What is the recommended treatment for sepsis using an abbreviated sepsis order set (ASOS)?

Abbreviated Sepsis Order Set (ASOS) for Treatment of Sepsis

The recommended treatment for sepsis using an abbreviated sepsis order set (ASOS) should include immediate administration of broad-spectrum antibiotics within one hour of recognition, aggressive fluid resuscitation with 30 mL/kg crystalloid for hypotension or lactate ≥4 mmol/L, and vasopressor therapy with norepinephrine as first-line agent to maintain mean arterial pressure ≥65 mmHg. 1, 2, 3

Initial Resuscitation and Hemodynamic Support

1. Fluid Resuscitation:

   • Administer 30 mL/kg crystalloid for hypotension or lactate ≥4 mmol/L 1, 2
   • Target MAP ≥65 mmHg 1, 2
   • After initial fluid bolus, assess fluid responsiveness before additional fluid administration 4

2. Vasopressor Therapy (if hypotension persists despite adequate fluid resuscitation):

   • First-line: Norepinephrine (0.1-1.3 μg/kg/min) 2, 3
   • Second-line options:
     • Add vasopressin (up to 0.03 U/min) to decrease norepinephrine dosage 1
     • Add epinephrine if target MAP not achieved 1, 3
   • Dopamine should only be used in highly selected patients with low risk of tachyarrhythmias 1
   • Place arterial catheter as soon as practical for patients requiring vasopressors 1

3. Corticosteroids:

   • Only for septic shock not responsive to adequate fluid resuscitation and vasopressor therapy
   • IV hydrocortisone 200 mg/day as continuous infusion 1, 2
   • Taper when vasopressors are no longer required 1
   • Do not use corticosteroids for sepsis without shock 1, 2

Antimicrobial Therapy

1. Timing and Selection:

   • Administer effective IV antimicrobials within the first hour of recognition of sepsis/septic shock 2, 3, 5
   • Obtain blood cultures before starting antibiotics (if no significant delay) 2
   • Choose broad-spectrum antibiotics covering both gram-positive and gram-negative organisms 2, 5

2. Recommended Empiric Regimens:

   • Moderate risk: Meropenem, imipenem/cilastatin, piperacillin/tazobactam, or ceftazidime 2
   • High risk: Antipseudomonal beta-lactam plus aminoglycoside 2
   • Consider adding vancomycin if suspected catheter-related infection, known MRSA colonization, skin/soft tissue infection, or hemodynamic instability 2

3. Duration and De-escalation:

   • Standard duration: 7-10 days for most serious infections 2
   • Daily reassessment for potential de-escalation 1, 2
   • De-escalate to most appropriate single therapy once susceptibility profile is known 2
   • Consider shorter courses (5-7 days) with rapid clinical resolution and adequate source control 2
   • Empiric combination therapy should not be administered for more than 3-5 days 2

Source Control

• Ensure adequate source control within 12 hours 2
• Remove infected catheters or devices 2

Blood Product Administration

• Transfuse RBCs only when hemoglobin <7.0 g/dL (target 7.0-9.0 g/dL) once tissue hypoperfusion has resolved 1, 2
• Do not use erythropoietin for anemia associated with sepsis 1
• Do not use fresh frozen plasma to correct laboratory clotting abnormalities without bleeding or planned procedures 1
• Administer platelets prophylactically when:
  • Counts <10,000/mm³ without bleeding
  • Counts <20,000/mm³ with significant bleeding risk
  • Higher counts (≥50,000/mm³) for active bleeding, surgery, or invasive procedures 1, 2

Mechanical Ventilation (for sepsis-induced ARDS)

• Target tidal volume of 6 mL/kg predicted body weight 1
• Plateau pressures ≤30 cm H2O 1
• Apply PEEP to avoid alveolar collapse 1
• Use higher rather than lower levels of PEEP for moderate or severe ARDS 1
• Consider prone positioning for PaO2/FiO2 ratio ≤100 mm Hg 1
• Elevate head of bed to 30-45 degrees 1

Monitoring and Reassessment

• Reassess antimicrobial regimen daily 2
• Consider procalcitonin levels to guide duration of therapy 2
• Monitor for signs of refractory shock (continued MAP ≤65 mm Hg, lactate ≥4 mmol/L, altered mental status despite initial interventions) 6
• Systematically evaluate for inadequate source control, insufficient volume resuscitation, or inappropriate antimicrobial coverage if patient fails to respond to initial therapy 6

Special Considerations

• For immunocompromised patients, consider longer courses of antibiotic therapy 2
• For specific pathogens like Staphylococcus aureus bacteremia, longer treatment (4-6 weeks) may be required 2
• Consider peripheral administration of vasopressors through a 20-gauge or larger IV line if central access is delayed 3

This abbreviated sepsis order set provides a structured approach to managing sepsis with focus on interventions that reduce morbidity and mortality through early recognition and aggressive treatment.