Sepsis Management Guidelines 2024 — Sepsis-3 & Surviving Sepsis Campaign

What is Sepsis?

Sepsis is defined (Sepsis-3, 2016) as life-threatening organ dysfunction caused by a dysregulated host response to infection. Operationally: suspected infection + acute SOFA score increase ≥2 from baseline. Septic shock is a subset: vasopressors required to maintain MAP ≥65 mmHg + serum lactate >2 mmol/L despite adequate fluid resuscitation. SIRS criteria are no longer used to define sepsis.

Pathophysiology

Sepsis results from an uncontrolled systemic inflammatory response to infection activating pro-inflammatory cascades (cytokines, complement, coagulation). This drives microvascular dysfunction, impaired oxygen extraction, mitochondrial dysfunction, and cellular apoptosis. The net result is multi-organ dysfunction. Immunological phenotypes range from hyperinflammatory (early) to immunoparalysis (late). Gram-negative endotoxins and gram-positive exotoxins trigger pattern recognition receptors (TLRs) initiating the cascade.

Clinical Features & Symptoms

High or low temperature (fever >38.3°C or hypothermia <36°C)
Tachycardia (>90 bpm)
Tachypnoea (>22/min) or respiratory failure
Altered mental status, confusion, agitation
Hypotension (SBP <100 mmHg)
Oliguria (<0.5 mL/kg/h)
Mottling, prolonged capillary refill
Elevated lactate (>2 mmol/L)

Diagnosis

Sepsis: suspected infection + SOFA score increase ≥2 (or qSOFA ≥2 as bedside screen outside ICU). Septic shock: requires vasopressors to maintain MAP ≥65 mmHg + lactate >2 mmol/L after adequate fluid resuscitation. Investigations: blood cultures (×2), lactate, FBC, CRP, procalcitonin, renal/liver function, coagulation. Source identification: urine, sputum, wound cultures; imaging for occult source.

Current Treatment Guidelines

Blood cultures before antibiotics

Class I, Level C

Obtain ≥2 sets (aerobic + anaerobic) before first antibiotic dose. Do not delay antibiotics >45 minutes to obtain cultures. CT imaging if clinically appropriate to identify source.

Broad-spectrum antibiotics within 1 hour

Class I, Level B

Administer IV antibiotics within 1 hour of sepsis recognition. Empirical coverage based on likely source and local resistance patterns. De-escalate within 48 hours based on culture results and procalcitonin.

IV fluid resuscitation

Class I, Level B

Balanced crystalloids (Ringer's lactate or Plasmalyte) preferred over normal saline (lower hyperchloraemic acidosis and AKI risk: SMART trial). 30 mL/kg over first 3 hours if hypotensive. Reassess frequently; avoid fluid overload.

Vasopressors for shock

Class I, Level A

Noradrenaline (norepinephrine) first-line vasopressor. Target MAP ≥65 mmHg. Add vasopressin if noradrenaline >0.25–0.5 µg/kg/min. Avoid dopamine except in bradycardia.

Corticosteroids in refractory shock

Class IIa, Level B

IV hydrocortisone 200 mg/day (continuous infusion or 50 mg QID) if MAP cannot be maintained despite adequate fluids + vasopressors. ADRENAL and APROCCHSS trials support use in vasopressor-dependent septic shock.

Source control

Class I, Level D

Identify and control source of infection within 6–12 hours. Drain abscess, remove infected catheter/device, debride necrotising fasciitis. Critical for recovery.

Monitoring & Treatment Targets

MAP ≥65 mmHg, lactate clearance ≥10% per 2 hours, urine output ≥0.5 mL/kg/h, SOFA score trend, lactate <2 mmol/L. Antibiotic de-escalation guided by procalcitonin (target <0.5 ng/mL or >80% fall). ICU monitoring: CVP, ScvO₂, daily fluid balance.

Key Clinical Trials

SMARTNEJM, 2018

Balanced crystalloids reduced MAKE30 (major adverse kidney events) by 1% vs normal saline (14.3% vs 15.4%, p=0.04) in critically ill adults

ADRENALNEJM, 2018

Hydrocortisone reduced time to resolution of shock and ICU LOS but did not reduce 90-day mortality in septic shock (28.8% vs 29.1%, p=0.50)

Clinical Guidelines

IDSA 2021

IDSA/ACEP Guidelines on Surviving Sepsis Campaign: International Guidelines for Management of Sepsis 2021

External Resources

Surviving Sepsis Campaign Guidelines 2021 Sepsis Alliance WHO Sepsis Fact Sheet

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Frequently Asked Questions

What are the Sepsis-3 diagnostic criteria?

Sepsis-3 (2016) defines sepsis as life-threatening organ dysfunction caused by dysregulated host response to infection: suspected infection plus acute SOFA score increase ≥2. Septic shock requires vasopressors to maintain MAP ≥65 mmHg plus lactate >2 mmol/L despite adequate fluid resuscitation. SIRS criteria are no longer part of the definition.

What antibiotics should be given in sepsis?

Surviving Sepsis Campaign 2021 recommends broad-spectrum IV antibiotics within 1 hour of sepsis recognition. The choice depends on the likely source and local resistance patterns. Common regimens: piperacillin-tazobactam for intra-abdominal/respiratory source; ceftriaxone + metronidazole for community-acquired; meropenem for resistant/healthcare-acquired infections. De-escalate within 48 hours based on culture results and procalcitonin.

Medical disclaimer: This content is intended for qualified healthcare professionals and does not constitute medical advice. Always apply clinical judgment and refer to current local guidelines and institutional protocols.