What are the 2026 Surviving Sepsis Campaign guidelines for the initial management of adult sepsis and septic shock?

Surviving Sepsis Campaign 2026 Guidelines for Adult Sepsis and Septic Shock

Immediate Recognition and First-Hour Bundle

Administer intravenous broad-spectrum antibiotics within the first hour of sepsis recognition; each hour of delay reduces survival by approximately 7.6%. 1 This is the single most time-critical intervention in sepsis management, with evidence demonstrating that delays beyond even 20 minutes for lactate measurement and 50 minutes for blood cultures begin to increase mortality risk. 2

Antimicrobial Therapy (Within 60 Minutes)

• Obtain at least two sets of blood cultures (aerobic and anaerobic) before starting antibiotics, but never delay antimicrobial administration beyond 45 minutes to obtain cultures. 1, 3

• Provide empiric coverage for:

  • Gram-positive organisms, including MRSA when risk factors are present 1
  • Gram-negative bacteria, including Pseudomonas aeruginosa in healthcare-associated infections 1
  • Anaerobes for intra-abdominal or aspiration sources 1

• Add empiric antifungal therapy (e.g., an echinocandin) for patients with immunosuppression, prolonged ICU stay, total parenteral nutrition, or recent broad-spectrum antibiotic exposure. 1

Fluid Resuscitation (First 3 Hours)

Give a minimum of 30 mL/kg of isotonic crystalloid (normal saline or balanced solution) within the first three hours of sepsis onset. 1, 3 For a 70-kg adult, this equals approximately 2 liters delivered as rapid 500–1000 mL boluses over 5–10 minutes. 1

• Use isotonic crystalloids as first-line fluid; they are inexpensive, well-tolerated, and have efficacy comparable to colloids. 1, 3

• Continue fluid administration while hemodynamic improvement is observed, guided by dynamic indices (pulse-pressure variation, stroke-volume variation) or static variables (arterial pressure, heart rate, urine output). 1, 3

• Avoid hydroxyethyl starch formulations because they increase the risk of acute kidney injury and mortality. 3

Hemodynamic Targets (First 6 Hours)

Target a mean arterial pressure (MAP) ≥ 65 mmHg in most adults; for patients with chronic hypertension, target MAP 70–85 mmHg because of a right-shifted autoregulatory curve. 1, 3

• Maintain urine output ≥ 0.5 mL/kg/h as a bedside marker of adequate renal perfusion. 1, 3

• Target central venous pressure (CVP) 8–12 mmHg (or 12–15 mmHg if mechanically ventilated) to assess fluid responsiveness. 1, 3

• Achieve central venous oxygen saturation (ScvO₂) ≥ 70% (or mixed venous O₂ saturation ≥ 65%) to confirm sufficient tissue oxygen delivery. 1, 3

• Monitor additional perfusion markers: capillary refill < 2 seconds, warm extremities, normal mental status, and palpable peripheral pulses. 1, 3

Vasopressor Therapy

Initiate norepinephrine as the first-line vasopressor at 0.05–0.1 µg/kg/min when MAP remains < 65 mmHg after the initial 30 mL/kg fluid bolus. 1, 3 Norepinephrine is more effective than dopamine for reversing hypotension and is associated with fewer arrhythmias. 1

• Peripheral administration of norepinephrine is acceptable initially to avoid delays while central venous access is obtained. 4

• Add vasopressin 0.03 U/min to norepinephrine when further MAP support is required or to reduce norepinephrine dose; vasopressin should not be used as the sole initial vasopressor. 1, 3

• Introduce epinephrine as a third-line agent if MAP targets are still unmet despite norepinephrine plus vasopressin. 1, 3

• Use dobutamine 2.5–5 µg/kg/min when myocardial dysfunction or persistent tissue hypoperfusion ("cold shock") is evident despite adequate MAP and volume status. 1, 3

Lactate Monitoring

Obtain a baseline serum lactate measurement at the time of sepsis recognition. 1, 3

• If the initial lactate is ≥ 2 mmol/L, repeat the measurement within six hours and use lactate normalization as a resuscitation endpoint. 1, 3

• Evidence demonstrates that delays beyond 20 minutes in obtaining lactate measurement begin to adversely impact outcomes. 2

Source Control

Identify or exclude a specific anatomic infection source requiring emergent intervention within 12 hours of sepsis onset (e.g., abscess, infected device, bowel perforation). 1, 3

• Perform definitive source-control procedures (drainage, debridement, removal of infected devices) as soon as feasible; inadequate source control is independently associated with increased mortality. 1, 3

• Whenever possible, obtain fluid or tissue samples from the suspected infection site for Gram stain, culture, and susceptibility testing. 1, 3

Respiratory Support

Provide supplemental oxygen to achieve SpO₂ ≥ 90%; if pulse-oximetry is unavailable, administer oxygen empirically. 1, 3

• Position patients semi-recumbently with the head of bed elevated 30–45° to reduce aspiration risk and ventilator-associated pneumonia. 1, 3

