From the Guidelines
The most current guidelines for the workup of sepsis recommend following the Surviving Sepsis Campaign's Hour-1 Bundle, which includes administering broad-spectrum antibiotics within one hour of sepsis recognition, measuring lactate levels, obtaining blood cultures before antibiotics, and beginning rapid fluid resuscitation with 30 mL/kg crystalloid for hypotension or lactate ≥4 mmol/L 1.
Key Components of Sepsis Workup
- Initial assessment should include measuring lactate levels, obtaining blood cultures before antibiotics, and administering broad-spectrum antibiotics within one hour of sepsis recognition 1
- For diagnosis, use the Sequential Organ Failure Assessment (SOFA) score or quick SOFA (qSOFA) criteria to identify patients at risk 2
- Laboratory workup should include complete blood count, comprehensive metabolic panel, coagulation studies, and cultures from all potential infection sources
- Imaging should be directed by suspected infection source ### Antibiotic Therapy
- Empiric antibiotic therapy should cover likely pathogens based on infection site, with vancomycin plus piperacillin-tazobactam or meropenem commonly used for broad coverage 1
- Antibiotics should be administered within one hour of sepsis recognition and de-escalated once pathogens are identified 1
- The antimicrobial regimen should be reassessed daily for potential de-escalation 1 ### Hemodynamic Support
- Norepinephrine is the first-line vasopressor for fluid-refractory shock, with a target mean arterial pressure of 65 mmHg 2
- Fluid therapy is needed to improve microvascular blood flow through an increased cardiac output as an essential part of the treatment of sepsis
- A fluid challenge should incorporate four determinant elements: crystalloid solutions, rapid infusion, goal of increasing systemic arterial pressure, and avoidance of pulmonary edema 2 ### Ongoing Management
- Ongoing management includes source control, daily reassessment of antibiotic therapy, and monitoring for organ dysfunction
- The duration of therapy typically ranges from 7 to 10 days, but may be longer in patients with a slow clinical response, undrainable foci of infection, or immunologic deficiencies 1
From the Research
Current Guidelines for Sepsis Workup
The current guidelines for the workup of sepsis, also known as Systemic Inflammatory Response Syndrome, involve several key steps:
- Early goal-directed resuscitation of the septic patient during the first 6 hours after recognition 3
- Appropriate diagnostic studies to ascertain causative organisms before starting antibiotics 3
- Early administration of broad-spectrum antibiotic therapy 3, 4
- Reassessment of antibiotic therapy with microbiology and clinical data to narrow coverage, when appropriate 3
- A usual 7-10 days of antibiotic therapy guided by clinical response 3
Fluid Resuscitation and Vasopressor Therapy
Fluid resuscitation and vasopressor therapy are crucial in managing sepsis:
- Liberal and restrictive fluid strategies are comparable in efficacy, but restrictive fluid regimens have a lower incidence of fluid overload 5
- Balanced crystalloids are safer and more effective than normal saline 5
- Albumin replacement is safe and effective in reducing mortality in patients with sepsis and septic shock 5
- Vasopressor therapy is indicated when fluid resuscitation fails to restore adequate mean arterial pressure and organ perfusion 4
Antibiotic Therapy and Timing
The timing of antibiotic therapy is critical in sepsis management:
- Early antibiotic therapy can improve clinical outcomes and should be given within one hour of suspected sepsis 4
- There is limited evidence on the optimal timing of broad-spectrum antibiotics in adult patients with severe sepsis in the ED pre-ICU admission 6
- High-dose meropenem may be effective in critically ill patients with sepsis and septic shock, but further research is needed to confirm its safety and efficacy 7
Other Considerations
Other important considerations in sepsis management include: