What is the medical management of sepsis?

Medical Management of Sepsis

The cornerstone of sepsis management is early recognition followed by immediate administration of appropriate antimicrobials within one hour of sepsis recognition, along with aggressive fluid resuscitation targeting tissue perfusion and a mean arterial pressure of at least 65 mmHg. 1

Initial Assessment and Diagnosis

• Obtain appropriate microbiological cultures (including at least two sets of blood cultures) before starting antimicrobial therapy, as long as this does not significantly delay treatment 1
• Screen acutely ill, high-risk patients for sepsis to allow earlier implementation of therapy 1
• Perform imaging studies promptly to confirm potential sources of infection 1

Antimicrobial Therapy

Timing and Selection

• Administer IV antimicrobials within one hour of sepsis recognition to reduce mortality 1, 2
• Use empiric broad-spectrum therapy with one or more antimicrobials that cover all likely pathogens (bacterial, fungal, or viral) 1
• For septic shock, use combination therapy with at least two antibiotics of different classes targeting the most likely pathogens 1
• For respiratory failure with septic shock, combine an extended-spectrum β-lactam with either an aminoglycoside or fluoroquinolone for suspected Pseudomonas aeruginosa 1
• For bacteremic Streptococcus pneumoniae infections with septic shock, combine a β-lactam and macrolide 1

Optimization and De-escalation

• Reassess antimicrobial regimen daily for potential de-escalation 1
• De-escalate to the most appropriate single therapy as soon as the susceptibility profile is known 1
• Limit empiric combination therapy to no more than 3-5 days 1
• Optimize antibiotic dosing based on pharmacokinetic/pharmacodynamic principles 1, 3
• For piperacillin-tazobactam in septic shock, maintain normal dosing (≥27g over 48 hours) rather than reducing doses, as dose reduction is associated with worse outcomes 4

Duration

• Typical duration of antimicrobial therapy is 7-10 days for most serious infections 1
• Consider longer courses for patients with slow clinical response, undrainable infection foci, S. aureus bacteremia, or certain fungal/viral infections 1

Hemodynamic Support

• Target a mean arterial pressure of at least 65 mmHg in patients requiring vasopressors 1
• Administer crystalloid fluids aggressively in patients with tissue hypoperfusion 1
• In adults with septic shock, initial fluid resuscitation should begin with immediate infusion of ≥30 ml/kg of crystalloid fluids 1
• If blood pressure is not restored after initial fluid resuscitation, initiate vasopressors, with norepinephrine as the first-line agent 1
• Guide resuscitation to normalize lactate levels in patients with elevated lactate as a marker of tissue hypoperfusion 1

Respiratory Support

• For patients with sepsis-induced ARDS, use lower tidal volumes and limit plateau pressures 1
• Maintain head of bed elevation between 30-45 degrees to limit aspiration risk and prevent ventilator-associated pneumonia 1
• Use spontaneous breathing trials and weaning protocols in mechanically ventilated patients with sepsis who are ready for weaning 1

Metabolic Management

• Use a protocolized approach to blood glucose management, targeting blood glucose levels ≤180 mg/dL 1
• Monitor blood glucose every 1-2 hours until glucose values and insulin infusion rates stabilize, then every 4 hours 1

Supportive Care

• Minimize continuous or intermittent sedation in mechanically ventilated patients 1
• Consider renal replacement therapy in patients with acute kidney injury 1
• Ensure continuous observation and frequent clinical examinations of septic patients 1
• Document vital signs at meaningful intervals and maintain good communication among team members 1

Common Pitfalls to Avoid

• Delaying antimicrobial administration beyond one hour of sepsis recognition significantly increases mortality 5
• Failing to obtain appropriate cultures before starting antibiotics can hinder pathogen identification 1
• Continuing broad-spectrum or combination therapy longer than necessary increases risk of antimicrobial resistance 1
• Inadequate fluid resuscitation or excessive fluid administration can worsen outcomes 1
• Reducing antibiotic dosing in septic shock patients due to concerns about renal dysfunction may lead to worse outcomes 4

By following this evidence-based approach to sepsis management with emphasis on early recognition, prompt antimicrobial therapy, appropriate fluid resuscitation, and supportive care, mortality and morbidity from sepsis can be significantly reduced 6.