What are the current guidelines for managing a patient with suspected sepsis?

Current Guidelines for Sepsis Management

Administer IV broad-spectrum antimicrobials within 1 hour of recognizing sepsis or septic shock, obtain blood cultures before antibiotics when possible without delaying treatment, and initiate immediate fluid resuscitation with at least 30 mL/kg of IV crystalloid within the first 3 hours for patients with sepsis-induced hypoperfusion. 1, 2, 3

Initial Recognition and Risk Stratification

• Calculate NEWS2 score immediately to standardize risk assessment and guide treatment urgency 2, 4
• High-risk patients (NEWS2 ≥7) require sepsis treatment within 1 hour and re-evaluation every 30 minutes 4
• Moderate-risk patients (NEWS2 5-6) require treatment within 3 hours and re-evaluation every hour 4
• Critical override criteria (mottled/ashen appearance, non-blanching rash, cyanosis) warrant immediate treatment regardless of NEWS2 score 4
• Measure serum lactate immediately upon recognition; if elevated (>1 mmol/L), remeasure within 2-6 hours to guide ongoing resuscitation 2, 3, 4

Microbiological Diagnosis

• Obtain at least two sets of blood cultures (aerobic and anaerobic) before starting antimicrobials, but do not delay antibiotics beyond 45 minutes 1, 2, 3, 4
• Draw one set percutaneously and one through each vascular access device (unless inserted <48 hours ago) 4
• Sample fluid or tissue from the suspected infection site whenever possible for Gram stain, culture, and antibiogram 3
• Perform imaging studies promptly to confirm potential infection sources 1

Antimicrobial Therapy

• Administer IV broad-spectrum antimicrobials within 1 hour of sepsis/septic shock recognition—each hour of delay decreases survival by 7.6% 1, 2, 3
• Use empiric therapy covering all likely pathogens including bacterial, and potentially fungal or viral coverage 2, 3
• For septic shock specifically, consider empiric combination therapy using at least two antibiotics of different antimicrobial classes aimed at the most likely bacterial pathogens 2
• Optimize dosing strategies based on pharmacokinetic/pharmacodynamic principles 2
• Reassess antimicrobial therapy daily for de-escalation once pathogen identification and sensitivities are established 1, 2, 3
• Narrow to most appropriate single therapy based on culture results and clinical improvement within 3-5 days 2, 3
• Plan for 7-10 days total duration for most serious infections; longer courses may be necessary for slow clinical response or undrainable infection sites 2, 3
• Consider using procalcitonin levels to support discontinuation of empiric antibiotics in patients with limited clinical evidence of infection 1, 2

Fluid Resuscitation

• Administer at least 30 mL/kg of IV crystalloid within the first 3 hours for sepsis-induced hypoperfusion (hypotension or elevated lactate) 1, 2, 3, 4
• Use crystalloids as the fluid of choice for initial resuscitation and subsequent intravascular volume replacement 1, 2
• Consider either balanced crystalloids or saline, though balanced crystalloids may improve patient-centered outcomes and should be preferred when available 1, 5, 6
• Albumin may be added to crystalloids when patients require substantial amounts of crystalloids to maintain adequate mean arterial pressure 1
• Avoid hydroxyethyl starches completely—strong evidence shows they decrease survival 1, 5
• Continue fluid challenge technique as long as hemodynamic factors continue to improve based on dynamic (pulse pressure variation, stroke volume variation) or static (arterial pressure, heart rate) variables 1
• Following initial resuscitation, guide additional fluids by frequent reassessment of hemodynamic status using dynamic measures of fluid responsiveness when available 2, 7

Critical Caveat on Fluid Volume

While the 30 mL/kg recommendation is guideline-based 1, 2, 3, emerging evidence suggests this may be excessive in some patients and that a more conservative, individualized approach after initial resuscitation may improve outcomes 8, 7. Monitor closely for signs of fluid overload (hepatomegaly, rales) and transition to a restrictive strategy once initial hypoperfusion resolves 1, 7.

