Septic Shock: Source, Cultures, Pressors

• Sepsis-3 pairs infection with SOFA ≥2; septic shock adds vasopressor need for MAP ≥65 plus lactate >2 despite fluids.
• Hour 1: draw lactate and blood cultures ×2, give broad-spectrum antibiotics inside 1 h, begin ~30 mL/kg balanced crystalloid for septic shock or hypoperfusion, then individualize further fluids with frequent reassessment (and deresuscitate once stable).
• Start noradrenaline (MAP target 65; a peripheral line through a large vein is acceptable while central access is placed); once the dose reaches 0.25–0.5, layer in vasopressin ≤0.03 U/min; refractory cases get hydrocortisone 200 mg/day.
• Achieve source control within 6–12 h and de-escalate antibiotics at 48–72 h once cultures return.
• Give β-lactams by prolonged (3–4 h) infusion where feasible; a negative MRSA nasal PCR rules out MRSA pneumonia and lets you withhold vancomycin.

Fluid Strategy in Septic Shock

• Sepsis picture plus: SBP <90 mm Hg, or MAP <65 mm Hg, or SBP drop >40 mm Hg, or lactate >4 mmol/L
• First fluid bolus: begin with ~30 mL/kg balanced crystalloid (lactated Ringer's/Plasmalyte preferred over normal saline), then individualize further fluids by frequent reassessment
• MAP <65 mm Hg or ongoing hypoperfusion signs?
• Continue fluid challenge with 500-mL boluses every 30 min, monitoring for hypoperfusion response
• Ensure oxygen delivery: Hgb >7 g/dL (transfuse if needed), SaO₂ >92%
• Vasopressors: start norepinephrine first-line 0.05–1 µg/kg/min — peripheral administration through a large vein is acceptable while central access is obtained; once it reaches 0.25–0.5 µg/kg/min add vasopressin as the second agent. Goal: MAP ≥65 mm Hg
• Adequate response?
• Maintain current management; monitor goals
• Add vasopressin 0.03 U/min or epinephrine; consider hydrocortisone 50 mg IV q6h when vasopressor-dependent
• Further fluid resuscitation not indicated; monitor perfusion endpoints
• Resuscitation goals: capillary refill normalization · MAP ≥65 mm Hg (60–65 acceptable ≥65 y) · urine ≥0.5 mL/kg/h · lactate clearance — CVP and ScvO₂ are no longer targets (ANDROMEDA-SHOCK-2: capillary-refill–guided wins)

Antibiotic Strategy in Sepsis and Septic Shock

• Immunocompromised? (HIV positive · neutropenia · chronic corticosteroids · malnutrition · receiving chemotherapy)
• Consider infectious disease consultation — antimicrobial therapy may need to cover opportunistic as well as bacterial pathogens
• Consider likely bacterial infection from the clinical presentation (non-immunocompromised patients with viral, fungal, or ehrlichial infections may also present with sepsis or septic shock)
• Health care–associated infection risk factors? (recent hospitalization · nursing home/rehabilitation residence · regular hospital clinic and dialysis visits · home infusion or wound therapy)
• Consider potentially resistant nosocomial bacterial pathogens: MRSA · Pseudomonas aeruginosa · Acinetobacter species · Klebsiella pneumoniae (ESBL+) · Escherichia coli (ESBL+)
• Carbapenem (imipenem, meropenem, doripenem) OR broad-spectrum cephalosporin (cefepime, ceftazidime, ceftolozane-tazobactam, ceftazidime-avibactam) OR β-lactam/β-lactamase inhibitor (piperacillin-tazobactam)
• ADD fluoroquinolone (ciprofloxacin or levofloxacin) OR aminoglycoside (gentamicin, tobramycin, amikacin)
• ADD MRSA-directed agent (vancomycin, linezolid, tigecycline, daptomycin [nonpneumonia]) — a negative MRSA nasal PCR rules out MRSA pneumonia, allowing vancomycin to be withheld
• Consider antibiotic-sensitive community bacterial pathogens: Streptococcus pneumoniae · Escherichia coli · Legionella pneumophila · methicillin-susceptible Staphylococcus aureus · Haemophilus influenzae · Klebsiella pneumoniae
• Pick one agent: fluoroquinolone (levofloxacin, moxifloxacin, ciprofloxacin) · ceftriaxone · ampicillin/sulbactam · ertapenem · macrolides (azithromycin, clarithromycin, telithromycin)
• Give β-lactams by prolonged (3–4 h) infusion where feasible; modify and/or narrow the regimen per identified organism and susceptibility testing