What are the guidelines for managing sepsis, including labs and medications to order?

Sepsis Management Guidelines: Labs and Medications

Antimicrobial therapy must be initiated within one hour of sepsis recognition, using broad-spectrum antibiotics that cover all likely pathogens. 1, 2

Initial Assessment and Diagnosis

Laboratory Tests

• Obtain at least two sets of blood cultures (both aerobic and anaerobic bottles) before starting antimicrobial therapy, as long as this doesn't delay treatment >45 minutes 1, 2
• Measure serum lactate levels as a marker of tissue hypoperfusion 1
• Consider 1,3-β-D-glucan assay, mannan, and anti-mannan antibody assays if invasive candidiasis is suspected 1
• Obtain appropriate cultures from suspected infection sites (urine, respiratory, wound, etc.) 2
• Complete blood count, comprehensive metabolic panel, coagulation studies, and inflammatory markers should be ordered 2

Imaging

• Perform prompt imaging studies to identify potential sources of infection 1, 2

Antimicrobial Therapy

Initial Antimicrobial Selection

• Administer IV antimicrobials within one hour of sepsis recognition 1, 2
• Use broad-spectrum antibiotics that cover all likely pathogens (bacterial, potentially fungal or viral) 1
• For septic shock, use combination therapy with at least two antibiotics of different antimicrobial classes targeting the most likely bacterial pathogens 1, 2
• Consider the following combinations for specific scenarios:
  • Extended-spectrum β-lactam plus either aminoglycoside or fluoroquinolone for Pseudomonas aeruginosa infections 1
  • β-lactam plus macrolide for bacteremic Streptococcus pneumoniae infections 1
  • Broader coverage for patients with neutropenia or at high risk for multidrug-resistant pathogens 1

Antimicrobial Management

• Reassess antimicrobial regimen daily for potential de-escalation 1
• Narrow therapy once pathogen identification and sensitivities are available 1
• Do not continue empiric combination therapy for more than 3-5 days 1
• Typical duration of therapy is 7-10 days 1
• Consider longer courses for:
  • Slow clinical response
  • Undrainable foci of infection
  • Bacteremia with Staphylococcus aureus
  • Some fungal and viral infections
  • Immunologic deficiencies including neutropenia 1

Hemodynamic Support

Fluid Resuscitation

• Administer crystalloid fluids at 30 mL/kg for initial resuscitation in patients with sepsis-induced hypoperfusion 1, 2
• Target a mean arterial pressure (MAP) ≥65 mmHg in patients requiring vasopressors 1, 2
• Consider albumin when patients require substantial amounts of crystalloids 1
• Avoid hetastarch formulations 1

Vasopressors and Inotropes

• Norepinephrine is the first-choice vasopressor 1
• Add epinephrine when an additional agent is needed to maintain adequate blood pressure 1
• Consider vasopressin (0.03 U/min) to either raise MAP or decrease norepinephrine dose 1
• Use dobutamine in patients with persistent hypoperfusion despite adequate fluid loading and vasopressors 1
• Place an arterial catheter as soon as practical in patients requiring vasopressors 1

Source Control

• Implement source control interventions as soon as possible after diagnosis 1
• Remove intravascular access devices confirmed to be the source of sepsis after establishing alternative vascular access 1

Additional Management Considerations

• Target hemoglobin of 7-9 g/dL in the absence of tissue hypoperfusion, ischemic coronary artery disease, or acute hemorrhage 1
• Use low tidal volume ventilation (6 mL/kg predicted body weight) for patients with sepsis-induced ARDS 1
• Maintain blood glucose ≤180 mg/dL using a protocolized approach 1, 2
• Provide deep vein thrombosis prophylaxis 1
• Use stress ulcer prophylaxis in patients with bleeding risk factors 1
• Elevate head of bed to 30-45 degrees in mechanically ventilated patients 1, 2

Common Pitfalls and Caveats

• Delays in antimicrobial administration significantly increase mortality - establish processes to ensure rapid delivery 1, 3
• Failure to obtain appropriate cultures before starting antibiotics can hinder pathogen identification 1, 2
• Inadequate source control is a common reason for persistent sepsis 1
• Inappropriate or prolonged broad-spectrum antibiotic use contributes to antimicrobial resistance 3, 4
• Underestimating fluid requirements or overaggressive fluid administration can both be detrimental 1, 2
• Failure to reassess and de-escalate antimicrobial therapy when appropriate 1, 3

Remember that sepsis is a medical emergency requiring immediate intervention. The most critical elements are rapid antimicrobial administration, appropriate fluid resuscitation, source control, and ongoing reassessment of therapy.