Immediate Management of Sepsis with Elevated Procalcitonin Levels
The immediate management of a patient with sepsis and elevated procalcitonin levels requires prompt administration of broad-spectrum intravenous antimicrobials within one hour of recognition, along with appropriate cultures, fluid resuscitation, and source control measures. 1
Initial Assessment and Diagnosis
Obtain appropriate microbiologic cultures before starting antimicrobial therapy (if no substantial delay >45 minutes)
- At least two sets of blood cultures (both aerobic and anaerobic bottles)
- One drawn percutaneously and one through each vascular access device (if present >48 hours)
- Other relevant cultures based on suspected source of infection
Perform imaging studies promptly to identify potential sources of infection requiring source control
Antimicrobial Therapy
- Administer broad-spectrum IV antimicrobials within one hour of sepsis recognition
- Select empiric therapy covering all likely pathogens (bacterial, potentially fungal or viral)
- For septic shock, consider empiric combination therapy using at least two antibiotics of different classes targeting the most likely pathogens
Antimicrobial Stewardship
- Reassess antimicrobial regimen daily for potential de-escalation
- Narrow therapy once pathogen identification and sensitivities are established
- Consider procalcitonin levels to guide antimicrobial duration:
Fluid Resuscitation
- Administer initial crystalloid fluid challenge of 30 mL/kg for patients with sepsis-induced hypoperfusion
- For ongoing resuscitation:
- Use boluses of 250-500 mL with reassessment after each bolus
- Evaluate clinical signs of tissue perfusion (capillary refill, skin temperature, mottling, mental status)
- Monitor urine output (target ≥0.5 mL/kg/h)
- Follow serial lactate measurements (target normalization ≤2 mmol/L) 4
Source Control
- Identify specific anatomic diagnosis of infection requiring source control as rapidly as possible
- Implement required source control intervention as soon as medically and logistically practical
- Remove intravascular access devices that are possible sources of sepsis after establishing alternative access 1
Vasopressor Support
- Initiate vasopressors if hypotension persists despite initial fluid resuscitation
- Target mean arterial pressure (MAP) of 65 mmHg
- Norepinephrine is the first-choice vasopressor 4
Ongoing Monitoring and Management
- Monitor procalcitonin levels to:
- Evaluate response to antimicrobial therapy
- Guide decisions on antimicrobial duration
- Support discontinuation of empiric antibiotics if limited clinical evidence of infection persists 1
- Typical antimicrobial duration is 7-10 days, but consider longer courses for:
- Slow clinical response
- Undrainable foci of infection
- Bacteremia with Staphylococcus aureus
- Some fungal and viral infections
- Immunologic deficiencies including neutropenia 1
Common Pitfalls to Avoid
- Delaying antimicrobial administration beyond one hour of sepsis recognition
- Failing to obtain appropriate cultures before starting antimicrobials
- Neglecting to identify and address source control needs
- Continuing broad-spectrum antimicrobials without daily reassessment for de-escalation
- Ignoring trends in procalcitonin levels when making decisions about antimicrobial therapy
- Excessive fluid administration without appropriate monitoring for fluid responsiveness
- Delaying vasopressor initiation when indicated
By following this structured approach with emphasis on early antimicrobial therapy, appropriate cultures, source control, and judicious fluid management, you can optimize outcomes for patients with sepsis and elevated procalcitonin levels.