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, while simultaneously initiating aggressive fluid resuscitation with 30 mL/kg of crystalloid. 1, 2

Immediate Actions (Within First Hour)

Antimicrobial Therapy

• Start IV antibiotics within 60 minutes of sepsis recognition—this is a strong recommendation with moderate quality evidence and represents the single most critical intervention for reducing mortality 1, 2
• Obtain at least two sets of blood cultures (aerobic and anaerobic) before antibiotics, but do not delay antimicrobials beyond 45 minutes if cultures cannot be obtained quickly 1, 2
• Use empiric broad-spectrum therapy covering all likely pathogens (bacterial, and consider fungal/viral if indicated) 1, 2
• For septic shock specifically, consider combination therapy using at least two antibiotics from different antimicrobial classes targeting the most likely bacterial pathogens 1, 2

Critical pitfall to avoid: While the 1-hour antibiotic mandate is emphasized in guidelines, recognize that approximately 30-40% of patients initially suspected of having sepsis have noninfectious conditions—however, in the acute setting when sepsis is suspected, err on the side of immediate treatment 3

Fluid Resuscitation

• Administer at least 30 mL/kg of IV crystalloid within the first 3 hours for sepsis-induced hypoperfusion or septic shock 1, 2, 4
• Use crystalloids as the initial fluid of choice (strong recommendation) 1
• Consider albumin only if patients continue requiring substantial crystalloid to maintain adequate mean arterial pressure 1
• Avoid hetastarch formulations entirely 1
• Continue fluid challenges as long as hemodynamic improvement occurs based on dynamic or static variables 1

Hemodynamic Monitoring and Targets

• Measure serum lactate immediately as a marker of tissue hypoperfusion 1, 2
• Target mean arterial pressure (MAP) ≥65 mmHg if vasopressors are required 1, 2, 4
• Consider normalizing lactate levels in patients with elevated lactate to guide resuscitation 1, 4

Vasopressor Support (If Hypotension Persists After Fluids)

• Norepinephrine is the first-choice vasopressor to maintain MAP ≥65 mmHg (strong recommendation) 1, 2
• Add epinephrine as a second agent if additional support is needed 1
• Vasopressin (0.03 U/min) can be added to norepinephrine to raise MAP or decrease norepinephrine dose, but should not be used as the initial vasopressor 1
• Avoid dopamine except in highly selected circumstances 1
• Add dobutamine if myocardial dysfunction is present (elevated cardiac filling pressures with low cardiac output) or ongoing hypoperfusion despite adequate volume and MAP 1

Source Control and Additional Diagnostics

• Perform imaging studies promptly to confirm potential infection source 1
• Implement source control interventions (drainage, debridement, device removal) as soon as possible after diagnosis, ideally within 12 hours if feasible 2, 4
• Remove intravascular access devices if confirmed as the infection source, after establishing alternative access 2

Risk Stratification and Monitoring

The Surviving Sepsis Campaign recommends hospitals have performance improvement programs including sepsis screening for acutely ill, high-risk patients 1. Use structured assessment tools:

• NEWS2 score ≥7 indicates high risk requiring monitoring every 30 minutes 4
• Score 5-6 indicates moderate risk requiring hourly monitoring 4
• Lower scores require monitoring every 4-6 hours, but do not be falsely reassured—patients can deteriorate rapidly regardless of initial scores 1, 4

Antimicrobial Selection Considerations

• Base selection on patient factors, suspected source, and local resistance patterns 5, 6, 7
• Consider healthcare-associated infection risk factors: hospitalization >1 week, previous antimicrobial therapy, or healthcare setting acquisition 4, 6
• Ensure good penetration into the presumed infection source 5, 7
• For intra-abdominal infections, include anaerobic coverage 7
• Consider 1,3-β-D-glucan assay if invasive candidiasis is suspected 2

Early Reassessment and De-escalation

• Narrow antimicrobial 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
• Typical treatment duration is 7-10 days for most serious infections associated with sepsis 1
• Perform daily reassessment for potential de-escalation once culture results are available 4

Important nuance: While older guidelines emphasized rigid 1-hour antibiotic targets for all suspected sepsis, more recent evidence suggests that in patients without septic shock who are not critically ill, brief delays (up to 3-6 hours) to confirm infection may be acceptable to avoid antibiotic overuse 4, 8, 3. However, for septic shock or severe sepsis with organ dysfunction, the 1-hour target remains absolute 1, 2, 7.