-We recommend that administration of IV antimicrobials be initiated as soon as possible after recognition and within 1 h for both sepsis and septic shock (strong recommendation, moderate quality of evidence; grade applies to both conditions). -We suggest that an antimicrobial treatment duration of 7–10 days is adequate for most serious infections associated with sepsis and septic shock (weak recommendation, low quality of evidence). -We suggest that longer courses are appropriate in patients who have a slow clinical response, undrainable foci of infection, bacteremia with S. aureus, some fungal and viral infections, or immunologic deficiencies, including neutropenia (weak recommendation, low quality of evidence). -We suggest that shorter courses are appropriate in some patients, particularly those with rapid clinical resolution following effective source control of intra-abdominal or urinary sepsis and those with anatomically uncomplicated pyelonephritis (weak recommendation, low quality of evidence). -We suggest that measurement of procalcitonin levels can be used to support shortening the dura- tion of antimicrobial therapy in sepsis patients (weak recommendation, low quality of evidence). - We recommend daily assessment for de-escalation of antimicrobial therapy in patients with sepsis and septic shock (BPS). -We recommend prompt removal of intravascular access devices that are a possible source of sepsis or septic shock after other vascular access has been established (BPS). -We suggest using albumin in addition to crystalloids for initial resuscitation and subsequent intravascular volume replacement in patients with sepsis and septic shock when patients require substantial amounts of crystalloids (weak recommendation, low quality of evidence). -We recommend against using hydroxyethyl starches (HESs) for intravascular volume replace- ment in patients with sepsis or septic shock (strong recommendation, high quality of evi- dence). -We suggest adding either vasopressin (up to 0.03 U/min) (weak recommendation, moderate quality of evidence) or epinephrine (weak recommendation, low quality of evidence) to norepinephrine with the intent of raising MAP to target, or adding vasopressin (up to 0.03 U/min) (weak recommendation, moderate quality of evidence) to decrease norepinephrine dosage. -We recommend against using low dose dopamine for renal protection (strong recommendation, high quality of evidence). -We suggest against using IV hydrocortisone to treat septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability. If this is not achievable, we suggest IV hydrocortisone at a dose of 200 mg per day (weak recommendation, low quality of evidence). One French multicenter RCT of patients in vasopressor-unresponsive septic shock (systolic blood pressure <90 mm Hg despite fluid resuscitation and vasopressors for more than 1 h) showed significant shock reversal and reduction of mortality rate in patients with relative adrenal insufficiency [defined as a maximal post- adrenocorticotropic hormone (ACTH) cortisol increase ≤9 μg/dL] Data from nine trials (n = 1324 patients with septic shock), comparing norepi- nephrine with vasopressin (or terlipressin) demonstrated no significant difference in mortality (RR 0.89; 95% CI 0.79–1.00; moderate-quality evidence)
-We recommend that administration of IV antimicrobials be initiated as soon as possible after recognition and within 1 h for both sepsis and septic shock (strong recommendation, moderate quality of evidence; grade applies to both conditions).
ResponderEliminar-We suggest that an antimicrobial treatment duration of 7–10 days is adequate for most serious infections associated with sepsis and septic shock (weak recommendation, low quality of evidence).
-We suggest that longer courses are appropriate in patients who have a slow clinical response, undrainable foci of infection, bacteremia with S. aureus, some fungal and viral infections, or immunologic deficiencies, including neutropenia (weak recommendation, low quality of evidence).
-We suggest that shorter courses are appropriate in some patients, particularly those with rapid clinical resolution following effective source control of intra-abdominal or urinary sepsis and those with anatomically uncomplicated pyelonephritis (weak recommendation, low quality of evidence).
-We suggest that measurement of procalcitonin levels can be used to support shortening the dura- tion of antimicrobial therapy in sepsis patients (weak recommendation, low quality of evidence).
- We recommend daily assessment for de-escalation of antimicrobial therapy in patients with sepsis and septic shock (BPS).
-We recommend prompt removal of intravascular access devices that are a possible source of sepsis or septic shock after other vascular access has been established (BPS).
-We suggest using albumin in addition to crystalloids for initial resuscitation and subsequent intravascular volume replacement in patients with sepsis and septic shock when patients require substantial amounts of crystalloids (weak recommendation, low quality of evidence).
-We recommend against using hydroxyethyl starches (HESs) for intravascular volume replace- ment in patients with sepsis or septic shock (strong recommendation, high quality of evi- dence).
-We suggest adding either vasopressin (up to 0.03 U/min) (weak recommendation, moderate quality of evidence) or epinephrine (weak recommendation, low quality of evidence) to norepinephrine with the intent of raising MAP to target, or adding vasopressin (up to 0.03 U/min) (weak recommendation, moderate quality of
evidence) to decrease norepinephrine dosage.
-We recommend against using low dose dopamine for renal protection (strong recommendation, high quality of evidence).
-We suggest against using IV hydrocortisone to treat septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability. If this is not achievable, we suggest IV hydrocortisone at a dose of 200 mg per day (weak recommendation, low quality of evidence).
One French multicenter RCT of patients in vasopressor-unresponsive septic shock (systolic blood pressure <90 mm Hg despite fluid resuscitation and vasopressors for more than 1 h) showed significant shock reversal and reduction of mortality rate in patients with relative adrenal insufficiency [defined as a maximal post- adrenocorticotropic hormone (ACTH) cortisol increase ≤9 μg/dL]
Data from nine trials (n = 1324 patients with septic shock), comparing norepi- nephrine with vasopressin (or terlipressin) demonstrated no significant difference in mortality (RR 0.89; 95% CI 0.79–1.00; moderate-quality evidence)