What are the essential elements of the Surviving Sepsis Campaign 1‑hour bundle and subsequent management for a patient with suspected infection and possible sepsis?

Surviving Sepsis Campaign: Essential Elements for Study

The 1-Hour Bundle (Current Standard)

Initiate all components of the sepsis bundle within 1 hour of recognition for both sepsis and septic shock. 1, 2, 3

Immediate Actions (Within 1 Hour)

• Measure serum lactate immediately upon sepsis recognition to identify tissue hypoperfusion and trigger resuscitation protocols 1, 2

• Obtain blood cultures before antibiotics (at least two sets via fresh venipuncture), but never delay antimicrobials beyond 45 minutes waiting for cultures 1, 2, 3

• Administer IV broad-spectrum antibiotics within 1 hour covering all likely pathogens (bacterial, and potentially fungal or viral) 1, 2, 3

  • Each hour of delay decreases survival by 7.6% 2
  • Use empiric therapy before culture results are available 2, 3

• Begin aggressive fluid resuscitation with 30 mL/kg IV crystalloid for sepsis-induced hypoperfusion or lactate ≥4 mmol/L 1

• Apply vasopressors if hypotension persists after initial fluid resuscitation to maintain mean arterial pressure ≥65 mmHg 1, 2

Hemodynamic Resuscitation Targets (First 6 Hours)

The original resuscitation bundle focused on achieving specific physiologic endpoints: 1

• Mean arterial pressure >65 mmHg 1
• Central venous pressure 8-12 mmHg (though this target has evolved and is less emphasized in recent guidelines) 1
• Central venous oxygen saturation (ScvO₂) >70% or mixed venous oxygen saturation (SvO₂) ≥65% 1
• Urine output ≥0.5 mL/kg/h 2
• Remeasure lactate within 2-4 hours if initially elevated, targeting lactate normalization 2

Antimicrobial Strategy

Initial Therapy

• For septic shock specifically, use combination therapy with at least two antibiotics from different antimicrobial classes targeting the most likely pathogens for the first 3-5 days 1, 3

• For respiratory failure with septic shock and suspected Pseudomonas, combine an extended-spectrum β-lactam with either an aminoglycoside or fluoroquinolone 1, 3

• For septic shock from Streptococcus pneumoniae bacteremia, combine a β-lactam with a macrolide 1, 3

De-escalation Protocol

• Reassess antimicrobial therapy daily for potential narrowing once culture results and clinical response are available 1, 2, 3

• Discontinue combination therapy within 3-5 days in response to clinical improvement or infection resolution 1, 2, 3

• Narrow therapy to the most appropriate single agent as soon as susceptibility profiles are known 1

• Plan 7-10 days total duration for most serious infections associated with sepsis 1, 2, 3

  • Longer courses may be necessary for slow clinical response, undrainable infection foci, Staphylococcus aureus bacteremia, fungal/viral infections, or immunodeficiency 1, 3

Source Control

• Identify and control the infection source within 12 hours of recognition 2

  • Antibiotics alone are insufficient if anatomic foci (abscesses, perforations, ischemic bowel, drainable collections) remain undrained 2

• Perform imaging promptly to identify source control targets 2

Management Bundle (First 24 Hours - Historical Context)

The original management bundle included: 1

• Low-dose steroids for septic shock per hospital policy 1
• Glucose control targeting >lower limit of normal but <150 mg/dL (8.3 mmol/L) 1
• Inspiratory plateau pressures <30 cm H₂O for mechanically ventilated patients 1
• Drotrecogin alfa (activated) per hospital policy (note: this drug was later withdrawn from the market) 1

Critical "Never Do" Actions

• Never delay antibiotics beyond 1 hour waiting for diagnostic studies, biomarker results, or imaging 2, 3

• Never use antimicrobials for non-infectious inflammatory states such as severe pancreatitis without documented infection 1, 2

• Never rely solely on biomarkers (procalcitonin, CRP) to initiate or withhold antibiotics when clinical suspicion is high 3, 4

Evolution of the Campaign

The Surviving Sepsis Campaign launched in 2002 as a collaboration between the European Society of Intensive Care Medicine, International Sepsis Forum, and Society of Critical Care Medicine, with the goal of reducing sepsis mortality by 25% through evidence-based guidelines and implementation bundles. 5, 6 The guidelines have been updated multiple times (2004,2008,2016,2021) to reflect evolving evidence, with the most significant shift being the consolidation of resuscitation elements into a single 1-hour bundle rather than the original 6-hour and 24-hour bundles. 7, 8, 9