What is the initial management for suspected sepsis?

Initial Management of Suspected Sepsis

For suspected sepsis, immediately assess risk using NEWS2 score, obtain blood cultures if feasible without delay, administer IV antibiotics within 1 hour (high-risk patients) to 3 hours (moderate-risk), and aggressively resuscitate with at least 30 mL/kg IV crystalloid fluids within the first 3 hours. 1, 2

Risk Stratification and Monitoring

• Calculate NEWS2 score immediately to determine risk level: score ≥7 indicates high risk, 5-6 indicates moderate risk, and 0-4 indicates low risk of severe illness or death from sepsis 3, 1, 2
• Monitor high-risk patients every 30 minutes, moderate-risk patients every hour, and low-risk patients every 4-6 hours 2
• Obtain serum lactate measurement immediately; if elevated, remeasure within 2-4 hours to guide resuscitation 1
• Look for signs of tissue hypoperfusion including mottled skin, decreased capillary refill, peripheral cyanosis, altered mental status, and arterial hypotension 3, 1

Fluid Resuscitation

• Administer at least 30 mL/kg of IV crystalloid fluid within the first 3 hours for patients with sepsis-induced hypoperfusion or tissue hypoperfusion 3, 1, 2
• Use crystalloids (either balanced crystalloids or saline) as the initial fluid of choice 3, 1
• Continue aggressive fluid administration for 24-48 hours; more than 4 L during the first 24 hours may be required in adults 3
• Guide additional fluids after initial resuscitation by frequent reassessment of hemodynamic status using dynamic variables (pulse pressure variation, stroke volume variation) when available 3, 1
• Consider albumin in addition to crystalloids when patients require substantial amounts of crystalloids 3, 1

Antimicrobial Therapy Timing

The timing of antibiotics is risk-stratified:

• High-risk patients (NEWS2 ≥7): Administer IV antimicrobials within 1 hour of sepsis recognition 1, 2, 4
• Moderate-risk patients (NEWS2 5-6): Administer within 3 hours 2
• Low-risk patients (NEWS2 0-4): Administer within 6 hours 2

This stratified approach balances the need for rapid treatment in critically ill patients against antimicrobial stewardship concerns in lower-risk patients 3.

Culture Acquisition

• Obtain at least two sets of blood cultures (aerobic and anaerobic) before initiating antimicrobials if this can be done without substantial delay (suggested maximum 45 minutes) 3, 1, 4
• All blood cultures may be drawn together on the same occasion; sequential draws or timing to temperature spikes does not improve yield 3
• For patients with intravascular catheters in place >48 hours, obtain at least one blood culture set from the catheter along with simultaneous peripheral blood cultures 3
• Obtain cultures from other sites (urine, wounds, respiratory secretions, cerebrospinal fluid) only when clinically indicated as potential sources; avoid "pan-culturing" all possible sites 3
• Do not delay antibiotics beyond 1 hour in high-risk patients to obtain cultures—the mortality risk of delaying antibiotics outweighs the benefit of pre-antibiotic cultures 3, 1

Antibiotic Selection

• Use empiric broad-spectrum therapy with one or more antimicrobials to cover all likely pathogens (bacterial, and potentially fungal or viral) 1, 4
• For septic shock specifically, use empiric combination therapy with at least two antibiotics from different antimicrobial classes aimed at the most likely bacterial pathogens 1, 4
• Consider local resistance patterns and whether infection was healthcare-acquired, as these patients have higher risk of resistant pathogens 2
• Optimize dosing strategies based on pharmacokinetic/pharmacodynamic principles and specific drug properties 1, 4

Hemodynamic Support

• Target mean arterial pressure (MAP) of 65 mmHg in patients requiring vasopressors 1, 2
• Initiate vasopressor therapy when fluid resuscitation fails to restore adequate MAP and organ perfusion 5
• Perform further hemodynamic assessment (such as cardiac function evaluation) if clinical examination doesn't lead to a clear diagnosis 1, 2

Source Control

• Identify or exclude anatomic diagnosis of infection requiring source control as rapidly as possible, and implement required intervention as soon as medically and logistically practical 3
• Remove intravascular access devices that are potential sources of sepsis promptly after establishing other vascular access 3, 1
• When feasible, perform source control intervention within the first 12 hours after diagnosis 3, 2

De-escalation and Duration

• Review antimicrobial regimen daily for possible de-escalation once culture results are available 3, 1, 4
• Narrow empiric antimicrobial therapy once pathogen identification and sensitivities are established and/or adequate clinical improvement is noted 1, 4
• Discontinue empiric combination therapy within 3-5 days in response to clinical improvement 1, 4
• Typical treatment duration is 7-10 days; longer courses may be necessary for slow clinical response, undrainable infection sites, or specific pathogens 1, 4
• Consider using procalcitonin levels to support discontinuation of empiric antibiotics in patients who initially appeared septic but have limited clinical evidence of infection 3, 1

Critical Pitfalls to Avoid

• Do not delay antibiotics in high-risk patients (NEWS2 ≥7) beyond 1 hour while waiting for cultures or additional testing—mortality increases significantly with delays 3, 1, 6
• Do not use hydroxyethyl starches for fluid resuscitation, as they are associated with harm 3, 1
• Avoid inadequate initial fluid resuscitation—be aggressive with the initial 30 mL/kg bolus, as under-resuscitation is associated with increased mortality 3, 1
• Do not continue broad-spectrum combination therapy beyond 3-5 days without reassessment—practice antimicrobial stewardship 1, 4
• Interpret NEWS2 scores in the context of the patient's underlying physiology and comorbidities, as baseline abnormalities may affect accuracy 3, 1