What are the treatment guidelines for patients with suspected sepsis?

Treatment Guidelines for Suspected Sepsis

Sepsis and septic shock are medical emergencies requiring immediate intervention, with treatment and resuscitation beginning immediately upon recognition to reduce mortality and improve outcomes. 1, 2

Initial Resuscitation and Assessment

• Obtain serum lactate measurement immediately; if elevated, remeasure within 2-4 hours to guide resuscitation 1, 2
• Administer at least 30 mL/kg of IV crystalloid fluid within the first 3 hours for patients with sepsis-induced hypoperfusion 1
• Following initial fluid resuscitation, guide additional fluids by frequent reassessment of hemodynamic status 1
• Target a mean arterial pressure (MAP) of 65 mmHg in patients requiring vasopressors 1, 2
• Use dynamic rather than static variables to predict fluid responsiveness when available 1
• Consider further hemodynamic assessment (such as cardiac function evaluation) if clinical examination doesn't lead to a clear diagnosis 1

Antimicrobial Therapy

• Obtain appropriate routine microbiologic cultures (including at least two sets of blood cultures) before starting antimicrobial therapy if doing so doesn't substantially delay antibiotic administration 1, 3
• Administer IV antimicrobials within one hour of sepsis or septic shock recognition 1, 3, 4
• Use empiric broad-spectrum therapy with one or more antimicrobials to cover all likely pathogens (including bacterial and potentially fungal or viral coverage) 1, 3
• For septic shock, consider empiric combination therapy using at least two antibiotics of different antimicrobial classes aimed at the most likely bacterial pathogens 1, 3
• Narrow empiric antimicrobial therapy once pathogen identification and sensitivities are established and/or adequate clinical improvement is noted 1, 3
• Optimize dosing strategies based on pharmacokinetic/pharmacodynamic principles and specific drug properties 1, 3
• Consider extended or continuous infusion of beta-lactams after an initial loading dose to achieve therapeutic levels 4, 5

Risk Stratification and Monitoring

• Use NEWS2 score to evaluate risk of severe illness or death from sepsis 1:
  • Score ≥7: High risk of severe illness or death
  • Score 5-6: Moderate risk of severe illness or death 1
• Re-evaluate risk periodically based on clinical status 1:
  • Every 30 minutes for high-risk patients
  • Every hour for moderate-risk patients
  • Every 4-6 hours for low-risk patients 1
• Monitor for signs of tissue hypoperfusion including mottled skin, decreased capillary refill, peripheral cyanosis, and mental status changes 1, 2

Source Control

• Implement source control intervention as soon as logistically possible when a controllable source of infection is identified 4
• Remove intravascular access devices that are potential sources of sepsis promptly after establishing other vascular access 1

Ongoing Management

• For patients with sepsis-induced ARDS, use lung-protective ventilation strategies with tidal volumes of 6 mL/kg predicted body weight and plateau pressures ≤30 cm H2O 1
• Maintain head of bed elevated to 30-45 degrees in mechanically ventilated patients to limit aspiration risk 1
• Use a conservative rather than liberal fluid strategy for patients with established sepsis-induced ARDS who don't have evidence of tissue hypoperfusion 1
• Consider RBC transfusion only when hemoglobin decreases to <7.0 g/dL (target 7.0-9.0 g/dL) once tissue hypoperfusion has resolved 1

De-escalation and Duration

• Review antimicrobial regimen daily for possible de-escalation 3, 5
• Consider discontinuing empiric combination therapy within 3-5 days in response to clinical improvement 3
• Typical treatment duration is 7-10 days; longer courses may be necessary for slow clinical response, undrainable infection sites, or specific pathogens 3, 6
• Consider using procalcitonin levels to guide antibiotic discontinuation (not initiation) in patients initially suspected of having sepsis 3, 4

Potential Pitfalls and Caveats

• Overly broad antibiotic use can lead to complications in up to 17% of patients within 90 days, including development of resistant organisms 7
• Studies show that approximately 1 in 3 patients treated for suspected sepsis may not have bacterial infection, and 4 in 5 patients with confirmed bacterial infections receive broader spectrum antibiotics than necessary 7
• Avoid sustained systemic antimicrobial prophylaxis in patients with severe inflammatory states of noninfectious origin (e.g., severe pancreatitis, burn injury) 1
• Interpret NEWS2 scores in context of the person's underlying physiology and comorbidities 1
• Consider the risk of antibiotic-associated complications when selecting empiric therapy 7