What is the immediate management plan for a patient presenting with sepsis?

Assessment/Plan: Sepsis

Immediate Recognition and Risk Stratification

Administer IV antimicrobials within 1 hour of sepsis recognition and initiate aggressive fluid resuscitation with at least 30 mL/kg crystalloids within the first 3 hours. 1, 2

• Use NEWS2 score to stratify risk: ≥7 indicates high risk, 5-6 moderate risk, with monitoring frequency adjusted accordingly (high-risk every 30 minutes, moderate-risk hourly) 1
• Recognize sepsis as a time-dependent medical emergency where every hour of antibiotic delay increases mortality by 8% 2

Initial Resuscitation (First 3 Hours)

Fluid Management

• Administer at least 30 mL/kg IV crystalloids within first 3 hours for sepsis-induced hypoperfusion 3, 2
• Continue fluid administration using fluid challenge technique as long as hemodynamic parameters improve 2
• Consider albumin supplementation when substantial crystalloids are required 2
• Avoid hydroxyethyl starches due to renal and coagulatory complications 2
• Monitor capillary refill time, extremity temperature, and urine output as markers of tissue perfusion 2

Hemodynamic Targets

• Target mean arterial pressure (MAP) ≥65 mmHg in patients requiring vasopressors 1, 2
• Initiate vasopressors if hypotension persists despite adequate fluid resuscitation 2
• Consider normalizing lactate levels as a marker of adequate tissue hypoperfusion resolution 1

Antimicrobial Therapy (Within 1 Hour)

Timing and Culture Acquisition

• Administer IV broad-spectrum antimicrobials within 1 hour for high-risk patients, within 3 hours for moderate-risk, and within 6 hours for low-risk patients 1
• Obtain at least two sets of blood cultures and cultures from other relevant sites before antibiotics, but do not delay antimicrobial administration 3, 2
• If vascular access is limited, consider intraosseous access or intramuscular administration of β-lactams (imipenem/cilastatin, cefepime, ceftriaxone, ertapenem) 3

Empiric Antibiotic Selection

• Select broad-spectrum therapy covering all likely pathogens including bacterial, and potentially fungal or viral coverage based on: 3
  • Clinical syndrome and infection site
  • Patient's underlying diseases, immunosuppression status, and indwelling devices
  • Recent antimicrobial exposure (within 3 months)
  • Location of infection acquisition (community vs. healthcare-associated)
  • Local pathogen prevalence and resistance patterns

Combination Therapy Indications

• Use combination therapy (≥2 antibiotics from different classes) for initial management of septic shock 3, 1
• Consider combination therapy for: 3
  • Neutropenic patients with severe sepsis
  • Multidrug-resistant pathogens (Acinetobacter, Pseudomonas species)
  • Respiratory failure with septic shock and suspected Pseudomonas (extended-spectrum β-lactam + aminoglycoside or fluoroquinolone)
  • Septic shock from bacteremic Streptococcus pneumoniae (β-lactam + macrolide)

Special Considerations for Resistant Pathogens

• Consider higher risk of resistant organisms if: 1
  • Healthcare-associated infection
  • Hospitalization >1 week
  • Previous antimicrobial therapy

Source Control

• Identify anatomic source of infection as rapidly as possible 2
• Implement source control interventions (drainage, debridement) within first 12 hours when medically and logistically practical 1, 2
• Remove intravascular access devices that may be infection source after establishing alternative access 2

Ongoing Management and De-escalation

Daily Reassessment

• Perform daily antimicrobial therapy reassessment for potential de-escalation once culture results available 1, 2
• Narrow therapy once pathogen identification and sensitivities established or adequate clinical improvement noted 3
• De-escalate combination therapy within 3-5 days in response to clinical improvement and/or infection resolution 3, 4

Duration of Therapy

• Typical duration: 7-10 days for most serious infections associated with sepsis 3, 2
• Consider longer courses for: 3, 4
  • Slow clinical response
  • Undrainable foci of infection
  • Staphylococcus aureus bacteremia
  • Specific fungal/viral infections
  • Immunologic deficiencies including neutropenia

Antimicrobial Optimization

• Optimize dosing strategies based on pharmacokinetic/pharmacodynamic principles 3, 4
• Consider extended or continuous infusion of β-lactams to achieve therapeutic levels 5, 6
• Use therapeutic drug monitoring when available 5, 6
• Administer loading doses regardless of organ dysfunction, then adjust subsequent doses for renal/hepatic dysfunction 5, 6

Critical Pitfalls to Avoid

• Do not delay antimicrobials beyond 1 hour while waiting for cultures or establishing vascular access 1, 2
• Do not use sustained antimicrobial prophylaxis in severe inflammatory states of noninfectious origin (severe pancreatitis, burns) 3
• Do not continue broad-spectrum antibiotics without attempting de-escalation once culture results available 2
• Do not provide inadequate initial fluid resuscitation or fail to reassess fluid status after initial bolus 2
• Do not use hydroxyethyl starches for resuscitation 2
• Consider procalcitonin or similar biomarkers to guide discontinuation of empiric antibiotics in patients without confirmed infection 4, 7