What are the guidelines for managing sepsis?

Sepsis Management Guidelines

The management of sepsis requires immediate administration of IV antimicrobials within one hour of recognition, along with at least 30 mL/kg of IV crystalloid fluid within the first 3 hours, as these interventions are critical for reducing mortality. 1, 2

Initial Assessment and Resuscitation

Recognition and Diagnosis

• Obtain appropriate routine microbiologic cultures (including at least two sets of blood cultures) before starting antimicrobial therapy if doing so does not substantially delay antibiotic administration 2
• Promptly perform imaging studies to confirm potential sources of infection 2
• Implement sepsis screening for acutely ill, high-risk patients 2

Initial Resuscitation

• Administer at least 30 mL/kg of IV crystalloid fluid within the first 3 hours 2, 1
• Target a mean arterial pressure (MAP) of 65 mmHg in patients requiring vasopressors 2, 1
• Use dynamic variables (pulse pressure variation, stroke volume variation, passive leg raise test) rather than static variables to predict fluid responsiveness 2, 1
• Guide resuscitation to normalize lactate levels in patients with elevated lactate as a marker of tissue hypoperfusion 2, 1

Antimicrobial Therapy

Timing and Selection

• Administer IV antimicrobials within one hour of recognition for both sepsis and septic shock 2, 1
• Use broad-spectrum agents with activity against all likely pathogens (bacterial, fungal, viral) 2, 3
• Consider empiric combination therapy for:
  • Neutropenic patients with severe sepsis 2
  • Patients with difficult-to-treat, multidrug-resistant pathogens 2
  • Patients with septic shock 1

Optimization and De-escalation

• Reassess antimicrobial regimen daily for potential de-escalation 2, 1
• De-escalate to the most appropriate single therapy once susceptibility profile is known 2, 1, 3
• Typical duration of therapy is 7-10 days 2, 1
• Consider longer courses for:
  • Slow clinical response
  • Undrainable foci of infection
  • Staphylococcus aureus bacteremia
  • Some fungal and viral infections
  • Immunologic deficiencies including neutropenia 2, 1

Source Control

• Identify the anatomical source of infection as rapidly as possible 1, 4
• Implement source control measures within 12 hours when feasible 1
• Interventions may include:
  • Draining abscesses
  • Debriding infected necrotic tissue
  • Removing infected devices 1

Hemodynamic Support

Vasopressors and Inotropes

• Use norepinephrine as the first-choice vasopressor 1
• Consider adding vasopressin (up to 0.03 U/min) to either raise MAP or decrease norepinephrine dosage 1
• Add epinephrine when an additional agent is needed to maintain adequate blood pressure 1
• Consider dobutamine (up to 20 μg/kg/min) for patients with myocardial dysfunction 1

Monitoring

• Consider arterial line placement for accurate continuous monitoring, especially in patients requiring vasopressors 1
• Use echocardiography to evaluate cardiac function and rule out septic cardiomyopathy 1
• Monitor for signs of tissue hypoperfusion:
  • Lactate levels
  • Capillary refill
  • Skin temperature
  • Mottling
  • Mental status
  • Urine output 1

Prevention of Complications

• Provide DVT prophylaxis with daily subcutaneous low-molecular-weight heparin 1
• Implement stress ulcer prophylaxis using proton pump inhibitors in patients with bleeding risk factors 1
• Target blood glucose ≤180 mg/dL using a protocolized approach 1
• Consider mechanical ventilation with lung-protective strategies for patients with ARDS 1

Common Pitfalls and Caveats

1. Delayed antimicrobial administration: Each hour delay in antibiotic administration increases mortality risk. However, obtaining appropriate cultures before antibiotics is important if it doesn't significantly delay treatment 5, 6

2. Fluid overload: While initial fluid resuscitation is critical, excessive fluid administration can lead to pulmonary edema and other complications. Use dynamic measures to guide additional fluid therapy after initial resuscitation 1

3. Inappropriate empiric coverage: Failure to cover likely pathogens, including resistant organisms in high-risk patients, can lead to treatment failure. Consider local resistance patterns and patient risk factors for MDR organisms 3, 4

4. Delayed source control: Failure to identify and control the source of infection promptly can lead to persistent sepsis despite appropriate antimicrobial therapy 1

5. Failure to de-escalate: Continuing broad-spectrum antibiotics unnecessarily contributes to antimicrobial resistance. Daily reassessment and de-escalation are essential components of antimicrobial stewardship 2, 3

The most recent guidelines emphasize early recognition, prompt intervention, and a structured approach to management that includes appropriate antimicrobial therapy, source control, and supportive care to improve outcomes in patients with sepsis and septic shock.