The latest guidelines for the management of sepsis and septic shock in adults from the Surviving Sepsis Campaign expand the focus from in-hospital care to prehospital settings.1
“Time and again, we see that the faster you can diagnose sepsis and initiate treatment, the better patients do, period,” said lead author Hallie C. Prescott, MD, MSc, Toews Family Legacy Professor of Pulmonary & Critical Care Medicine at the University of Michigan Medical School.
While sepsis management has traditionally focused on arrival at the hospital and what happens afterward, Dr. Prescott said the guidelines now include a conditional recommendation to screen for sepsis while en route to the hospital. The goal is to recognize sepsis sooner, she said.
However, balanced with the goal of recognizing sepsis as early as possible, there is some flexibility to delay initiating antibiotic treatment in some cases.
“One of the things that jumps out to me from the hospital side is they have backed off a bit on the instruction to absolutely give antibiotics within that first hour to a more risk-based approach,” said Kathryn Pendleton, MD, FCCP, Director of the Medical Intensive Care Unit at the University of Minnesota Medical Center, Section Head of Critical Care, and Associate Professor of Pulmonary, Allergy, Critical Care and Sleep Medicine at the University of Minnesota Medical School.
“If this is definitely sepsis, absolutely give antibiotics as we always have, but also allow some latitude to be thoughtful and balance the need for antimicrobial stewardship. If there’s a reasonable chance this is not sepsis, it’s OK to get some testing and reassess the situation.”
The international sepsis guidelines for adults were last revised in 2021. The latest edition includes 44 recommendations carried forward from the previous edition and 46 statements addressing new questions.1
Key new or revised recommendations include:
- Implementation of code sepsis or sepsis huddle protocols to expedite diagnosis and treatment
- Initiation of antibiotics while en route to the hospital in select patients when transport time is long
- Avoidance of empiric antianerobic therapy in patients at low risk of anaerobic infection
- Avoidance of empiric antifungal therapy outside of case-by-case use in high-risk scenarios
- Lower mean arterial pressure goals of 60 to 65 mm Hg for older patients
- Active fluid removal in the deresuscitation phase of sepsis
The 69-person panel found insufficient information to make recommendations for some clinical questions. For example, the guidelines do not include a recommendation regarding the use of the current generation of rapid diagnostics for sepsis.
“Everybody is looking for some kind of clinical scoring system we can use,” Dr. Pendleton said. “How can we better identify appropriate patients to get early treatment while still realizing that sepsis is a clinical syndrome? There are other conditions that look like sepsis, and there are times we are going to guess wrong. We have to balance that reality with antibiotic stewardship, particularly thinking about multidrug-resistant organisms as a growing problem.”
The guidelines include a number of “in our practice” statements to address questions with low certainty or no evidence. These statements summarize the panel’s current approach to scenarios in which rigorous evidence is lacking.
Most panel members (86.6%) use peripheral vasopressors on at least some occasions. But there are insufficient data to recommend specific limits for duration of use, dose, or access route, including the size of the peripheral IV line or anatomic location. The balance of effects and resource use probably favors initial peripheral vasopressor administration, but the certainty of evidence is very low and further studies are needed.
Screening and early management recommendations may be the most visible changes in the current guidelines, Dr. Prescott said. Screening patients for sepsis during transit lets emergency medical services personnel give hospital staff an early jump on treatment, but there are insufficient comparative data to recommend a specific screening tool.
The narrow recommendation to implement antibiotic use in the prehospital setting is specific to regions with long transit times. The recommendation applies only to patients who screen positive for probable sepsis, are hypotensive, and have an anticipated ≥ 60-minute delay to in-hospital medical evaluation. Additionally, this was a conditional recommendation with a very low certainty of evidence.
“For urban centers, this recommendation doesn’t really come into play,” Dr. Prescott said. “They are going to get to the hospital in minutes, not hours. But for a critically ill patient with a very long transport time, this is something we suggest. It might be rare for any given ambulance but carrying antibiotics to treat one or two patients could make the difference. Time to treatment is critical, especially for patients with low blood pressure. We are always trying to balance timely treatment, particularly for the sickest patients, with the antimicrobial stewardship and avoiding unnecessary treatment in patients who turn out to have other diagnoses.”
With that in mind, the update places greater emphasis on antibiotic stewardship. Patients at low risk of anaerobic infection should not get empiric antibiotic therapy with anaerobic coverage. This includes individuals with lung or urinary tract infections, the most common causes of sepsis, who should not get metronidazole or clindamycin, which are typically prescribed for anaerobic organisms. When selecting gram-negative coverage, clinicians should also be mindful of the spectrum of coverage and, where feasible, avoid agents that include antianaerobic coverage.
“For a long time, the message has been to give broad-spectrum antibiotics, don’t miss the likely pathogen,” Dr. Prescott said. “Now we’re trying to add more nuance. We haven’t really thought about the off-target effects of antibiotics before. There is greater recognition that depleting the anaerobic bugs also depletes the healthy gut microbiome. There are downstream consequences that are associated with worse outcomes. Empiric antibiotic therapy should be tailored to likely pathogens and avoid coverage of unlikely pathogens.”
References
1. Prescott HC, Antonelli M, Alhazzani W, et al. Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock 2026. Crit Care Med. 2026;54(4):725-812. doi:10.1097/CCM.0000000000007075
