Bacterial Sepsis Guidelines

Updated: Feb 05, 2019
  • Author: Amber Mahmood Bokhari, MBBS; Chief Editor: Michael Stuart Bronze, MD  more...
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Guidelines

Guidelines Summary

The initial sepsis guidelines were published in 2004 and then revised in 2008 and 2012. The current clinical practice guidelines are a revision of the 2012 Surviving Sepsis Campaign (SSC) guidelines for the management of severe sepsis and septic shock.

Major New Recommendations in the 2012 Update

Emphasis was directed to (1) first-hour fluid resuscitation and inotrope therapy directed to goals of threshold heart rates, normal blood pressure, and capillary refill of 2 seconds or less with specific evaluation after each bolus for signs of fluid overload, as well as first-hour antibiotic administration and (2) subsequent ICU hemodynamic support directed to goals of ScVO2 greater than 70% and cardiac index (CI) 3.3-6 L/min/m2 with appropriate antibiotic coverage and source control. [59]

Another major new recommendation in the 2012 update was that hemodynamic support of septic shock should be addressed at the institutional level rather than only at the practitioner level, with well-planned coordination between the family, community, prehospital, emergency department, hospital, and ICU settings. The 2012 guidelines recommend that each institution implement their own adopted or home-grown bundles that include the following:

  • Recognition bundle containing a trigger tool for rapid identification of patients with suspected septic shock at that institution
  • Resuscitation and stabilization bundle to drive adherence to consensus best practice at that institution
  • Performance bundle to monitor, improve, and sustain adherence to that best practice

The 2016 Surviving Sepsis Campaign Guidelines

The 2016 guidelines [60, 61] give a detailed overview of initial resuscitation, screening, and diagnosis of sepsis. The management decisions concerning antibiotic therapy, fluid administration, source control, administration of pressors and steroids, blood products, anticoagulants, immunoglobulins, mechanical ventilation, sedation, analgesia, glucose control, blood purification, renal replacement therapy, bicarbonate, venous thromboembolism and stress ulcer prophylaxis, nutrition, and setting goals of care are addressed. The main differences between the 2012 and 2016 guidelines are discussed in detail in the cited reference. [62]

Unfortunately, a consensus could not be reached between some of the sponsoring organizations. A position paper issued by the IDSA does not endorse the Society of Critical Care Medicine/European Society of Intensive Care Medicine (SCCM/ESICM) 2016 Surviving Sepsis Campaign guidelines for the management of sepsis and septic shock, despite the IDSA's participation in the development of the guidelines. In particular, while the IDSA agrees that the SCCM/ESICM recommendations are life-saving for patients with septic shock, they may lead to overtreatment in those with milder variants of sepsis and sepsis syndromes. The IDSA does not endorse routine initiation of antibiotic therapy within one hour of suspecting sepsis nor administration of combination antibiotic therapy and a 7- to 10-day course of antibiotic therapy for all patients, regardless of presentation factors. The IDSA also notes unclear recommendations for removal of catheters when considered as the source of sepsis and for the role of procalcitonin when monitoring therapeutic response. [63]

As more research related to timing of therapy is completed, further guideline refinement is expected, and perhaps a consensus regarding the treatment approach can be achieved.