What are the guidelines for managing sepsis?

Sepsis Management Guidelines

Administer IV antimicrobials within 60 minutes of recognizing sepsis or septic shock—this is the single most critical intervention for reducing mortality. 1, 2

Immediate Recognition and Initial Actions (First Hour)

Time-critical interventions must occur simultaneously:

• Obtain blood cultures immediately (at least two sets: one percutaneous, one through each vascular access device if present), but never delay antimicrobials beyond 45 minutes waiting for cultures 1, 2

• Measure serum lactate as a marker of tissue hypoperfusion to guide resuscitation 1, 2

• Administer 30 mL/kg IV crystalloid fluids within 3 hours for sepsis-induced hypoperfusion (hypotension or lactate ≥4 mmol/L) 1, 2

• Start broad-spectrum antimicrobials within 60 minutes—mortality risk increases 8% for each hour of delay 3, 4

Antimicrobial Therapy Strategy

Empiric antibiotic selection:

• Use broad-spectrum therapy covering all likely pathogens (bacterial, fungal, viral) based on the presumed infection source, patient risk factors, and local resistance patterns 1, 2

• Consider combination therapy (≥2 antibiotics from different classes) for:

  • Septic shock with respiratory failure, particularly for Pseudomonas aeruginosa 1, 2
  • Bacteremic Streptococcus pneumoniae with septic shock 2
  • Neutropenic patients 2
  • Multidrug-resistant pathogens like Acinetobacter 2

• Ensure adequate tissue penetration to the presumed infection source when selecting agents 1, 2

De-escalation strategy:

• Reassess antimicrobial therapy daily for potential narrowing once pathogen identification and sensitivities are available 1, 2

• Limit combination therapy to 3-5 days maximum, then de-escalate to single-agent therapy 2, 5

• Target total duration of 7-10 days for most patients 2, 5

• Consider longer courses only for slow clinical response, undrainable foci, S. aureus bacteremia, fungal/viral infections, or immunodeficiency 2

• Use procalcitonin levels to assist in discontinuing empiric antibiotics in patients without subsequent evidence of infection 2

Hemodynamic Resuscitation

Vasopressor management:

• Target mean arterial pressure (MAP) ≥65 mmHg in patients requiring vasopressors 1, 2

• Use norepinephrine as first-choice vasopressor 1

Fluid management:

• After initial 30 mL/kg crystalloid bolus, guide additional fluids by frequent reassessment of hemodynamic status using thorough clinical examination 1, 2

• Normalize lactate in patients with elevated levels as a resuscitation endpoint 2

Source Control

Implement source control interventions as soon as possible after diagnosis:

• Perform imaging studies promptly to confirm the infection source 1, 2

• Drain or debride infected tissues when feasible 1, 2

• Remove potentially infected foreign bodies or devices (catheters, prosthetics) 1, 2

Respiratory Support

Oxygenation and ventilation strategy:

• Apply oxygen to achieve saturation >90% 1, 2

• Position patients semi-recumbent (head of bed 30-45°) to reduce aspiration risk 1, 2

• Use low tidal volume ventilation (6 mL/kg predicted body weight) for sepsis-induced ARDS 1, 2

Metabolic and Supportive Care

Glucose management:

• Target blood glucose ≤180 mg/dL using a protocolized approach 1, 2

Transfusion strategy:

• Target hemoglobin 7-9 g/dL in the absence of tissue hypoperfusion, coronary disease, or acute hemorrhage 1, 2

Sedation:

• Minimize continuous sedation in mechanically ventilated patients 1, 2

Nutritional Support

Enteral feeding approach:

• Initiate early enteral feeding rather than complete fasting or IV glucose only in patients who can be fed enterally 2

• Use either early trophic/hypocaloric or early full enteral feeding; advance feeds according to patient tolerance if starting with trophic feeding 2

• Use prokinetic agents for feeding intolerance 2

• Place post-pyloric feeding tubes in patients with feeding intolerance or high aspiration risk 2

• Avoid omega-3 fatty acids as immune supplements, IV selenium, arginine, and glutamine supplementation 2

Performance Improvement and Systems

Hospital-wide implementation:

• Implement sepsis screening programs for acutely ill, high-risk patients 1, 2

• Establish multidisciplinary teams including physicians, nurses, pharmacy, and respiratory therapy 1, 2

• Use sepsis bundles and protocols with regular education and performance feedback 1, 2

Goals of Care

Communication with patients and families:

• Discuss goals of care and prognosis with patients and families, ideally within 72 hours of ICU admission 1, 2

• Incorporate palliative care principles into treatment planning when appropriate 1, 2

Common Pitfalls to Avoid

• Never delay antimicrobials waiting for diagnostic studies—the 60-minute window is critical for mortality reduction 1, 2, 4

• Avoid standard dosing approaches—individualized dosing based on pharmacokinetics/pharmacodynamics and organ dysfunction is essential 3

• Do not continue combination therapy beyond 3-5 days without clear justification—this drives resistance 2, 5

• Avoid prolonged antibiotic courses without specific indications—7-10 days is sufficient for most patients 2, 5