infection foci
     • S. aureus bacteremia
     • Certain fungal/viral infections
     • Immunocompromised patients including neutropenia 1

3. Discontinuation:

   • Consider using procalcitonin levels to guide antibiotic discontinuation in patients with no subsequent evidence of infection 1
   • Discontinue antimicrobials if infection is ruled out 1

Monitoring

• Monitor clinical indicators of tissue perfusion:
  • Capillary refill time
  • Skin mottling
  • Peripheral pulses
  • Mental status
  • Urine output >0.5 mL/kg/hour 4
• Consider normalizing lactate levels as a resuscitation target if elevated 1, 4

Special Considerations

Adjunctive Therapies

• Consider hydrocortisone (up to 300 mg/day) in patients requiring escalating vasopressor doses 4
• Position patients semi-recumbent (head of bed raised 30-45°) 4
• Apply oxygen to achieve saturation >90% 4

Common Pitfalls to Avoid

• Delayed antimicrobial administration: Every hour delay increases mortality 3
• Inadequate source control: Failure to identify and control infection source promptly 4
• Inappropriate empiric coverage: Not considering local resistance patterns or patient risk factors for MDR organisms 2, 5
• Failure to de-escalate: Continuing broad-spectrum antibiotics despite culture results 2
• Prolonged antimicrobial therapy: Continuing antibiotics beyond necessary duration 2
• Inadequate dosing: Not accounting for altered pharmacokinetics in critically ill patients 2

Performance Improvement

• Implement hospital-wide sepsis screening for acutely ill, high-risk patients 1
• Establish antimicrobial stewardship programs to optimize antibiotic use 2
• Recognize sepsis as a medical emergency requiring immediate intervention 4

By following these guidelines, clinicians can optimize outcomes for patients with sepsis and septic shock, reducing morbidity and mortality through prompt recognition and appropriate management.