Initial Management of Sepsis

Antimicrobial Therapy

Administer intravenous broad-spectrum antibiotics within the first hour of sepsis recognition, as each hour of delay increases mortality by 7.6% 1, 2
The Surviving Sepsis Campaign recommends starting antimicrobial therapy immediately, with the goal of administering the first dose within one hour of sepsis recognition 1, 2
Obtain at least two sets of blood cultures (aerobic and anaerobic) before starting antibiotics, but do not delay antibiotic administration to obtain cultures 1, 2
Perform appropriate cultures according to local protocol (urine, wounds, etc.) 1, 3

Use empiric broad-spectrum antibiotic therapy covering all likely pathogens (bacterial, fungal, viral) 1, 2, 4
For septic shock, consider using a combination of antibiotics, including a beta-lactam and an aminoglycoside or a fluoroquinolone, but do not use combination therapy routinely for other severe infections 1, 2
The American College of Critical Care Medicine recommends using a beta-lactam antibiotic, such as piperacillin-tazobactam, meropenem, or imipenem-cilastatin, as the initial empiric therapy for septic shock 5, 2

Restore cardiovascular function aggressively within the first 6 hours with goal-directed fluid resuscitation 3, 2
Target a mean arterial pressure of ≥ 65 mmHg, central venous pressure of 8-12 mmHg, and urine output of ≥ 0.5 ml/kg/h 3, 2
Administer ≥ 30 ml/kg of crystalloids immediately to adults in septic shock 2

Optimize dosing strategies according to accepted pharmacokinetic/pharmacodynamic principles and specific drug properties 1, 5
Consider prolonged or continuous infusion of beta-lactam antibiotics to maximize time above the minimum inhibitory concentration 5

De-escalate antimicrobial therapy once the pathogen is identified and sensitivities are established, and/or adequate clinical improvement is noted 1, 4
Discontinue combination therapy within the first few days in response to clinical improvement 1
A duration of 7-10 days is adequate for most severe infections associated with sepsis and septic shock, but longer durations may be necessary in certain cases 1, 2

Perform urgent surgical debridement of necrotic tissue as soon as medically possible, ideally within 12 hours 5
Inadequate source control requires longer antibiotic courses 5

Do not delay antibiotics to obtain cultures or establish vascular access 1, 2
Do not use prolonged systemic antimicrobial prophylaxis in patients with severe inflammatory conditions of non-infectious origin 1
Do not continue combination therapy beyond 3-5 days without clear justification 1, 5