Hemodynamic Support and Vasopressors

• Target mean arterial pressure (MAP) ≥65 mmHg as the primary hemodynamic goal 1, 2, 3
• Initiate norepinephrine as the first-choice vasopressor if hypotension persists despite adequate fluid resuscitation 1, 3
• Add epinephrine when an additional agent is needed to maintain adequate blood pressure 1, 3
• For epinephrine dosing in septic shock: start at 0.05 mcg/kg/min IV infusion, titrate up to 2 mcg/kg/min in increments of 0.05-0.2 mcg/kg/min every 10-15 minutes to achieve desired MAP 9
• Vasopressin (0.03 U/min) can be added to norepinephrine to raise MAP or decrease norepinephrine dose, but should not be used as the initial vasopressor 1, 3
• Dopamine is not recommended except in highly selected circumstances 1
• Add dobutamine infusion to vasopressor therapy in presence of myocardial dysfunction (elevated cardiac filling pressures and low cardiac output) or ongoing signs of hypoperfusion despite adequate volume and MAP 1

Source Control

• Identify or exclude a specific anatomic diagnosis of infection requiring emergent source control as rapidly as possible 1, 3
• Implement required source control intervention (drainage, debridement) as soon as medically and logistically practical after diagnosis, ideally within 12 hours 1, 3
• Use the effective intervention associated with the least physiologic insult (e.g., percutaneous rather than surgical drainage of an abscess) 1
• Remove intravascular access devices that are possible sources of sepsis promptly after establishing other vascular access 1, 2, 3
• For infected peripancreatic necrosis, delay definitive intervention until adequate demarcation of viable and nonviable tissues has occurred 1

Ongoing Monitoring and Supportive Care

• Monitor for signs of adequate tissue perfusion: capillary refill time <2 seconds, absence of skin mottling, warm extremities, normal pulses, normal mental status, and urine output >0.5 mL/kg/h 1, 3, 4
• Guide resuscitation to normalize lactate in patients with elevated levels as a marker of tissue hypoperfusion 2, 3, 4
• For sepsis-induced ARDS, use lung-protective ventilation with tidal volumes of 6 mL/kg predicted body weight and plateau pressures ≤30 cm H₂O 2
• Maintain head of bed elevated to 30-45 degrees in mechanically ventilated patients 2, 3
• Use conservative fluid strategy for established sepsis-induced ARDS without evidence of tissue hypoperfusion 2

Adjunctive Therapies

• Avoid routine use of IV hydrocortisone in septic shock patients if adequate fluid resuscitation and vasopressor therapy restore hemodynamic stability 1, 3
• Consider timely hydrocortisone therapy only in children with fluid-refractory, catecholamine-resistant shock and suspected or proven absolute adrenal insufficiency 1
• Target hemoglobin 7-9 g/dL in the absence of tissue hypoperfusion, ischemic coronary artery disease, or acute hemorrhage 1, 3
• Provide deep vein thrombosis prophylaxis with pharmacologic agents unless contraindicated 3
• Use stress ulcer prophylaxis (H2 blockers or proton pump inhibitors) in patients with bleeding risk factors 3

Performance Improvement

• Hospital systems should implement routine sepsis screening for acutely ill, high-risk patients 4
• Maintain performance improvement programs for sepsis management to ensure adherence to time-sensitive interventions 4
• Discuss goals of care and prognosis with patients and families as early as feasible, but no later than within 72 hours of ICU admission 3

Common Pitfalls to Avoid

• Never delay antibiotics to obtain cultures—obtain cultures quickly but administer antibiotics within 1 hour regardless 1, 2, 3
• Do not use hetastarch formulations under any circumstances 1, 5
• Avoid sustained systemic antimicrobial prophylaxis in patients with severe inflammatory states of noninfectious origin (severe pancreatitis, burn injury) 2
• Do not continue aggressive fluid administration once hemodynamic improvement plateaus or signs of fluid overload appear 1, 2, 7
• Interpret NEWS2 scores in context of the patient's underlying physiology and comorbidities, particularly in elderly patients who may have attenuated inflammatory responses 2, 4