Septic Shock: Source, Cultures, Pressors

• Sepsis is infection with acute organ dysfunction, operationalized as a SOFA increase of at least 2 points. Septic shock adds vasopressor need for MAP ≥65 mm Hg and lactate >2 mmol/L despite adequate volume assessment/resuscitation.
• Obtain lactate and blood cultures without delaying treatment. Give antimicrobials immediately, ideally within 1 hour, for septic shock or probable/definite sepsis; begin balanced crystalloid and reassess frequently.
• Start norepinephrine promptly when shock persists, including through a monitored proximal peripheral IV when appropriate. Add vasopressin, then epinephrine, if pressure remains inadequate; consider hydrocortisone for ongoing vasopressor-dependent shock.
• Arrange indicated source control urgently, ideally within 6 hours, and review antimicrobial need and spectrum every day.
• Give a prompt β-lactam loading dose, then use drug-specific prolonged maintenance infusion when appropriate. In pneumonia, a recent negative MRSA nasal PCR can support de-escalation when clinical risk and local test performance agree.

Fluid and Vasopressor Strategy in Septic Shock

• Sepsis-induced hypoperfusion or septic shock → obtain lactate and cultures without delaying antibiotics; assess perfusion and fluid tolerance
• SSC suggests at least 30 mL/kg IV crystalloid within the first 3 hours; prefer balanced crystalloid, give in reassessed aliquots and individualize for comorbidity and overload risk
• MAP <65 mm Hg or ongoing hypoperfusion?
• Shock persists
• Start norepinephrine promptly, concurrently with fluid when indicated; monitored proximal peripheral administration is acceptable while central access is obtained. Initial MAP target: 65 mm Hg
• Give another crystalloid aliquot, commonly up to 500 mL, only when a valid dynamic assessment suggests likely benefit and fluid tolerance is acceptable
• Adequate pressure and perfusion response?
• Adequate response
• Continue close reassessment; stop further fluid when no longer responsive or when intolerance develops
• Inadequate response
• Add vasopressin, then epinephrine if needed. Consider IV hydrocortisone 200 mg/day for ongoing vasopressor-dependent shock
• Shock resolved
• Do not give routine additional boluses; monitor perfusion, fluid balance and readiness for deresuscitation
• Follow capillary refill, mentation, urine output, blood pressure and lactate trend. Interpret every target in the clinical context; CVP and ScvO₂ are not routine resuscitation targets

Antibiotic Strategy in Sepsis and Septic Shock

• Obtain appropriate cultures without delaying treatment. Septic shock or probable/definite sepsis: give antimicrobials immediately, ideally within 1 hour. Possible sepsis without shock: investigate rapidly and treat within 3 hours if concern persists
• Identify the likely source, arrange urgent source control and use the local antibiogram. In immunocompromised patients, assess opportunistic pathogens and involve infectious-disease expertise early
• Specific risk for MRSA or resistant Gram-negative infection?
• MDR risk present
• Base empiric coverage on prior cultures/colonization, recent antimicrobial exposure, infection source, severity and local resistance—not healthcare contact alone
• For critically ill invasive nonurinary ESBL infection, prefer meropenem or imipenem; cefepime and piperacillin–tazobactam are not equivalent substitutes
• Reserve double Gram-negative coverage for a justified empiric MDR risk and narrow promptly when microbiology returns
• If MRSA coverage is indicated, choose by infection site: vancomycin or linezolid for pneumonia under the local pathway; use a bloodstream-infection regimen for suspected bacteremia. Daptomycin is not a pneumonia drug
• In suspected pneumonia, a recent negative MRSA nasal PCR can support withholding or stopping anti-MRSA therapy when clinical risk and local test performance support it
• No specific MDR risk
• Choose an IV regimen for the suspected source and severity. Severe community-acquired pneumonia generally requires a β-lactam plus a macrolide or respiratory fluoroquinolone; use dedicated pathways for urinary, abdominal, CNS and other sources
• Give a prompt β-lactam loading dose, then use drug-specific prolonged maintenance infusion with renal adjustment when appropriate
• Review the diagnosis, cultures, dose and spectrum every day; narrow or stop therapy when the evidence permits