What is the initial management for a patient with sepsis?

Initial Management of Sepsis

Administer IV broad-spectrum antimicrobials within one hour of recognizing sepsis or septic shock, immediately after obtaining blood cultures, and simultaneously initiate aggressive fluid resuscitation with at least 30 mL/kg of crystalloid within the first 3 hours. 1

Immediate Priorities (Within First Hour)

Obtain Cultures Before Antibiotics

• Draw at least two sets of blood cultures (aerobic and anaerobic) before starting antimicrobials 1, 2
• This should not delay antibiotic administration beyond 45 minutes 2, 3
• Sample any suspected infection sites (fluid, tissue) when feasible 3

Antimicrobial Therapy

• Administer IV antimicrobials within one hour of sepsis recognition—this is a strong recommendation with moderate quality evidence 1
• Use broad-spectrum therapy covering all likely pathogens (bacterial, and consider fungal/viral if indicated) 1, 2
• For septic shock specifically, use combination therapy with at least two antibiotics from different antimicrobial classes targeting the most likely bacterial pathogens 1, 2
• Select agents based on suspected source, local resistance patterns, and patient risk factors for multidrug-resistant organisms 4

Fluid Resuscitation

• Administer at least 30 mL/kg of IV crystalloid fluid within the first 3 hours for sepsis-induced hypoperfusion 1, 2, 3
• Use crystalloids as first-line fluid 1
• Continue fluid challenges as long as hemodynamic improvement occurs, guided by dynamic or static variables 1

Hemodynamic Monitoring

• Measure serum lactate levels as a marker of tissue hypoperfusion 2
• Consider guiding resuscitation to normalize lactate in patients with elevated levels 1
• Document Glasgow Coma Scale for prognostic value and monitoring 1

Vasopressor Support (If Needed)

• Norepinephrine is the first-choice vasopressor to maintain mean arterial pressure ≥65 mmHg 1, 2
• Add epinephrine when an additional agent is needed 1
• Vasopressin (0.03 U/min) can be added to norepinephrine but should not be used as initial vasopressor 1
• Dopamine is not recommended except in highly selected circumstances 1
• Add dobutamine if myocardial dysfunction is present with elevated cardiac filling pressures and low cardiac output 1

Source Control

• Identify and control the source of infection within 12 hours when feasible 3
• Remove intravascular access devices confirmed as the infection source after establishing alternative access 2
• Drain or debride infected sites as appropriate 3

De-escalation and Duration

• Reassess antimicrobial therapy daily for potential de-escalation once culture results are available 1, 5, 3
• Narrow therapy once pathogen identification and sensitivities are established 1
• If combination therapy is used for septic shock, discontinue within the first few days in response to clinical improvement 1
• Antimicrobial duration of 7-10 days is adequate for most serious infections associated with sepsis 1
• Longer courses are appropriate for slow clinical response, undrainable foci, S. aureus bacteremia, fungal/viral infections, or immunodeficiency 1

Common Pitfalls to Avoid

• Do not delay antibiotics beyond one hour while waiting for imaging or other diagnostics in patients with sepsis or septic shock 1, 6
• Avoid inadequate initial fluid resuscitation—the 30 mL/kg bolus is a minimum, and some patients require more rapid administration and greater volumes 1
• Do not use hetastarch formulations for fluid resuscitation 1
• Avoid continuing broad-spectrum or combination therapy longer than necessary—practice antimicrobial stewardship 1, 4
• Do not miss occult sources requiring surgical or procedural source control 3

Risk Stratification Considerations

While the Surviving Sepsis Campaign emphasizes one-hour antibiotic administration for all sepsis patients 1, some evidence suggests that patients without septic shock may tolerate slightly longer evaluation periods to confirm infection and avoid antibiotic overuse 7, 8. However, in clinical practice, err on the side of early treatment for any patient with suspected sepsis, as the mortality risk increases with each hour of delay in truly infected patients 9.