Initial Approach to Sepsis with Rash

Initial Assessment and Stabilization

The Surviving Sepsis Campaign recommends stabilization of the patient's airway, breathing, and circulation as an immediate priority, and a decision regarding the need for senior review and/or intensive care admission should be made within the first hour 2
Blood cultures should be taken as soon as possible and within 1 hour of arrival at hospital, according to the Journal of Infection guidelines 2
The patient's conscious level should be documented using the Glasgow Coma Scale, as recommended by the Journal of Infection 2

The American College of Critical Care Medicine recommends obtaining blood cultures immediately and administering effective intravenous antimicrobials within the first hour of recognition 3
The Journal of Infection guidelines suggest beginning fluid resuscitation immediately with an initial bolus of 500 ml of crystalloid 1, 2
The Surviving Sepsis Campaign guidelines recommend following their guidelines for ongoing management, and not performing lumbar puncture at this time 1, 2

The Infectious Diseases Society of America recommends initial empiric therapy should include one or more drugs with activity against all likely pathogens (bacterial and/or fungal or viral) 3
For suspected meningococcal sepsis, the Centers for Disease Control and Prevention suggest using broad-spectrum beta-lactam antibiotics 4

The Society of Critical Care Medicine recommends capillary refill time less than 2 seconds, mean blood pressure > 65 mmHg, normal pulses with no differential between peripheral and central pulses, warm extremities, urine output > 0.5 ml/kg/hour, normal mental status, central venous pressure 8-12 mmHg, and lactate < 2 mmol/L as therapeutic endpoints 1, 2

The Infectious Diseases Society of America recommends reassessing antimicrobial regimen daily for potential de-escalation, and empiric combination therapy should not be administered for more than 3-5 days 3, 5
The Society of Critical Care Medicine suggests de-escalating to the most appropriate single therapy once susceptibility profile is known, and typical duration of therapy is 7-10 days 3, 5

The American College of Emergency Physicians recommends avoiding delaying antimicrobial administration beyond one hour, as this can increase mortality by 8% for each hour delay 4
The Journal of Infection guidelines suggest avoiding performing lumbar puncture in patients with sepsis and rapidly evolving rash before stabilization 1, 2

The Centers for Disease Control and Prevention recommend that meningococcal disease is a common cause of sepsis with rash and requires immediate treatment, and the rash may be petechial or purpuric and rapidly evolving 1, 2
The Journal of Infection guidelines suggest that even if treatment has been initiated, a lumbar puncture should still be performed as soon as possible after the patient is stabilized, preferably within 4 hours of commencing antibiotics 1