What is the recommended treatment approach for septicemia assessment?

Recommended Treatment Approach for Septicemia Assessment

The recommended treatment approach for septicemia assessment includes immediate administration of IV antimicrobials within one hour of recognition of sepsis or septic shock, followed by source control within 12 hours, and daily reassessment for de-escalation of therapy. 1

Initial Assessment and Antimicrobial Therapy

• Administer IV antimicrobials as soon as possible and within one hour of recognition of sepsis or septic shock 1
• Obtain appropriate cultures before starting antimicrobial therapy if this does not significantly delay administration (>45 minutes) 2
• Use empiric broad-spectrum therapy with one or more antimicrobials to cover all likely pathogens (including bacterial and potentially fungal or viral coverage) 1
• For patients with septic shock, use empiric combination therapy (using at least two antibiotics of different antimicrobial classes) aimed at the most likely bacterial pathogens 1
• For patients with sepsis without shock, combination therapy is not routinely recommended 1
• Optimize antimicrobial dosing based on pharmacokinetic/pharmacodynamic principles and specific drug properties 1

Source Control

• Identify a specific anatomic diagnosis of infection requiring source control as rapidly as possible 1
• Implement source control intervention as soon as medically and logistically practical, within the first 12 hours after diagnosis 1
• Promptly remove intravascular access devices that are a possible source of sepsis or septic shock after other vascular access has been established 1
• Use the intervention associated with the least physiologic insult (e.g., percutaneous rather than surgical drainage of an abscess) 1

Ongoing Management and De-escalation

• Narrow antimicrobial therapy once pathogen identification and sensitivities are established and/or adequate clinical improvement is noted 1
• Perform daily assessment for de-escalation of antimicrobial therapy 1
• If combination therapy is used for septic shock, de-escalate with discontinuation of combination therapy within the first few days in response to clinical improvement 1
• Consider using procalcitonin levels to support shortening the duration of antimicrobial therapy or discontinuing empiric antibiotics in patients with limited clinical evidence of infection 1

Duration of Therapy

• For most serious infections associated with sepsis and septic shock, an antimicrobial treatment duration of 7 to 10 days is adequate 1
• Consider longer courses for patients with slow clinical response, undrainable foci of infection, bacteremia with Staphylococcus aureus, some fungal and viral infections, or immunologic deficiencies including neutropenia 1
• Consider shorter courses for patients with rapid clinical resolution following effective source control, particularly for intra-abdominal or urinary sepsis 1

Special Considerations

• For neutropenic patients with sepsis, combination therapy is not routinely recommended 1
• For patients with Pseudomonas infections, consider combination therapy with a beta-lactam and either an aminoglycoside or fluoroquinolone 3, 4
• Do not use antimicrobial agents in patients with severe inflammatory states determined to be of noninfectious cause 1

Common Pitfalls and Caveats

• Delaying antimicrobial therapy increases mortality - each hour delay in antibiotic administration increases mortality risk 5, 6
• Failure to obtain adequate source control can lead to persistent infection despite appropriate antimicrobial therapy 2
• Continuing broad-spectrum combination therapy beyond 3-5 days without de-escalation increases risk of antimicrobial resistance and adverse effects 1, 2
• Inadequate initial antimicrobial coverage significantly increases mortality (51.7% vs 36.4% with appropriate therapy) 4
• Overuse of antibiotics can drive antimicrobial resistance - commitment to de-escalation and antimicrobial stewardship is essential 7