What is the immediate management for a patient presenting with symptoms of sepsis?

Immediate Management of Sepsis

Sepsis and septic shock are medical emergencies requiring immediate treatment and resuscitation within the first hour of recognition. 1

Recognition and Risk Assessment

• Use NEWS2 score to evaluate risk of severe illness or death from sepsis:

  • Score ≥7 indicates high risk of severe illness or death 1
  • Score 5-6 indicates moderate risk 1
  • Consider higher risk regardless of NEWS2 if patient has mottled appearance, non-blanching rash, cyanosis, or deteriorating condition 1

• Monitor patients according to risk level:

  • High risk: Every 30 minutes 1
  • Moderate risk: Every hour 1
  • Low risk: Every 4-6 hours 1

Initial Resuscitation

• Administer at least 30 mL/kg of IV crystalloid fluid within the first 3 hours for sepsis-induced hypoperfusion 1
• Guide additional fluid administration based on frequent reassessment of hemodynamic status 1
• Target mean arterial pressure of 65 mmHg in patients requiring vasopressors 1
• Consider normalizing lactate levels in patients with elevated lactate as a marker of tissue hypoperfusion 1
• Establish vascular access promptly; consider intraosseous access if IV access is difficult 1

Antimicrobial Therapy

• Administer IV antimicrobials based on risk level:

  • High risk (NEWS2 ≥7): Within 1 hour 1
  • Moderate risk (NEWS2 5-6): Within 3 hours 1
  • Low risk: Within 6 hours 1

• Obtain appropriate microbiologic cultures before starting antimicrobial therapy if doing so does not substantially delay administration 1

  • Always include at least two sets of blood cultures (aerobic and anaerobic) 1

• Use broad-spectrum therapy with one or more antimicrobials to cover all likely pathogens (including bacterial and potentially fungal or viral coverage) 1

• Consider combination therapy (using at least two antibiotics of different classes) for initial management of septic shock 1

• Narrow antimicrobial therapy once pathogen identification and sensitivities are established and/or adequate clinical improvement is noted 1

Special Considerations

• For patients with limited vascular access, consider:

  • Antimicrobials that can be administered as bolus or rapid infusion (e.g., β-lactams) 1
  • Intraosseous access for rapid administration of initial antimicrobial doses 1
  • Intramuscular preparations of certain first-line β-lactams (imipenem/cilastatin, cefepime, ceftriaxone, ertapenem) if vascular access is unavailable 1

• Consider higher risk of resistant pathogens if:

  • Infection was acquired in a healthcare setting 1
  • Patient has been hospitalized for more than 1 week 1
  • Patient has received previous antimicrobial therapy 1
  • Patient has underlying pulmonary or hepatic disease 1
  • Patient is on corticosteroids or has had organ transplantation 1

Ongoing Management

• Perform daily reassessment of antimicrobial therapy for potential de-escalation once culture results are available 2
• Continue broad-spectrum antibiotics for 7-10 days, depending on clinical response 2, 3
• Perform further hemodynamic assessment (such as cardiac function evaluation) if clinical examination does not lead to a clear diagnosis 1
• Consider source control (e.g., drainage of purulent collections) within the first 12 hours if feasible 2

Common Pitfalls to Avoid

• Delaying antimicrobial therapy while waiting for cultures - obtain cultures quickly but do not delay antibiotics 1
• Using inadequate empiric coverage - ensure broad-spectrum coverage of all likely pathogens 1
• Failing to reassess fluid status - continue frequent reassessment after initial resuscitation 1
• Neglecting to narrow antimicrobial therapy once pathogen is identified - practice antimicrobial stewardship 1
• Overlooking source control - identify and control source of infection when possible 2
• Failing to consider resistant organisms in healthcare-associated infections - adjust empiric therapy accordingly 1