How should a patient with suspected sepsis be managed?

Management of Suspected Sepsis

Sepsis is a medical emergency requiring immediate recognition and treatment within the first hour, with aggressive fluid resuscitation (30 mL/kg crystalloid within 3 hours), broad-spectrum IV antibiotics within 1 hour for high-risk patients, and continuous hemodynamic monitoring to achieve a mean arterial pressure ≥65 mmHg. 1, 2

Immediate Recognition and Risk Stratification

• Calculate a NEWS2 score immediately upon suspicion of sepsis to guide urgency of interventions: 1

  • NEWS2 ≥7 indicates high risk of severe illness or death
  • NEWS2 5-6 indicates moderate risk
  • NEWS2 <5 indicates low risk

• Override the NEWS2 score and escalate risk assessment if any of these clinical danger signs are present: 1

  • Mottled or ashen skin appearance
  • Non-blanching petechial or purpuric rash
  • Cyanosis of skin, lips, or tongue
  • Clinical deterioration despite interventions

• Recalculate NEWS2 and reassess at specific intervals based on risk level: 1

  • Every 30 minutes for high-risk patients
  • Every hour for moderate-risk patients
  • Every 4-6 hours for low-risk patients

Antibiotic Administration (Time-Critical)

Administer broad-spectrum IV antibiotics based on risk stratification, NOT as a universal 1-hour target for all patients: 1

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

Select empiric antibiotics covering all likely pathogens based on: 1, 3, 4

• Suspected infection source (urinary, pulmonary, abdominal, skin/soft tissue)
• Patient's recent antibiotic exposure and healthcare contacts
• Local resistance patterns and hospital antibiogram
• Risk factors for multidrug-resistant organisms

Recommended empiric regimens include: 1, 2, 4

• Meropenem, imipenem/cilastatin, or piperacillin-tazobactam as monotherapy
• Add vancomycin or linezolid if MRSA or catheter-related infection suspected
• Add aminoglycoside for severe septic shock (despite increased renal toxicity risk)

Fluid Resuscitation (First 3 Hours)

Administer at least 30 mL/kg of IV crystalloid fluid within the first 3 hours for sepsis-induced hypoperfusion or lactate ≥4 mmol/L: 1, 2, 5

• Use balanced crystalloids (lactated Ringer's or Plasma-Lyte) as first-line fluid, NOT normal saline 2
• Reassess hemodynamic status after each fluid bolus using clinical endpoints: 1, 2
  • Capillary refill <2 seconds
  • Warm extremities with palpable peripheral pulses
  • Urine output >0.5 mL/kg/hour
  • Normal mental status
  • Heart rate normalization

Stop fluid administration immediately if: 2

• Hepatomegaly develops
• Lung crackles/rales appear
• No improvement occurs despite continued fluid boluses

Hemodynamic Targets and Vasopressor Support

Target a mean arterial pressure (MAP) ≥65 mmHg throughout resuscitation: 1, 2, 5, 6

If hypotension persists despite adequate fluid resuscitation (30 mL/kg), initiate vasopressors: 1, 2, 6

• Norepinephrine is the first-line vasopressor at 0.1-1.3 µg/kg/min 1, 2, 5
• Dopamine should only be used in highly selected patients with bradycardia and low tachyarrhythmia risk 2
• Never use low-dose dopamine for "renal protection" 2

Consider IV hydrocortisone 200 mg/day for fluid-refractory, catecholamine-resistant shock: 2

• Taper when vasopressors are no longer required
• Do NOT use ACTH stimulation test to guide therapy

Diagnostic Sampling (Before Antibiotics, But Never Delay Treatment)

Obtain cultures before starting antimicrobials if this causes no substantial delay (≤45 minutes): 1, 5, 6

• At least two sets of blood cultures (aerobic and anaerobic)
• One drawn percutaneously, one through vascular access if present
• Urine culture using appropriate sterile technique
• Cultures from other suspected infection sources

Measure serum lactate at diagnosis and repeat within 6 hours if initially elevated: 1, 6

Source Control

Identify and control the infection source as soon as medically feasible: 2, 5, 6

• Perform detailed history and physical examination focusing on infection source
• Obtain imaging (ultrasound or CT) to identify obstruction, abscesses, or collections
• Drain abscesses or debride infected tissue urgently (within 12 hours for obstructive uropathy)
• Remove potentially infected foreign bodies (catheters, devices)

Respiratory Support

Apply supplemental oxygen to maintain SpO₂ >90%: 2, 6

• Position patient semi-recumbent (head of bed 30-45 degrees) to reduce aspiration risk
• Use non-invasive ventilation for persistent hypoxemia if trained staff and equipment available
• Prepare for intubation if respiratory failure worsens, ensuring adequate fluid resuscitation beforehand

Continuous Monitoring

Never leave the septic patient alone; ensure continuous observation: 1, 6

• Monitor blood pressure, heart rate, respiratory rate, temperature, oxygen saturation, and urine output
• Assess tissue perfusion markers: capillary refill, skin mottling, extremity temperature, peripheral pulses, mental status
• Document vital signs at meaningful intervals in patient record

Antimicrobial De-escalation (24-48 Hours)

Review antibiotic choice within 24-48 hours when culture results are available: 1, 2, 5

• Switch to narrower spectrum therapy based on identified pathogens and sensitivities
• Discontinue unnecessary antimicrobials
• Typical duration is 7-10 days for most infections

Critical Pitfalls to Avoid

Do not delay resuscitation due to concerns about fluid overload—delayed resuscitation kills more patients than fluid overload 2

Do not use CVP alone to guide fluid therapy, as it has poor predictive value for fluid responsiveness 2

Do not use hydroxyethyl starches, as they increase mortality and acute kidney injury 2

Do not delay antibiotics beyond 1 hour in high-risk patients—each hour of delay increases mortality by 7.6% 1, 5

Do not fail to address source control, particularly in obstructive uropathy—this is as important as antibiotic therapy 5, 6