What is the initial management for a patient with sepsis?

Initial Management of Sepsis

The initial management of a patient with sepsis should include administration of IV antimicrobials within one hour of recognition, obtaining appropriate microbiologic cultures before starting antibiotics, and early fluid resuscitation with 30 mL/kg of crystalloids for patients with hypoperfusion. 1

Immediate Assessment and Diagnosis

• Obtain at least two sets of blood cultures (both aerobic and anaerobic bottles) before starting antimicrobial therapy, with at least one drawn percutaneously and one drawn through each vascular access device (unless the device was recently inserted within 48 hours) 1
• Perform appropriate microbiologic cultures without delaying antimicrobial administration beyond one hour 1
• Consider 1,3-β-D-glucan assay, mannan, and anti-mannan antibody assays if invasive candidiasis is suspected 1, 2
• Measure serum lactate levels as a marker of tissue hypoperfusion 2
• Conduct prompt imaging studies to confirm potential sources of infection 1

Antimicrobial Therapy

• Administer IV antimicrobials within one hour of recognition for both sepsis and septic shock 1, 3
• Use empiric broad-spectrum therapy with one or more antimicrobials to cover all likely pathogens (including bacterial and potentially fungal or viral coverage) 1, 4
• For septic shock, consider empiric combination therapy using at least two antibiotics of different antimicrobial classes aimed at the most likely bacterial pathogens 1, 5
• Optimize antimicrobial dosing strategies based on pharmacokinetic/pharmacodynamic principles 1
• Reassess antimicrobial regimen daily for potential de-escalation once pathogen identification and sensitivities are established and/or adequate clinical improvement is noted 1, 4

Common Pitfalls in Antimicrobial Management:

• Delaying antimicrobial therapy while waiting for cultures - this increases mortality 6, 7
• Failing to cover all likely pathogens in the initial empiric regimen 5
• Continuing broad-spectrum antibiotics longer than necessary 3

Fluid Resuscitation and Hemodynamic Support

• Administer initial fluid challenge of at least 30 mL/kg of crystalloids for patients with sepsis-induced tissue hypoperfusion and suspicion of hypovolemia 1, 5
• Continue fluid challenge technique as long as hemodynamic improvement occurs based on either dynamic or static variables 1
• Target a mean arterial pressure (MAP) ≥65 mmHg in patients requiring vasopressors 1, 2
• Use norepinephrine as the first-choice vasopressor 1, 2
• Consider epinephrine when an additional agent is needed to maintain adequate blood pressure 1
• Add vasopressin (0.03 U/min) to either raise MAP to target or decrease norepinephrine dose, but don't use it as the initial vasopressor 1
• Consider dobutamine infusion in the presence of myocardial dysfunction (elevated cardiac filling pressures and low cardiac output) or ongoing signs of hypoperfusion despite adequate volume and MAP 1

Source Control

• Implement source control interventions as soon as possible after diagnosis 2
• Remove intravascular access devices if confirmed as the source of sepsis after establishing alternative vascular access 2

Duration of Therapy

• Treat most serious infections associated with sepsis and septic shock for 7-10 days 1
• Consider longer courses for patients with slow clinical response, undrainable foci of infection, Staphylococcus aureus bacteremia, certain fungal/viral infections, or immunologic deficiencies including neutropenia 1
• Consider shorter courses for patients with rapid clinical resolution following effective source control of intra-abdominal or urinary sepsis 1
• De-escalate combination therapy within the first few days in response to clinical improvement and/or evidence of infection resolution 1

Additional Management Considerations

• Target hemoglobin of 7-9 g/dL in the absence of tissue hypoperfusion, ischemic coronary artery disease, or acute hemorrhage 1, 2
• Use low tidal volume ventilation for patients with sepsis-induced ARDS 2
• Maintain blood glucose ≤180 mg/dL using a protocolized approach 2

By following this algorithmic approach to sepsis management with prompt recognition, early antimicrobial therapy, appropriate fluid resuscitation, and source control, patient outcomes can be significantly improved.