Sepsis and septic shock are medical emergencies that require immediate action. Early resuscitation should begin with early antibiotics and fluids, as well as the identification of the source of infection, according to new guidelines that were released at the Society of Critical Care Medicine’s (SCCM) 2017 Critical Care Congress.
In addition, the new guidelines say a health care provider who is trained and skilled in the management of sepsis should reassess the patient frequently at the bedside. “It is not the initial assessment, but the frequent reassessment that will make a difference,” said Andrew Rhodes, MD, FRCP, FRCA, FFICM, the co-chair of the guidelines committee.
“The biggest challenge with sepsis management is that potentially lethal events such as organ system failure occur, but they’re not sequential; everything often happens at the same time,” said Michael Kenes, PharmD, BCPF, BCCCP, a medical ICU clinical pharmacy specialist and intensive care recovery clinical pharmacist at Wake Forest Baptist Health, in Winston-Salem, N.C. “And it’s multifactorial; it’s not just optimizing fluid status. So you have to consider adding vasopressors, for example, then antibiotics—you have to be thinking about those all in parallel with each other.”
Early Identification Key
The consensus committee of 55 international experts updated the 2012 Surviving Sepsis Campaign Guidelines for Management of Sepsis and Septic Shock to emphasize important advancements for clinicians caring for patients with the condition, starting with the need to identify at-risk patients sooner. (The guidelines are available at goo.gl/NfTe8o.)
The stakes are high for optimizing sepsis care: Sepsis is the leading cause of death from infection, and its reported incidence is on the rise, committee members noted. Moreover, despite advances in treatment, “septic shock still has a mortality rate of approximately 40%,” Dr. Rhodes said. “Even for those who survive a sepsis event, it causes considerable long-term health issues. Getting the right management early in the disease process is vital to improving the chances of a good outcome.”
The guidelines were released by the SCCM and the European Society of Intensive Care Medicine (ESICM) , which updated the recommendations. The committee’s revised guidelines encompass 21 categories, from initial resuscitation to setting goals of care. Two categories with important advancements for clinicians since the last guidelines in 2012 are those addressing initial resuscitation and antimicrobial therapy.
The initial resuscitation recommendations address what some clinicians had considered a controversial issue in the 2012 guidelines: giving specific targets for fluid resuscitation, including central venous pressure and central venous oxygen saturation. Following the initial fluid resuscitation, additional fluids should be guided by frequent reassessment of hemodynamic status, which was a best-practice statement.
The guidelines recommend IV antibiotics be initiated as soon as possible after recognition and within one hour for both sepsis and septic shock. In addition, they recommend that empirical broad-spectrum antibiotics with one or more antimicrobials to cover all likely pathogens be delivered.
“This recommendation was present in the previous guidelines for septic shock, but more recent data give greater strength to the recommendation and expand the recommendation to include both sepsis and septic shock,” said Anthony Gerlach, PharmD, BCPS, FCCP, FCCM, who attended the session at SCCM, but was not part of the guidelines panel.
Dr. Kenes echoed the importance of early intervention. “We know that antibiotics within the first hour improve survival, so give those up front early and make them a priority,” he said. But speed is not the only important consideration: Finding the source of the infection also is critical to helping the clinician empirically choose an appropriate broad-spectrum antibiotic, Dr. Kenes noted.
“You have to look at the anatomic site of infection and typical pathogens that might reside there [when making an empirical choice for antibiotics],” he said. “If we’re considering peritonitis, then [it is important to] cover the bugs that might cause infection there. If we’re thinking meningitis, then we [focus on] different antibiotics and different dosing for specific organisms. Importantly, we can tailor our antibiotic selection as well as dosing to optimize pharmacokinetic and pharmacodynamic parameters to tailor to that specific infection.”
“When we’re choosing antibiotics, it’s important to take into account our hospital and local community antibiogram and look at just what those resistant factors are,” explained Dr. Gerlach, a specialty practice pharmacist in the surgical ICU at the Ohio State University Wexner Medical Center, in Columbus. “Once we use that to make an initial antibiotic choice, we want to make sure that we’re obtaining appropriate cultures. Using rapid diagnostic testing can definitely play a role in helping to identify organisms as well as common resistance genes much sooner than traditional cultures would have done.”
The sepsis guidelines recommend that appropriate routine microbiological cultures, including blood, be obtained before starting antimicrobial therapy. “The reason why we feel good about making that recommendation is by marrying it to antibiotic stewardship,” explained Mitchell M. Levy, MD, MCCM, of Brown University in Providence, R.I., who was one of the founders of the Surviving Sepsis campaign in 2000.
As soon as the test results are available, he said, clinicians can narrow the spectrum. However, for the benefits of such testing to be fully realized, hospitals need to have robust antibiotic stewardship programs in place, Dr. Levy noted—which is why the updated sepsis guidelines emphasize the need for ASPs in hospitals.
The panel suggested that a treatment duration of seven to 10 days is adequate for most serious infections with sepsis and septic shock, and said patients should be assessed daily to determine whether antibiotics should be de-escalated.
A broader change in the current guidelines is the absence of pediatric recommendations because children have different needs. Work to develop pediatric guidelines is in process and will be available at a later date, the panel said.
Overall, the committee identified 93 statements on early management and resuscitation of patients with sepsis or septic shock. The results yielded 32 strong recommendations, 39 weak recommendations and 18 best-practice statements. No recommendation was provided for four questions.
Many Moving Parts
The guidelines took four years to revise, according to Laura E. Evans, MD, FCCM, the co-chair of the committee. “One of the big challenges that faced this group is that the Sepsis-3 definitions were copublished by the SCCM and the European Society of Intensive Care Medicine,” Dr. Evans explained. “They redefined sepsis as a life-threatening organ dysfunction caused by dysregulated host response to infection; septic shock [was deemed a] subset of sepsis with circulatory and cellular metabolic dysfunction associated with a higher risk of mortality. They eliminated the term ‘severe sepsis.’”
Although such changes in terminology are important, for Dr. Rhodes, the initial resuscitation of patients with sepsis is a key consideration. “If we are looking at the initial resuscitation,” he said, “there are three key components to think about: getting control of the source of the infection; giving early antibiotics; and getting on with the resuscitation. Sometimes, all three elements will have to happen in parallel.”