What are the guidelines for managing sepsis?

Sepsis Management Guidelines

Sepsis requires immediate intervention with administration of IV antimicrobials within one hour of recognition for both sepsis and septic shock to reduce mortality and improve outcomes. 1

Initial Assessment and Recognition

• Implement routine screening of potentially infected seriously ill patients for early sepsis identification to allow earlier implementation of therapy 1, 2
• Obtain appropriate routine microbiologic cultures (including at least two sets of blood cultures - aerobic and anaerobic) before starting antimicrobial therapy if doing so doesn't cause substantial delay (>45 minutes) in antibiotic administration 1
• Measure serum lactate levels as a marker of tissue hypoperfusion; if elevated, remeasure within 2-4 hours to guide resuscitation 2, 3
• Perform imaging studies promptly to confirm and identify potential sources of infection 1, 2

Initial Resuscitation

• Administer at least 30 mL/kg of IV crystalloid fluid within the first 3 hours for patients with sepsis-induced hypoperfusion 1, 3
• Guide additional fluid administration by frequent reassessment of hemodynamic status using dynamic rather than static variables to predict fluid responsiveness when available 1, 3
• Target a mean arterial pressure (MAP) ≥65 mmHg in patients requiring vasopressors 1
• Use norepinephrine as the first-choice vasopressor for septic shock 2
• For refractory shock, consider vasopressin at 0.01 to 0.07 units/minute as an adjunct to norepinephrine 4

Antimicrobial Therapy

• Administer IV antimicrobials within one hour of recognition of sepsis or septic shock 1
• Use empiric broad-spectrum therapy with one or more antimicrobials to cover all likely pathogens (bacterial, potentially fungal or viral) 1, 5
• For septic shock, consider empiric combination therapy (using at least two antibiotics of different antimicrobial classes) aimed at the most likely bacterial pathogens 1, 6
• Optimize antimicrobial dosing based on pharmacokinetic/pharmacodynamic principles, especially in critically ill patients with altered drug metabolism 5, 7
• Reassess antimicrobial regimen daily for potential de-escalation to prevent resistance development 1
• De-escalate combination therapy within 3-5 days in response to clinical improvement and/or evidence of infection resolution 1, 8
• Duration of therapy typically 7-10 days; longer courses may be appropriate in patients with slow clinical response, undrainable infection foci, bacteremia with S. aureus, fungal/viral infections, or immunologic deficiencies 1
• Consider using procalcitonin levels to assist in discontinuation of empiric antibiotics in patients initially appearing septic but with no subsequent evidence of infection 1, 6

Source Control

• Implement source control interventions (drainage, debridement) as soon as possible after diagnosis 2, 9
• Remove intravascular access devices that are potential sources of sepsis promptly after establishing other vascular access 2, 3

Ongoing Management

• For patients with sepsis-induced ARDS, use lung-protective ventilation strategies with tidal volumes of 6 mL/kg predicted body weight 2, 3
• Place patients in semi-recumbent position (head of bed elevated 30-45°) to limit aspiration risk 2, 3
• Target hemoglobin of 7-9 g/dL in the absence of tissue hypoperfusion, ischemic coronary artery disease, or acute hemorrhage 2, 9
• Maintain blood glucose ≤180 mg/dL using a protocolized approach 2

Special Considerations

• For neutropenic patients with severe sepsis, consider combination empirical therapy 1
• For patients with difficult-to-treat, multidrug-resistant pathogens (Acinetobacter, Pseudomonas), consider combination therapy 1
• For severe infections with respiratory failure and septic shock due to P. aeruginosa, consider combination therapy with extended-spectrum β-lactam and either an aminoglycoside or fluoroquinolone 1
• For septic shock from bacteremic S. pneumoniae infections, consider combination of β-lactam and macrolide 1
• Initiate antiviral therapy as early as possible in patients with sepsis or septic shock of viral origin 1

Common Pitfalls and Caveats

• Avoid delay in antimicrobial administration - each hour delay increases mortality 5, 8
• Avoid sustained systemic antimicrobial prophylaxis in patients with severe inflammatory states of noninfectious origin (e.g., severe pancreatitis, burn injury) 1, 3
• Don't wait for all cultures before starting antibiotics if it will delay treatment 1, 6
• Don't continue broad-spectrum antibiotics unnecessarily - de-escalate as soon as possible based on culture results 1, 9
• Don't forget to evaluate for and reverse pneumothorax, pericardial tamponade, or endocrine emergencies in patients with refractory shock 1