What is the recommended initial management for sepsis?

Initial Management of Sepsis

The recommended initial management for sepsis includes obtaining blood cultures, administering broad-spectrum antibiotics within one hour of recognition, and initiating appropriate fluid resuscitation, with early source control within 12 hours. 1, 2

Immediate Assessment and Interventions

Diagnosis and Initial Testing

• Obtain at least 2 sets of blood cultures (aerobic and anaerobic) before starting antibiotics
  • One drawn percutaneously and one through each vascular access device (unless inserted <48 hours ago)
  • Do not delay antibiotics >45 minutes to obtain cultures 1, 2
• Measure serum lactate as part of initial assessment 2
• Order appropriate imaging studies promptly to identify potential source of infection 1, 2

Antimicrobial Therapy

• Administer broad-spectrum IV antibiotics within 1 hour of recognition of sepsis or septic shock 1, 2
• Select empiric antimicrobial therapy that:
  • Covers all likely pathogens (bacterial, fungal, or viral)
  • Provides adequate tissue penetration to the presumed source
  • Accounts for local resistance patterns and patient factors 1, 2

Fluid Resuscitation

• For hypotension or lactate >4 mmol/L, administer initial crystalloid fluid bolus of 20-30 mL/kg 2
• Reassess hemodynamic status frequently during initial resuscitation

Vasopressor Support

• If hypotension persists despite initial fluid resuscitation, initiate vasopressors
• Target mean arterial pressure (MAP) ≥65 mmHg 2
• Norepinephrine is the first-line vasopressor agent 2

Source Control

• Identify specific anatomical source of infection requiring intervention
• Implement source control measures within 12 hours when feasible 1, 2
• This may include:
  • Removal of infected devices or catheters
  • Drainage of abscesses
  • Debridement of infected tissue 2

Ongoing Management

Antimicrobial Stewardship

• Reassess antimicrobial regimen daily for potential de-escalation 1, 2
• Narrow therapy once pathogen identification and sensitivities are established 1
• Discontinue antibiotics if infection is ruled out as cause 2
• Typical duration of therapy is 7-10 days, though may be longer for certain infections 1

Additional Supportive Care

• For mechanically ventilated patients:
  • Maintain plateau pressures <30 cm H₂O
  • Target tidal volume of 6 mL/kg predicted body weight
  • Elevate head of bed 30-45 degrees 2
• Consider low-dose steroids for septic shock per hospital policy 2, 3
• Maintain glucose control <150 mg/dL (8.3 mmol/L) 2

Common Pitfalls to Avoid

• Delaying antibiotics - Each hour delay in administration of effective antibiotics is associated with measurable increase in mortality 1, 4
• Inadequate source control - Failure to identify and address the source of infection within 12 hours when possible 1, 2
• Inappropriate empiric antibiotic selection - Mortality rates are significantly higher with inappropriate initial antibiotic therapy (36.8% vs 17.5%) 4
• Failure to de-escalate - De-escalation is associated with lower mortality rates (5.0% for severe sepsis and 9.7% for septic shock) compared to no de-escalation (19.0% and 35.7%, respectively) 4
• Inadequate fluid resuscitation - Insufficient initial fluid administration can worsen tissue hypoperfusion 2

The most recent guidelines emphasize rapid recognition of sepsis through screening programs, prompt administration of appropriate antibiotics, adequate fluid resuscitation, and early source control as the cornerstones of initial sepsis management 1, 2.