What intervention provides a mortality benefit for a septic patient with hypotension, impaired renal function, and signs of infection?

Initiation of Broad-Spectrum Antibiotics Provides Mortality Benefit

The correct answer is C: initiation of broad-spectrum antibiotics. In septic shock, each hour of delay in appropriate antimicrobial administration is associated with a 7.6% decrease in survival, making immediate antibiotic therapy the single intervention with proven mortality benefit. 1

Why Antibiotics Are the Priority

The Surviving Sepsis Campaign guidelines emphasize that antimicrobial therapy must be initiated within one hour of recognizing septic shock, as this timing directly impacts survival. 1 This patient presents with classic septic shock from presumed urosepsis (fever, flank pain, hypotension, elevated lactate, acute kidney injury), making immediate broad-spectrum antibiotics the life-saving intervention. 2

• The largest and highest-quality studies demonstrate that survival rates drop from 79.9% when antibiotics are given within the first hour to progressively worse outcomes with each hour of delay. 1
• In patients with septic shock specifically, the mortality benefit of prompt antibiotics is even more pronounced than in sepsis without shock. 1
• Blood cultures should be obtained before antibiotics when possible, but antibiotic administration must never be delayed for diagnostic procedures. 1, 2

Why the Other Options Don't Provide Mortality Benefit

A. Corticosteroids

While corticosteroids may have a role in refractory septic shock, they have not demonstrated mortality benefit in randomized trials and are not part of initial resuscitation. 1

B. Central Venous Catheter Placement

Central line placement is a monitoring tool, not a therapeutic intervention. While it may facilitate resuscitation monitoring (central venous pressure, central venous oxygen saturation), the catheter itself provides no mortality benefit. 1 The resuscitation targets can often be achieved with peripheral access and clinical assessment. 2

D. Urinary Catheter Placement

A urinary catheter is essential for monitoring urine output (targeting ≥0.5 mL/kg/h) during resuscitation, but it is a monitoring device, not a therapeutic intervention that reduces mortality. 2, 3 In this case of likely urosepsis, source control may eventually require urologic intervention, but the catheter placement itself doesn't provide mortality benefit. 1

The Complete Resuscitation Algorithm

While antibiotics are the answer to this question, optimal septic shock management requires a coordinated approach:

1. Immediate antibiotic administration (within 1 hour): Choose broad-spectrum coverage such as meropenem, imipenem/cilastatin, or piperacillin/tazobactam to cover likely uropathogens including ESBL-producing organisms. 2

2. Aggressive fluid resuscitation: Crystalloids are preferred, targeting mean arterial pressure ≥65 mmHg, though this alone has not shown mortality benefit compared to antibiotics. 2, 4

3. Vasopressor support: Norepinephrine (0.1-1.3 mcg/kg/min) should be added if hypotension persists despite adequate fluid resuscitation. 2, 3

4. Source control: Identify and address the anatomic source (likely urinary tract obstruction requiring drainage). 2

Critical Pitfalls to Avoid

• Do not delay antibiotics for complete diagnostic workup, imaging, or central line placement. The one-hour window is critical and non-negotiable. 1, 2
• Do not use narrow-spectrum antibiotics initially despite stewardship concerns. Septic shock demands broad empiric coverage until the pathogen is identified. 2, 5
• Do not assume fluid resuscitation alone will suffice. This patient's elevated lactate (6 mmol/L) and profound hypotension indicate septic shock, where antibiotics are the definitive mortality-reducing intervention. 6