What is the initial approach for a patient with suspected sepsis?

Initial Approach for Suspected Sepsis

The initial approach for a patient with suspected sepsis should include prompt recognition, immediate resuscitation, obtaining appropriate cultures, and administration of broad-spectrum antibiotics within one hour of recognition for those at high risk of severe illness or death from sepsis. 1, 2

Step 1: Recognition and Risk Stratification

1. Suspect sepsis in any patient with:

   • Signs of infection
   • Altered mental status
   • Abnormal vital signs (tachycardia, tachypnea, hypotension, fever/hypothermia)
   • Mottled or ashen appearance
   • Non-blanching petechial or purpuric rash
   • Cyanosis of skin, lips, or tongue 1

2. Calculate NEWS2 score to stratify risk of severe illness or death:

   • Score ≥7: High risk
   • Score 5-6: Moderate risk
   • Lower scores: Lower risk 1

3. Re-evaluate risk periodically:

   • Every 30 minutes for high-risk patients
   • Every hour for moderate-risk patients
   • Every 4-6 hours for low-risk patients 1

Step 2: Initial Resuscitation

1. Begin fluid resuscitation immediately:

   • Administer at least 30 mL/kg of IV crystalloid fluid within the first 3 hours 1, 2
   • Prefer balanced crystalloids (e.g., Lactated Ringer's) over normal saline when possible 2

2. Monitor hemodynamic response:

   • Reassess frequently to guide additional fluid administration
   • Target mean arterial pressure (MAP) ≥65 mmHg 1, 2

3. For persistent hypotension:

   • Initiate vasopressors (norepinephrine as first choice)
   • Consider adding vasopressin (up to 0.03 U/min) if needed 2

4. For tissue hypoperfusion with elevated lactate:

   • Guide resuscitation to normalize lactate levels 1, 2

Step 3: Diagnostic Workup

1. Obtain cultures before starting antibiotics (if no substantial delay >45 minutes):

   • At least 2 sets of blood cultures (aerobic and anaerobic)
   • One drawn percutaneously and one through each vascular access device (unless recently inserted <48 hours)
   • Cultures from suspected sources (urine, wounds, respiratory secretions, etc.) 1, 2

2. Laboratory investigations:

   • Complete blood count with differential
   • Comprehensive metabolic panel
   • Coagulation studies (PT/INR, PTT)
   • Lactate level
   • C-reactive protein and procalcitonin (if available)
   • Arterial blood gas if respiratory compromise 2

3. Imaging studies:

   • Chest X-ray
   • Site-specific imaging based on suspected source (CT, ultrasound, etc.)
   • Consider bedside cardiac ultrasonography for hemodynamically unstable patients 1, 2

Step 4: Antimicrobial Therapy

1. Timing of antibiotics based on risk stratification:

   • High risk: Within 1 hour of recognition
   • Moderate risk: Within 3 hours
   • Low risk: Within 6 hours 1, 2

2. Select broad-spectrum antibiotics covering all likely pathogens:

   • Consider local epidemiology and resistance patterns
   • Include coverage for gram-positive, gram-negative, and if indicated, anaerobic organisms
   • Consider antifungal coverage for immunocompromised patients 1, 3, 4

3. Optimize dosing:

   • Use appropriate loading doses
   • Adjust based on pharmacokinetic/pharmacodynamic principles
   • Consider extended or continuous infusion for beta-lactams in critically ill patients 2, 3

4. Reassess antibiotic therapy daily:

   • De-escalate based on culture results and clinical improvement
   • Narrow spectrum when pathogen identified
   • Typical duration 7-10 days, may be longer for specific conditions 1, 2

Step 5: Source Control

1. Identify anatomical source of infection as rapidly as possible 1, 2

2. Implement source control measures within 12 hours when feasible:

   • Drain abscesses
   • Debride infected necrotic tissue
   • Remove infected devices
   • Control ongoing contamination 1, 2

3. Choose least invasive effective approach:

   • Prefer percutaneous over surgical drainage when appropriate
   • Remove intravascular devices that may be sources of infection 2

Pitfalls and Caveats

1. Avoid delayed recognition and treatment:

   • Each hour delay in appropriate antibiotics increases mortality in septic shock 3, 4

2. Balance antimicrobial stewardship with prompt treatment:

   • Approximately 1 in 3 patients treated for suspected sepsis may not have bacterial infection
   • About 4 in 5 patients with bacterial infections receive broader spectrum antibiotics than necessary
   • Around 1 in 6 patients develop antibiotic-associated complications 5

3. Don't rely solely on single parameters:

   • Interpret vital signs and laboratory values in clinical context
   • Consider underlying conditions that may affect baseline parameters 1

4. Avoid excessive fluid administration:

   • Particularly in patients with cardiac dysfunction
   • Use dynamic measures of fluid responsiveness when available 2

5. Don't forget ongoing reassessment:

   • Frequent reevaluation of clinical status
   • Adjust treatment based on response and new information 1

By following this structured approach, clinicians can optimize the recognition, diagnosis, and early management of patients with suspected sepsis, potentially reducing morbidity and mortality associated with this life-threatening condition.