Praxis Medical Insights

Est. 2024 • Clinical Guidelines Distilled

Made possible by volunteer editors from the University of Calgary & University of Alberta

Last Updated: 8/22/2025

Sepsis Management

Introduction to Sepsis

  • Sepsis is a life-threatening condition that requires prompt recognition and treatment, with the Society of Critical Care Medicine and the Infectious Diseases Society of America recommending immediate intervention 1, 2, 3

Fluid Resuscitation

  • Initiate immediate crystalloid fluid resuscitation with a minimum of 30 mL/kg within the first 3 hours, as recommended by the Society of Critical Care Medicine and the Critical Care Medicine society 1, 4
  • Target mean arterial pressure (MAP) ≥65-70 mmHg, as recommended by the Society of Critical Care Medicine, the World Journal of Emergency Surgery, and the Critical Care Medicine society 1, 5, 6
  • Monitor for signs of fluid overload, including peripheral edema, decreasing oxygen saturation, pulmonary crackles, and jugular venous distension, to guide fluid management, as recommended by the Society of Critical Care Medicine and the World Journal of Emergency Surgery 5, 7, 8
  • Use dynamic measures to guide fluid administration (e.g., IVC diameter by ultrasound) 7

Antibiotic Therapy

  • Administer broad-spectrum antibiotics within 1 hour of recognition of sepsis, as recommended by the Society of Critical Care Medicine and the Infectious Diseases Society of America 1, 6, 2, 3
  • The Intensive Care Society recommends broad-spectrum carbapenem (e.g., meropenem) or extended-range penicillin/β-lactamase inhibitor combination (e.g., piperacillin-tazobactam) as the cornerstone of therapy, with additional coverage based on suspected source, local resistance patterns, and patient risk factors 1
  • Consider adding vancomycin for MRSA coverage if risk factors are present 1
  • Ensure anaerobic coverage with piperacillin-tazobactam or carbapenem 1
  • Reassess antibiotic regimen daily for potential de-escalation, according to the Society of Critical Care Medicine and the Infectious Diseases Society of America 1, 2, 3
  • Duration of therapy typically 7-10 days for most serious infections associated with sepsis, as recommended by the Society of Critical Care Medicine and the Infectious Diseases Society of America 1, 2, 3
  • Consider procalcitonin levels to guide antibiotic duration, according to the Society of Critical Care Medicine 1

  • The following antibiotics are recommended for specific pathogens:

    Pathogen Recommended Antibiotic Therapy
    Escherichia coli Third-generation cephalosporins or piperacillin/tazobactam, with consideration of local resistance patterns [9]
    Staphylococcus aureus Vancomycin, with a recommended duration of 4-6 weeks due to the high risk of metastatic complications, with a strength of evidence of high [2]
    Candida species Prolonged course of antifungal therapy (amphotericin B or fluconazole for susceptible strains), with the Infectious Diseases Society of America recommending oral fluconazole 200mg (3mg/kg) daily for 2 weeks for fluconazole-susceptible Candida infections [10, 11]
    Carbapenem-resistant Klebsiella Newer agents such as ceftolozane/tazobactam, ceftazidime/avibactam, and meropenem-vaborbactam, with consideration of local resistance patterns, as recommended by the Infectious Diseases Society of America [6, 12]

Vasopressor Therapy

  • Norepinephrine is the first-line vasopressor for septic shock not responding to fluid resuscitation, according to the Society of Critical Care Medicine, the World Journal of Emergency Surgery, the Intensive Care Medicine guidelines, and supported by the Surviving Sepsis Campaign and the American College of Critical Care Medicine 1, 5, 13, 14, 2
  • Vasopressors should be used for hypotension not responding to initial fluid resuscitation, with a target mean arterial pressure (MAP) ≥65 mmHg, as recommended by the Critical Care Medicine society and the Infectious Diseases Society of America 4, 1, 2

