What is the recommended treatment for postoperative sepsis?

Treatment of Postoperative Sepsis

Administer broad-spectrum intravenous antibiotics within 1 hour of sepsis recognition, perform immediate source control when indicated, and initiate aggressive fluid resuscitation with crystalloids. 1, 2

Immediate Antimicrobial Therapy

Start empiric broad-spectrum IV antibiotics within 1 hour of recognizing postoperative sepsis—each hour of delay decreases survival by approximately 7.6%. 1, 3, 2

• Obtain at least 2 sets of blood cultures (aerobic and anaerobic) before starting antibiotics if this causes no substantial delay (<45 minutes). 1, 3, 2
• Empiric therapy must cover the most likely pathogens based on the surgical site and local resistance patterns. 1
• For suspected MRSA coverage, use IV vancomycin 15-20 mg/kg/dose every 8-12 hours, or alternatives including daptomycin 6 mg/kg IV once daily or linezolid 600 mg PO/IV twice daily. 3
• Combination therapy (at least two antibiotics of different classes) is suggested for initial management of septic shock, but should not exceed 3-5 days. 1, 3
• Optimize antibiotic dosing based on pharmacokinetic/pharmacodynamic principles, accounting for organ dysfunction that affects drug clearance. 1

Source Control

Identify and control the anatomic source of infection as rapidly as possible, ideally within 12 hours of diagnosis. 1

• Emergent source control intervention should be implemented as soon as possible after diagnosis. 1
• Use the least physiologically invasive effective intervention (e.g., percutaneous drainage rather than surgical drainage when appropriate). 1
• Remove intravascular access devices promptly if they are the suspected source, after establishing alternative vascular access. 1
• For abdominal sepsis, relaparotomy on-demand has become the preferred approach over planned relaparotomy. 4

Fluid Resuscitation and Hemodynamic Support

• Provide at least 30 mL/kg of IV crystalloid fluid within the first 3 hours for sepsis-induced hypoperfusion. 2
• Use balanced/buffered crystalloids rather than 0.9% saline for initial resuscitation. 1
• Titrate fluids to clinical markers of cardiac output (heart rate, blood pressure, capillary refill, mental status, urine output) and discontinue if signs of fluid overload develop. 1
• Target mean arterial pressure ≥65 mmHg in patients requiring vasopressors. 2
• Monitor lactate levels and target normalization in patients with elevated levels. 2

Daily Reassessment and De-escalation

Perform daily assessment for antimicrobial de-escalation starting after the first 48 hours, guided by microbiological results and clinical improvement. 1

• Narrow antimicrobial therapy once pathogen identification and sensitivities are established. 1, 3, 2
• Discontinue combination therapy within the first few days in response to clinical improvement or evidence of infection resolution. 1
• Review the ongoing indication for empiric therapy after 48 hours based on culture results and clinical response. 1
• Consider procalcitonin levels to support shortening antibiotic duration or discontinuing empiric antibiotics in patients with limited clinical evidence of infection. 1

Duration of Antimicrobial Therapy

• A 7-10 day course is adequate for most serious infections associated with postoperative sepsis. 1
• For complicated intra-abdominal infections with adequate source control, a fixed duration of approximately 4 days produces similar outcomes to longer courses (8 days). 1
• Extend therapy to 4-6 weeks for slow clinical response, undrainable foci, Staphylococcus aureus bacteremia, or immunodeficiency. 1, 3
• Shorter courses are appropriate for rapid clinical resolution following effective source control of intra-abdominal or urinary sepsis. 1

Special Considerations

• Do not use sustained systemic antimicrobial prophylaxis in severe inflammatory states of noninfectious origin (e.g., severe pancreatitis, burn injury). 1
• For immunocompromised patients or those at high risk for multidrug-resistant pathogens, use empiric multi-drug therapy when septic shock is present. 1
• Consider previous antibiotic therapy, healthcare-associated acquisition, ICU stay >1 week, and recent travel when selecting empiric coverage for resistant organisms. 1
• Monitor for abdominal compartment syndrome in patients with significant distention. 2
• Implement early mobilization when hemodynamically stable to promote recovery. 2

Common Pitfalls

• Avoid delaying antibiotics beyond 1 hour while pursuing diagnostic workup—the mortality penalty is substantial and immediate treatment is lifesaving for truly septic patients. 3, 5
• Do not continue broad-spectrum combination therapy beyond 3-5 days without reassessing the need for de-escalation. 1, 3
• Recognize that differentiating postoperative sepsis from normal SIRS can be challenging—maintain high clinical suspicion and aggressively search for a septic focus, particularly at the original surgical site. 4
• Avoid relying on wound swab cultures due to contamination risk; obtain deep tissue or bone samples when indicated. 3