What is the initial treatment for a patient with sepsis?

Initial Treatment for Sepsis

The initial treatment for a patient with sepsis should include administration of intravenous antimicrobials within one hour of sepsis recognition, along with at least 30 mL/kg of crystalloid fluids within the first 3 hours. 1, 2

Immediate Actions

Antimicrobial Therapy

• Administer broad-spectrum IV antimicrobials within 1 hour of sepsis recognition 1, 2

  • Use one or more antimicrobials that cover all likely pathogens (bacterial, potentially fungal or viral)
  • Choose antibiotics based on:
    • Suspected source of infection
    • Local resistance patterns
    • Patient's risk factors for multidrug-resistant organisms
    • Previous antibiotic exposure

• Obtain appropriate cultures before starting antibiotics 1, 2

  • At least two sets of blood cultures (aerobic and anaerobic)
  • Cultures from all potential sites of infection
  • Do not delay antimicrobial administration >45 minutes to obtain cultures

Fluid Resuscitation

• Administer at least 30 mL/kg of IV crystalloids within the first 3 hours 2
  • Give as boluses of 10-20 mL/kg (up to 40-60 mL/kg in the first hour)
  • Use balanced crystalloids rather than 0.9% saline to reduce risk of acute kidney injury
  • Avoid synthetic colloids (hydroxyethyl starch, gelatin) due to increased risk of renal failure

Risk Stratification

• Calculate NEWS2 score to determine risk level and guide treatment timing 1
  • High risk (NEWS2 ≥7): Antibiotics within 1 hour
  • Moderate risk: Antibiotics within 3 hours
  • Low risk: Antibiotics within 6 hours

Ongoing Management

Hemodynamic Monitoring and Support

• Target mean arterial pressure (MAP) ≥65 mmHg 2
• Monitor for response to fluid administration:
  • Improvement in blood pressure
  • Increased urine output
  • Normalized capillary refill

Reassessment and De-escalation

• Reassess antimicrobial regimen daily 1
• Narrow therapy once pathogen identification and sensitivities are established 1
• De-escalate to most appropriate single therapy as soon as susceptibility profile is known 1
• Limit combination therapy to 3-5 days maximum 1

Source Control

• Identify source of infection as rapidly as possible 2
• Implement source control interventions promptly (e.g., drainage of abscess, removal of infected device) 2

Monitoring for Complications

Fluid Overload

• Monitor for signs of fluid overload 2:
  • Increased jugular venous pressure
  • Pulmonary crackles
  • Peripheral edema
  • Decreased oxygen saturation
• Reduce or suspend fluid administration if signs of overload appear 2

Antibiotic-Related Complications

• Monitor for adverse effects of antibiotics
• Adjust dosing based on organ function and pharmacokinetic/pharmacodynamic principles 2

Common Pitfalls to Avoid

1. Delaying antimicrobial therapy - Each hour delay in appropriate antibiotic administration increases mortality 3
2. Inadequate source control - Failure to identify and control the source of infection compromises treatment efficacy
3. Inappropriate antibiotic selection - Failure to cover likely pathogens increases mortality
4. Excessive fluid administration - Can lead to pulmonary edema and other complications
5. Failure to de-escalate therapy - Continuing broad-spectrum antibiotics unnecessarily promotes resistance

Duration of Therapy

• Typically limit antibiotic therapy to 7-10 days 4, 5
• Consider longer duration if:
  • Response is slow
  • Inadequate source control
  • Immunologic deficiencies are present

The evidence strongly supports that early recognition and prompt intervention are critical for improving outcomes in sepsis. While some recent studies have questioned the precise relationship between time-to-antibiotics and mortality 6, the consensus from major guidelines remains that rapid administration of appropriate antimicrobials and adequate fluid resuscitation are cornerstones of initial sepsis management.