What is the initial management of sepsis?

Initial Management of Sepsis

The initial management of sepsis requires administration of intravenous antimicrobials within the first hour of recognition for both sepsis and septic shock, along with appropriate cultures and source control. 1

Immediate Actions

Recognition and Diagnosis

• Implement routine screening of potentially infected seriously ill patients for sepsis to allow earlier intervention 1
• Obtain appropriate routine microbiologic cultures (including at least two sets of blood cultures - both aerobic and anaerobic) before starting antimicrobial therapy if doing so results in no substantial delay (>45 minutes) in antibiotic administration 1
• Perform imaging studies promptly to confirm potential sources of infection 1

Antimicrobial Therapy

• Administer IV antimicrobials within one hour of recognition of sepsis and septic shock 1, 2
• Use empiric broad-spectrum therapy with one or more antimicrobials to cover all likely pathogens (bacterial, potentially fungal or viral) 1
• Select antimicrobials that penetrate in adequate concentrations into tissues presumed to be the source of sepsis 1, 2
• For septic shock, consider empiric combination therapy (using at least two antibiotics of different antimicrobial classes) aimed at the most likely bacterial pathogens 1
• For specific scenarios requiring combination therapy:
  • Pseudomonas aeruginosa bacteremia: extended-spectrum β-lactam plus either an aminoglycoside or fluoroquinolone 1
  • Bacteremic Streptococcus pneumoniae infections with septic shock: β-lactam plus macrolide 1

Ongoing Management

Antimicrobial Optimization

• Reassess antimicrobial regimen daily for potential de-escalation 1
• De-escalate to the most appropriate single therapy as soon as susceptibility profile is known 1
• If combination therapy is used for septic shock, discontinue it within the first few days in response to clinical improvement and/or evidence of infection resolution 1
• Optimize dosing strategies based on pharmacokinetic/pharmacodynamic principles and specific drug properties 1, 3

Duration of Therapy

• Typical duration of antimicrobial therapy is 7-10 days for most serious infections associated with sepsis and septic shock 1
• Consider longer courses in patients who:
  • Have a slow clinical response 1
  • Have undrainable foci of infection 1
  • Have bacteremia with Staphylococcus aureus 1
  • Have certain fungal or viral infections 1
  • Have immunologic deficiencies, including neutropenia 1
• Consider shorter courses in patients with rapid clinical resolution following effective source control of intra-abdominal or urinary sepsis 1

Source Control

• Identify specific anatomical diagnosis of infection requiring source control as rapidly as possible 1
• Implement source control measures within the first 12 hours after diagnosis when feasible 1

Special Considerations

Biomarkers

• Consider using procalcitonin levels to support shortening the duration of antimicrobial therapy 1
• Low procalcitonin levels may assist in discontinuing empiric antibiotics in patients who initially appeared septic but have no subsequent evidence of infection 1

Antimicrobial Stewardship

• Do not use antimicrobial agents in patients with severe inflammatory states determined to be of noninfectious cause 1
• Avoid sustained systemic antimicrobial prophylaxis in patients with severe inflammatory states of noninfectious origin (e.g., severe pancreatitis, burn injury) 1

Common Pitfalls to Avoid

• Delaying antimicrobial therapy beyond one hour of recognition of sepsis or septic shock 1, 4
• Using inadequate empiric coverage that doesn't address all likely pathogens 1, 3
• Continuing broad-spectrum or combination therapy longer than necessary 1, 5
• Failing to obtain appropriate cultures before starting antimicrobials 1
• Not reassessing the antimicrobial regimen daily for potential de-escalation 1, 2