What is the initial management for a patient with sepsis?

Initial Management of Sepsis

The initial management of sepsis requires immediate administration of IV antimicrobials within one hour of recognition, along with obtaining appropriate microbiologic cultures and providing early fluid resuscitation with 30 mL/kg of crystalloids for patients with hypoperfusion. 1

Diagnosis and Initial Assessment

• 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 (<48 hrs) inserted 1
• Measure serum lactate levels as a marker of tissue hypoperfusion 2
• Consider 1,3-β-D-glucan assay, mannan, and anti-mannan antibody assays if invasive candidiasis is suspected 1
• Perform prompt imaging studies to confirm a potential source of infection 1

Antimicrobial Therapy

• Administer IV antimicrobials within one hour of recognition for both sepsis and septic shock 1
• 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 septic shock, consider empiric combination therapy using at least two antibiotics of different antimicrobial classes aimed at the most likely bacterial pathogens 1
• Optimize antimicrobial dosing based on pharmacokinetic/pharmacodynamic principles and specific drug properties 1
• De-escalate antimicrobial therapy once pathogen identification and sensitivities are established and/or adequate clinical improvement is noted 1
• Duration of antimicrobial treatment should typically be 7-10 days for most serious infections associated with sepsis and septic shock 1

Hemodynamic Support and Fluid Resuscitation

• Administer at least 30 mL/kg of IV crystalloid fluid within the first 3 hours for sepsis-induced hypoperfusion 1, 3
• Continue fluid challenge technique as long as hemodynamic improvement is observed 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 norepinephrine to either raise MAP to target or to decrease norepinephrine dose, but do not use as the initial vasopressor 1
• Consider dobutamine infusion in patients with myocardial dysfunction (elevated cardiac filling pressures and low cardiac output) or ongoing signs of hypoperfusion despite adequate intravascular volume and MAP 1

Source Control

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

Ongoing Management and Monitoring

• Reassess antimicrobial therapy daily for potential de-escalation 1, 4
• Guide resuscitation to normalize lactate in patients with elevated lactate levels as a marker of tissue hypoperfusion 1
• Monitor patients according to their risk level, with higher-risk patients requiring more frequent monitoring 3

Common Pitfalls to Avoid

• Delaying antimicrobial therapy while waiting for cultures - this increases mortality risk by approximately 8% for each hour of delay 5
• Using sustained systemic antimicrobial prophylaxis in patients with severe inflammatory states of noninfectious origin (e.g., severe pancreatitis, burn injury) 1
• Continuing combination therapy beyond the first few days in patients showing clinical improvement 1
• Failing to narrow antimicrobial therapy once the pathogen is identified, which can lead to antibiotic resistance and adverse effects 4

Special Considerations

• Consider longer antimicrobial courses for patients with slow clinical response, undrainable foci of infection, Staphylococcus aureus bacteremia, some fungal and viral infections, or immunologic deficiencies including neutropenia 1
• Consider shorter antimicrobial courses for patients with rapid clinical resolution following effective source control of intra-abdominal or urinary sepsis and those with anatomically uncomplicated pyelonephritis 1
• Be aware of higher risk of resistant pathogens if the infection was acquired in a healthcare setting, the patient has been hospitalized for more than 1 week, or has received previous antimicrobial therapy 3