Source Control

  • Identify and control the source of infection within 12 hours of diagnosis, as recommended by the Society of Critical Care Medicine, the World Journal of Emergency Surgery, and the Infectious Diseases Society of America 1, 5, 6, 10
  • Surgical intervention may be indicated for intra-abdominal infections (e.g., perforated viscus), according to the World Journal of Emergency Surgery and the European Society of Intensive Care Medicine 5, 7, 14
  • Remove intravascular access devices if they are a potential source of infection, as recommended by the Society of Critical Care Medicine 1
  • Obtain joint fluid sample for culture and Gram stain to assess for sepsis in knee infections, as recommended by the American College of Radiology 15
  • Use imaging studies to identify potential source of infection, as recommended by the Critical Care Medicine society 6
  • Remove any infected prosthetic material or foreign bodies if present, as suggested by the European Society of Intensive Care Medicine 14
  • Drainage of abscesses is recommended if present, as recommended by the Infectious Diseases Society of America 12

Supportive Care

  • Initiate early enteral feeding rather than complete fasting or IV glucose alone, as recommended by the Society of Critical Care Medicine and the European Society of Intensive Care Medicine 1, 14
  • Avoid early parenteral nutrition, according to the Society of Critical Care Medicine 1
  • Consider trophic/hypocaloric feeding initially, advancing as tolerated, as recommended by the Society of Critical Care Medicine 1
  • Provide stress ulcer prophylaxis (PPI or H2 blocker) for patients with risk factors for GI bleeding, according to the Society of Critical Care Medicine 1
  • Maintain blood glucose <150 mg/dL (8.3 mmol/L) as part of supportive care, following guidelines from the European Society of Intensive Care Medicine 14
  • Implement VTE prophylaxis with LMWH unless contraindicated, as recommended by the Society of Critical Care Medicine 1
  • Monitor for signs of organ dysfunction using SOFA score parameters, according to the World Journal of Emergency Surgery 7
  • Regularly assess vital signs, urine output, lactate levels, electrolytes and renal function, and signs of fluid overload, as recommended by the Society of Critical Care Medicine, the World Journal of Emergency Surgery, and the Critical Care Medicine society 1, 5, 7, 6
  • Inspiratory plateau pressures should be kept <30 cm H₂O for mechanically ventilated patients, as recommended by the Intensive Care Medicine guidelines 1
  • Target tidal volume of 6 mL/kg predicted body weight, as recommended by the Intensive Care Medicine guidelines 1
  • Plateau pressures should be ≤30 cm H2O, according to the Intensive Care Medicine guidelines 1
  • Apply PEEP to avoid alveolar collapse, as suggested by the Intensive Care Medicine guidelines 1
  • Use higher rather than lower levels of PEEP for moderate or severe ARDS, according to the Intensive Care Medicine guidelines 1
  • Consider prone positioning for PaO2/FiO2 ratio ≤100 mm Hg, as recommended by the Intensive Care Medicine guidelines 1
  • Transfuse RBCs only when hemoglobin <7.0 g/dL (target 7.0-9.0 g/dL) once tissue hypoperfusion has resolved, as recommended by the Intensive Care Medicine guidelines and the Society of Critical Care Medicine 1
  • Elevate head of bed to 30-45 degrees, according to the Intensive Care Medicine guidelines 1

Antimicrobial Therapy for Urinary Tract Infections

  • The European Association of Urology recommends the use of newer broad-spectrum antimicrobial agents, including Meropenem-vaborbactam (2g q8h), Ceftolozane-tazobactam (1.5g q8h), Ceftazidime-avibactam (2.5g q8h), and Cefiderocol (2g q8h) for the treatment of urinary tract infections 12
  • Prompt differentiation between uncomplicated and potentially obstructive pyelonephritis is crucial, as the latter can rapidly progress to urosepsis, according to the European Urology guidelines 12
  • If imaging reveals a urinoma or abscess, percutaneous drainage and empiric antibiotics are indicated, as recommended by the World Journal of Emergency Surgery 9
  • For Carbapenem-resistant Enterobacteriaceae, the World Journal of Emergency Surgery suggests considering combination therapy with polymyxins, tigecycline, or fosfomycin 9
  • The World Journal of Emergency Surgery recommends considering empiric antifungal therapy in patients with risk factors, such as recent abdominal surgery, broad-spectrum antibiotics, or central venous catheters 9

REFERENCES

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