What is the immediate treatment protocol for a patient suspected of having sepsis?

Immediate Sepsis Treatment Protocol

For patients with suspected sepsis, immediately initiate the "1-hour bundle": obtain blood cultures, measure lactate, administer broad-spectrum IV antibiotics within 1 hour for high-risk patients (NEWS2 ≥7), begin rapid crystalloid resuscitation with 30 mL/kg, and start vasopressors if hypotension persists despite fluids, targeting MAP ≥65 mmHg. 1, 2, 3

Initial Risk Stratification (First 5 Minutes)

Calculate NEWS2 score immediately upon recognition of suspected infection: 1, 2

• NEWS2 ≥7 = High risk - requires immediate critical care team involvement 1
• NEWS2 5-6 = Moderate risk - requires urgent clinician review 1
• NEWS2 1-4 = Low risk 1

Override NEWS2 if any of these "red flag" signs present, regardless of score: 1

• Mottled or ashen appearance
• Non-blanching petechial/purpuric rash
• Cyanosis of skin, lips, or tongue
• Altered mental status (document GCS) 2

Diagnostic Testing (Within First Hour)

Obtain these labs immediately, before antibiotics if no delay >45 minutes: 1, 2, 4

• At least 2 sets of blood cultures - one percutaneous, one from each vascular access device if present >48 hours 1, 2, 4
• Serum lactate - critical for risk stratification and resuscitation monitoring 1, 2, 4, 3
• Complete blood count with differential 2, 4
• Comprehensive metabolic panel 2, 4
• Coagulation studies 2, 4
• Consider procalcitonin for bacterial infection likelihood 4

Obtain imaging promptly to identify infection source requiring drainage or surgical intervention 1, 4

Antibiotic Administration (Time-Critical)

Timing based on risk stratification: 1, 2

• High risk (NEWS2 ≥7 or septic shock): IV antibiotics within 1 hour of recognition 1, 2
• Moderate risk (NEWS2 5-6): IV antibiotics within 3 hours 1
• Low risk (NEWS2 <5): IV antibiotics within 6 hours 1

Antibiotic selection principles: 1, 2, 4, 5

• Broad-spectrum coverage of all likely pathogens (bacterial, consider fungal/viral if indicated) 1, 2, 4
• Must penetrate adequately into presumed infection source 1, 4
• Consider combination therapy for neutropenic patients or suspected multidrug-resistant organisms 1, 4
• Administer beta-lactams as extended or continuous infusion after loading dose 6

Fluid Resuscitation (Immediate)

For hypotension or lactate ≥4 mmol/L: 1, 2, 4, 3

• Administer 30 mL/kg IV crystalloid rapidly within first 3 hours (minimum 20 mL/kg initial bolus) 1, 2, 4, 3
• Use crystalloids as first-line (normal saline or balanced crystalloids) 4, 3
• Reassess frequently for fluid overload after initial 2L 3, 6

Resuscitation targets to guide ongoing fluid administration: 1, 2

• Mean arterial pressure (MAP) ≥65 mmHg 1, 2, 4
• Urine output ≥0.5 mL/kg/hour 1, 2, 4
• Capillary refill <2 seconds 2
• Lactate normalization (<2 mmol/L) 1, 2, 4
• Improved mental status and peripheral perfusion 4

Important caveat: After initial 30 mL/kg, use dynamic assessment (not static CVP targets) to guide further fluids - less is more after initial resuscitation 3, 6

Vasopressor Support (If Hypotension Persists)

If MAP <65 mmHg despite adequate fluid resuscitation: 1, 2, 4, 3

• Start norepinephrine as first-line vasopressor 4
• Target MAP ≥65 mmHg 1, 2, 4, 3
• Consider adding epinephrine if inadequate response to norepinephrine 4
• Consider low-dose corticosteroids if requiring high-dose vasopressors (≥0.25 µg/kg/min) for ≥4 hours 4

Source Control

Identify and address infection source as rapidly as possible: 1, 2, 4

• Remove or replace indwelling catheters before starting antimicrobials 2
• Address urinary obstruction or anatomical abnormality within 12 hours 2
• Implement surgical/interventional drainage as soon as logistically feasible after initial resuscitation 4

Ongoing Monitoring and Reassessment

Re-calculate NEWS2 and reassess at these intervals: 1, 2, 4

• High risk: Every 30 minutes 1, 2, 4
• Moderate risk: Every 1 hour 1, 2, 4
• Low risk: Every 4-6 hours 1, 2, 4

Remeasure lactate within 2-4 hours if initially elevated 4, 3

Monitor continuously: 2, 4, 3

• Vital signs (heart rate, blood pressure, respiratory rate, temperature, oxygen saturation)
• Mental status and GCS
• Urine output
• Skin perfusion (capillary refill, mottling)
• Sequential Organ Failure Assessment (SOFA) score for organ dysfunction 4

Antimicrobial Stewardship (Daily)

Reassess antibiotic regimen daily: 1, 2, 4

• De-escalate to narrower spectrum once pathogen identified and sensitivities available 1, 2, 4
• Shorten duration when clinically appropriate - shorter courses preferred when safe 4, 5, 6
• Consider procalcitonin to guide discontinuation decisions 4, 6

Critical Pitfalls to Avoid

• Do not delay antibiotics for blood cultures if obtaining cultures takes >45 minutes 1, 2
• Do not continue aggressive fluid resuscitation beyond initial 30 mL/kg without dynamic reassessment - fluid overload worsens outcomes 3, 6
• Do not use CVP as sole guide for fluid responsiveness - use dynamic variables and clinical assessment 3, 6
• Do not continue broad-spectrum antibiotics indefinitely - daily reassessment and de-escalation are mandatory 1, 2, 4, 5