What are the steps for treating sepsis?

Sepsis Management: Step-by-Step Protocol with Medications and Doses

Immediate Recognition (Within Minutes)

Begin treatment immediately when sepsis is suspected—sepsis and septic shock are medical emergencies requiring instant action. 1

• Screen using qSOFA (quick Sequential Organ Failure Assessment): altered mental status, systolic BP ≤100 mmHg, respiratory rate ≥22/min—if ≥2 criteria present, suspect sepsis 2
• Alternatively, use NEWS2 score: ≥7 indicates high risk requiring immediate intervention 2
• Critical pitfall: Do NOT wait for qSOFA confirmation to start treatment—qSOFA has poor sensitivity (31-50%) and should never delay the Hour-1 Bundle 2

The Hour-1 Bundle (Complete Within 60 Minutes)

Step 1: Measure Lactate Immediately

• Draw serum lactate level stat 2
• Remeasure within 2-4 hours if elevated (≥2 mmol/L) 2
• Lactate ≥4 mmol/L defines septic shock (along with hypotension requiring vasopressors) 1

Step 2: Obtain Blood Cultures Before Antibiotics

• Draw at least two sets of blood cultures (aerobic and anaerobic bottles) from different sites 2, 3
• Do NOT delay antibiotics beyond 45 minutes if cultures cannot be obtained quickly 2
• Each hour of antibiotic delay decreases survival by approximately 7.6% 2

Step 3: Administer Broad-Spectrum Antibiotics Within 1 Hour

• Give IV broad-spectrum antimicrobials within 60 minutes of sepsis recognition 2, 3, 4
• Use combination therapy covering all likely pathogens (gram-positive, gram-negative, anaerobes) 3
• For septic shock specifically: Use at least two antibiotics of different classes 3

Common empiric regimens (adjust based on local resistance patterns and suspected source):

• Unknown source: Piperacillin-tazobactam 4.5g IV every 6 hours OR meropenem 1-2g IV every 8 hours PLUS vancomycin 15-20 mg/kg IV loading dose (actual body weight)
• Abdominal source: Meropenem 1-2g IV every 8 hours OR piperacillin-tazobactam 4.5g IV every 6 hours
• Pneumonia: Ceftriaxone 2g IV daily PLUS azithromycin 500mg IV daily OR levofloxacin 750mg IV daily
• Urinary source: Ceftriaxone 2g IV daily OR ciprofloxacin 400mg IV every 12 hours
• Add vancomycin 15-20 mg/kg IV if MRSA suspected (skin/soft tissue infection, healthcare-associated, known colonization)

Step 4: Aggressive Fluid Resuscitation

• Administer 30 mL/kg IV crystalloid bolus for hypotension or lactate ≥4 mmol/L 1, 2
• Infuse rapidly over 5-10 minutes 2
• Use either normal saline OR balanced crystalloids (Lactated Ringer's, Plasma-Lyte) as first choice 2, 3
• Never use hydroxyethyl starches—they are contraindicated in sepsis 2

Example: For a 70 kg patient, give 2,100 mL (30 mL/kg × 70 kg) crystalloid rapidly

Step 5: Start Vasopressors if Hypotension Persists

• Initiate vasopressors for hypotension despite adequate fluid resuscitation 1, 2
• Target mean arterial pressure (MAP) ≥65 mmHg 1, 3
• First-line vasopressor: Norepinephrine starting at 0.05-0.1 mcg/kg/min, titrate up to 2 mcg/kg/min 2
• If MAP target not achieved with norepinephrine alone, add vasopressin 0.03-0.04 units/min (fixed dose, do not titrate)
• If still inadequate, add epinephrine 0.05-0.2 mcg/kg/min

Source Control (Within 12 Hours)

• Identify and control infection source within 12 hours when feasible 2, 3
• Use least invasive effective intervention: percutaneous drainage preferred over open surgery for abscesses 2
• Remove intravascular catheters promptly if suspected source 2
• Do NOT delay surgical intervention if indicated (e.g., perforated viscus, necrotizing fasciitis) 2

Ongoing Resuscitation and Monitoring (Hours 1-6)

Reassess Hemodynamic Status Every 30-60 Minutes

• Monitor: capillary refill, skin temperature/mottling, mental status, urine output (target >0.5 mL/kg/hour), lactate clearance 2, 3
• Use dynamic variables (pulse pressure variation, stroke volume variation) over static variables to predict fluid responsiveness 1
• Continue fluid administration as long as hemodynamic factors improve 2
• Stop fluids when no improvement occurs or signs of fluid overload develop (lung crackles, elevated JVP) 1

Consider Albumin for Massive Fluid Requirements

• Add albumin 20-25g IV when patients require substantial crystalloids (>4-5 liters) 2

Add Inotropes if Cardiac Dysfunction Present

• If low cardiac output persists despite adequate volume (occurs in 10-20% of cases): add dobutamine 2.5-20 mcg/kg/min 2
• Monitor for tachycardia and arrhythmias

Corticosteroids for Refractory Shock

• Consider hydrocortisone 50 mg IV every 6 hours (200 mg/day total) for patients requiring ongoing catecholamines despite adequate fluid resuscitation 1, 2
• Use continuous infusion preferred over bolus dosing 1
• Do NOT use corticosteroids for sepsis without shock 1

Respiratory Support

• Administer oxygen to achieve SpO₂ ≥90% 2
• Position semi-recumbent (head of bed 30-45 degrees) to prevent aspiration 1, 2
• Use non-invasive ventilation for increased work of breathing or hypoxemia despite oxygen 2

If mechanical ventilation required:

• Use low tidal volume ventilation: 6 mL/kg ideal body weight 1, 3
• Limit plateau pressure ≤30 cmH₂O 1
• Apply adequate PEEP to prevent atelectasis 1
• Consider prone positioning if PaO₂/FiO₂ ratio ≤100 mmHg 1

Antimicrobial Stewardship (Daily Reassessment)

• Reassess antimicrobial therapy daily for de-escalation once culture results available 2, 4
• Use procalcitonin levels to support shortening duration or discontinuing empiric antibiotics 2, 5
• De-escalate to narrower spectrum based on culture sensitivities 4, 5
• Most patients can complete 7-10 days total antibiotic therapy unless specific circumstances warrant longer duration 5

Supportive Care

• Target hemoglobin 7-9 g/dL (transfuse if <7 g/dL unless active ischemia) 1, 2
• Provide DVT prophylaxis (pharmacological or mechanical) 2, 3
• Target blood glucose ≤180 mg/dL with insulin infusion if needed 3
• Resume oral feeding after resuscitation and regaining consciousness 2
• Minimize sedation in mechanically ventilated patients 3
• Initiate early mobilization 2

Critical Pitfalls to Avoid

• Never delay antibiotics waiting for cultures—obtain cultures quickly but give antibiotics within 1 hour 2, 4
• Never use hydroxyethyl starches for resuscitation 2
• Never give corticosteroids for sepsis without shock 1
• Never continue broad-spectrum antibiotics without daily reassessment for de-escalation 2, 5
• Never use static measurements alone (CVP, PAOP) to guide fluid therapy—use dynamic assessment 1, 2