What are the updated treatment guidelines for sepsis according to the Surviving Sepsis Campaign?

Updated Surviving Sepsis Campaign Guidelines

The most critical update is that antimicrobials must be administered within 1 hour of recognizing sepsis or septic shock, with immediate resuscitation including 30 mL/kg IV crystalloid within the first 3 hours. 1, 2

Immediate Recognition and Resuscitation (First Hour)

Sepsis and septic shock are medical emergencies requiring immediate action. 2, 3

Fluid Resuscitation

• Administer at least 30 mL/kg of IV crystalloid fluid within the first 3 hours for sepsis-induced hypoperfusion (defined as hypotension persisting after initial fluid challenge or lactate ≥4 mmol/L). 1, 2
• Following initial fluid bolus, guide additional fluids by frequent reassessment of hemodynamic status using thorough clinical examination (heart rate, blood pressure, oxygen saturation, respiratory rate, temperature, urine output). 1, 2
• Consider dynamic variables over static variables to predict fluid responsiveness when available. 3
• The 2021 guidelines downgraded the initial 30 mL/kg recommendation from strong to weak, reflecting evolving evidence. 4

Antimicrobial Therapy (The Single Most Critical Intervention)

• Administer IV antimicrobials within 60 minutes of recognizing sepsis or septic shock—this is the most important intervention for reducing mortality. 1, 2, 5
• Use empiric broad-spectrum therapy with one or more antimicrobials covering all likely pathogens (bacterial, and potentially fungal or viral). 1, 2
• Select drugs with adequate tissue penetration to the presumed infection source based on local resistance patterns. 2, 5

Important caveat: When the diagnosis is uncertain, the 2021 guidelines provide additional recommendations allowing clinicians time for rapid investigation in patients not in septic shock to minimize antibiotic overuse. 4, 6 However, for confirmed septic shock, immediate antibiotics remain mandatory. 2, 3

Diagnostic Studies

• Obtain at least two sets of blood cultures (aerobic and anaerobic) before antimicrobials—one drawn percutaneously and one through each vascular access device. 1, 2
• Never delay antimicrobials beyond 45 minutes waiting for cultures. 1, 2
• Measure serum lactate immediately as a marker of tissue hypoperfusion and normalize it as a resuscitation endpoint. 2
• Perform imaging studies promptly to confirm the infection source. 1, 2

Hemodynamic Support

Vasopressor Therapy

• Target mean arterial pressure ≥65 mmHg in patients requiring vasopressors. 2, 3
• Use norepinephrine as first-line vasopressor. 3
• The 2021 guidelines added a new weak recommendation for peripheral initiation of vasopressors over delaying for central venous access. 4

Fluid Type

• The 2021 guidelines include a new weak recommendation for balanced crystalloid over 0.9% saline. 4

Antimicrobial Strategy Details

Combination Therapy Indications

• Use empiric combination therapy (at least two antibiotics of different classes) for septic shock, particularly with respiratory failure and Pseudomonas aeruginosa risk. 1, 2
• Use combination therapy for septic shock from bacteremic Streptococcus pneumoniae (β-lactam plus macrolide). 1, 2
• Consider combination therapy for neutropenic patients and multidrug-resistant pathogens (Acinetobacter, Pseudomonas). 1, 2
• Do not routinely use combination therapy for ongoing treatment of most other serious infections without shock. 1

De-escalation and Duration

• Reassess antimicrobial therapy daily for potential narrowing to single-agent therapy once susceptibility profiles are known. 1, 2
• Limit combination therapy to 3-5 days maximum, then de-escalate to the most appropriate single therapy. 1, 2
• Target total duration of 7-10 days for most patients. 1, 2
• Longer courses may be needed for slow clinical response, undrainable foci, S. aureus bacteremia, fungal/viral infections, or immunodeficiency including neutropenia. 1, 2
• Use procalcitonin levels to assist in discontinuing empiric antibiotics in patients without subsequent evidence of infection. 1, 2

Contraindications

• Do not use antimicrobials in patients with severe inflammatory states determined to be of noninfectious cause (severe pancreatitis, burn injury). 1

Source Control

• Implement source control interventions as soon as possible after diagnosis. 2
• Drain or debride infected tissues when feasible. 2
• Remove potentially infected foreign bodies or devices. 2

Corticosteroid Therapy

• The 2021 guidelines include a new weak recommendation for IV corticosteroids in septic shock when there is ongoing vasopressor requirement. 4

Respiratory Support for Sepsis-Induced ARDS

• Apply oxygen to achieve saturation >90%. 2
• Use target tidal volume of 6 mL/kg predicted body weight. 3
• Limit plateau pressures to ≤30 cm H₂O. 3
• Use higher PEEP in patients with moderate to severe ARDS. 3
• Consider prone positioning for PaO₂/FiO₂ ratio <150. 3
• Maintain head of bed elevated 30-45 degrees. 2, 3

Metabolic Management

Glucose Control

• Target blood glucose ≤180 mg/dL using a protocolized approach after initial stabilization. 2, 3
• Monitor blood glucose every 1-2 hours until values and insulin infusion rates are stable. 3

Transfusion Threshold

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

Nutritional Support

• Initiate early enteral feeding rather than complete fasting or IV glucose only in patients who can be fed enterally. 1, 2, 3
• Use either early trophic/hypocaloric or early full enteral feeding; advance feeds according to patient tolerance if starting with trophic feeding. 1, 2
• Use prokinetic agents for feeding intolerance. 1, 2
• Place post-pyloric feeding tubes in patients with feeding intolerance or high aspiration risk. 1, 2
• Avoid omega-3 fatty acids, IV selenium, arginine, and glutamine supplementation. 1, 2

Systems and Performance Improvement

• Implement hospital-wide sepsis screening programs for acutely ill, high-risk patients. 1, 2, 3
• Establish multidisciplinary teams including physicians, nurses, pharmacy, and respiratory therapy. 2
• Use sepsis bundles and protocols with regular education and performance feedback. 2

Goals of Care and Long-Term Outcomes

• Discuss goals of care and prognosis with patients and families, ideally within 72 hours of ICU admission. 1, 2, 3
• Incorporate palliative care principles into treatment planning when appropriate. 1, 2, 3
• The 2021 guidelines added 12 new recommendations addressing long-term outcomes, including strong recommendations to screen for economic and social support, use shared decision-making in discharge planning, reconcile medications at ICU and hospital discharge, provide written and verbal information about sepsis sequelae, and assess for physical, cognitive, and emotional problems after discharge. 4