What are the recommendations for managing sepsis according to the Surviving Sepsis Campaign?

Surviving Sepsis Campaign: Management Recommendations

Immediate Recognition and Resuscitation

Sepsis and septic shock are medical emergencies requiring immediate treatment and resuscitation. 1

Initial Fluid Resuscitation

• Administer at least 30 mL/kg of IV crystalloid fluid within the first 3 hours of recognition of sepsis-induced hypoperfusion 1
• Use crystalloids as the primary resuscitation fluid (strong recommendation), with consideration of albumin in patients requiring substantial ongoing crystalloid to maintain adequate mean arterial pressure 1
• Avoid hetastarch formulations entirely 1
• Continue fluid challenges as long as hemodynamic improvement occurs, guided by frequent reassessment using dynamic variables (preferred over static variables when available) 1

Hemodynamic Targets

• Target mean arterial pressure ≥65 mmHg in patients requiring vasopressors 1
• Norepinephrine is the first-choice vasopressor to maintain this target 1
• Add epinephrine when an additional agent is needed to maintain adequate blood pressure 1
• Vasopressin (0.03 U/min) can be added to norepinephrine to raise MAP to target or decrease norepinephrine dose, but should not be used as the initial vasopressor 1
• Dopamine is not recommended except in highly selected circumstances 1
• Administer dobutamine when myocardial dysfunction is present (elevated cardiac filling pressures and low cardiac output) or ongoing signs of hypoperfusion persist despite adequate volume and MAP 1

Lactate-Guided Resuscitation

• Normalize lactate in patients with elevated lactate levels as a marker of tissue hypoperfusion (weak recommendation) 1

Antimicrobial Therapy

Timing and Initiation

Administer IV antimicrobials within 1 hour of recognition for both sepsis and septic shock (strong recommendation) 1, 2

This represents the single most critical time-dependent intervention, though recent evidence suggests nuance based on risk stratification:

• For patients with probable sepsis (regardless of shock risk), mortality is significantly lower with antibiotics within 1 hour 3
• For patients with possible sepsis unlikely to develop shock, mortality rates are similar whether antibiotics are given within 1 hour versus 3 hours, allowing time for more detailed evaluation 3, 4

Culture Acquisition

• Obtain at least two sets of blood cultures (aerobic and anaerobic) before starting antimicrobials, provided this causes no substantial delay (>45 minutes) 1
• Perform imaging studies promptly to confirm potential source of infection 1

Empiric Therapy Selection

• Use empiric broad-spectrum therapy with one or more antimicrobials covering all likely pathogens (bacterial, and potentially fungal or viral) 1, 2
• For septic shock, consider empiric combination therapy using at least two antibiotics from different antimicrobial classes aimed at the most likely bacterial pathogens (weak recommendation) 1, 2
• For severe infections with respiratory failure and septic shock, use combination of extended-spectrum β-lactam with either aminoglycoside or fluoroquinolone for Pseudomonas aeruginosa coverage 1, 2
• For septic shock from bacteremic Streptococcus pneumoniae, use combination of β-lactam and macrolide 1, 2
• For neutropenic patients with severe sepsis, use combination empirical therapy 1
• For multidrug-resistant pathogens such as Acinetobacter and Pseudomonas species, use combination therapy 1

De-escalation and Duration

• Reassess antimicrobial regimen daily for potential de-escalation 1
• Narrow therapy once pathogen identification and sensitivities are established and/or adequate clinical improvement is noted 1, 2
• Discontinue empiric combination therapy after 3-5 days, de-escalating to most appropriate single therapy once susceptibility profile is known 1, 2
• Typical duration is 7-10 days; longer courses may be appropriate for slow clinical response, undrainable foci, S. aureus bacteremia, fungal/viral infections, or immunologic deficiencies including neutropenia 1, 2

Optimization and Biomarker Use

• Optimize antimicrobial dosing based on accepted pharmacokinetic/pharmacodynamic principles and specific drug properties 1, 2
• Use low procalcitonin levels or similar biomarkers to assist in discontinuing empiric antibiotics in patients who initially appeared septic but have no subsequent evidence of infection 1, 2

Critical Caveat

Do not use antimicrobial agents in patients with severe inflammatory states determined to be of noninfectious cause (e.g., severe pancreatitis, burn injury) 1

Source Control

• Identify anatomical diagnosis of infection requiring source control as rapidly as possible 1
• Undertake intervention for source control within 12 hours after diagnosis is made, if feasible 1
• Use the effective intervention with least physiologic insult (e.g., percutaneous rather than surgical drainage of abscess) 1
• For infected peripancreatic necrosis, delay definitive intervention until adequate demarcation of viable and nonviable tissues has occurred 1
• Remove intravascular access devices promptly if they are a possible source, after establishing other vascular access 1

Screening and Performance Improvement

Hospitals and hospital systems should have a performance improvement program for sepsis, including sepsis screening for acutely ill, high-risk patients 1

Additional Supportive Care

Transfusion Targets

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

Mechanical Ventilation (for ARDS/ALI)

• Use low tidal volume ventilation 1
• Implement recruitment maneuvers in patients with severe refractory hypoxemia due to ARDS 1
• Consider prone positioning in sepsis-induced ARDS patients with PaO₂/FiO₂ ratio ≤100 mmHg in facilities with experience 1
• Maintain head-of-bed elevation in mechanically ventilated patients unless contraindicated 1

Corticosteroids

• Avoid IV hydrocortisone in adult septic shock patients if adequate fluid resuscitation and vasopressor therapy restore hemodynamic stability 1

Prophylaxis

• Provide prophylaxis for deep vein thrombosis 1
• Use stress ulcer prophylaxis to prevent upper gastrointestinal bleeding in patients with bleeding risk factors 1
• Consider selective oral/digestive decontamination to reduce ventilator-associated pneumonia incidence 1
• Use oral chlorhexidine gluconate for oropharyngeal decontamination to reduce ventilator-associated pneumonia risk 1

Goals of Care

• Address goals of care, including treatment plans and end-of-life planning, as early as feasible but within 72 hours of ICU admission 1