• Consider non-invasive ventilation for patients with dyspnea or persistent hypoxemia when staff are adequately trained. 1, 3

• If invasive mechanical ventilation is required, use a tidal volume of 6 mL/kg predicted body weight and keep plateau pressures ≤ 30 cm H₂O to minimize ventilator-induced lung injury. 1, 5

Antimicrobial De-escalation

Reassess antimicrobial therapy daily once pathogen identification and susceptibility results are available, typically within 48–72 hours. 1, 3

• De-escalate to the most appropriate single agent within 3–5 days based on culture data and clinical improvement; de-escalation is a protective factor for mortality. 1, 3

• Plan a total antibiotic course of 7–10 days for most serious infections associated with sepsis. 1, 3

• Extend duration for slow clinical response, undrained foci, Staphylococcus aureus bacteremia, fungal/viral infections, or immunodeficiency (e.g., neutropenia). 1, 3

Adjunctive Therapies

Corticosteroids

Do not use routine intravenous hydrocortisone in septic shock patients who achieve hemodynamic stability with fluids and vasopressors. 1, 5

• Consider hydrocortisone 200 mg/day (e.g., 50 mg IV every 6 hours) only if hemodynamic stability cannot be attained despite adequate fluid resuscitation and vasopressor therapy. 1, 5

• Taper hydrocortisone when vasopressors are no longer required. 1, 5

• Do not use ACTH stimulation testing to decide whether a patient receives hydrocortisone. 5

Blood Product Management

Target hemoglobin 7–9 g/dL unless there is tissue hypoperfusion, ischemic coronary disease, or acute hemorrhage. 1, 5

• Transfuse red blood cells only when hemoglobin falls below 7 g/dL. 1, 5

• Platelet transfusion thresholds: give prophylactically when < 10,000/mm³ without bleeding; consider when < 20,000/mm³ with high bleeding risk; aim for ≥ 50,000/mm³ for active bleeding, surgery, or invasive procedures. 5

• Do not use erythropoietin for sepsis-associated anemia. 5

• Do not give fresh-frozen plasma to correct laboratory coagulopathy unless there is active bleeding or an invasive procedure is planned. 5

Prophylaxis

Provide pharmacologic deep-vein thrombosis prophylaxis unless contraindicated. 1, 3

Use stress-ulcer prophylaxis (H₂-blocker or proton-pump inhibitor) in patients with bleeding risk factors. 1, 3

Mechanical Ventilation for Sepsis-Induced ARDS

For sepsis-induced ARDS, set a tidal volume of 6 mL/kg predicted body weight and keep plateau pressures ≤ 30 cm H₂O. 1, 5

• Apply positive end-expiratory pressure (PEEP) to prevent alveolar collapse; employ higher PEEP strategies in moderate-to-severe ARDS. 1, 5

• Use prone positioning in patients with a PaO₂/FiO₂ ratio < 150 mmHg to improve oxygenation. 5

• Maintain head-of-bed elevation of 30–45° to reduce ventilator-associated pneumonia risk. 1, 5

• Consider neuromuscular blockade for ≤ 48 hours when PaO₂/FiO₂ < 150 mmHg. 5

• Do not use high-frequency oscillatory ventilation. 5

Weaning and Extubation

Follow a weaning protocol that includes regular spontaneous breathing trials when patients meet five criteria: 5

1. Arousable mental status and able to protect airway 5
2. Hemodynamically stable without vasopressors (absolute contraindication to extubation) 5
3. No new serious conditions developing 5
4. Low ventilatory requirements (PEEP ≤ 8 cm H₂O) 5
5. Low FiO₂ requirements (≤ 40%) that can be delivered via face mask or nasal cannula 5

Interventions Not Recommended

Do not use routine intravenous immunoglobulins in adult sepsis or septic shock patients. 5

Do not use antithrombin therapy for sepsis and septic shock. 5

Do not use pulmonary artery catheters routinely in patients with sepsis-induced ARDS. 5

Do not use β₂-agonists for treatment of sepsis-induced ARDS unless specific indications such as bronchospasm are present. 5

Common Pitfalls to Avoid

• Delaying antimicrobial administration beyond 1 hour directly increases mortality; even delays of 50 minutes for blood cultures or 125 minutes for antibiotics significantly worsen outcomes. 1, 2

• Providing less than the recommended 30 mL/kg initial fluid bolus is inadequate; many patients require additional fluids guided by dynamic assessment. 1, 3

• Failing to initiate vasopressors when MAP remains < 65 mmHg after adequate fluid resuscitation prolongs tissue hypoperfusion and worsens outcomes. 1, 3

• Relying solely on MAP without monitoring lactate, urine output, mental status, and skin perfusion can miss ongoing hypoperfusion. 1, 3

• Using dopamine as a first-line vasopressor is associated with more arrhythmias and worse outcomes compared with norepinephrine. 1

• Excessive fluid administration when vasopressor support is already required increases the risk of fluid overload, especially in patients with abdominal pathology or ARDS. 1, 6

• Attempting extubation while the patient remains on vasopressors is an absolute contraindication. 5