Treatment Protocol

We recommend administering antimicrobials immediately, ideally within 1 hr of recognition.

We recommend rapid assessment of the likelihood of infectious versus noninfectious causes of acute illness.

We suggest a time-limited course of rapid investigation and if concern for infection persists, the administration of antimicrobials within 3 hr from the time when sepsis was first recognized.

We suggest deferring antimicrobials while continuing to closely monitor the patient.

We suggest against using procalcitonin plus clinical evaluation to decide when to start antimicrobials, as compared to clinical evaluation alone.

We recommend using empiric antimicrobials with MRSA coverage over using antimicrobials without MRSA coverage.

We suggest against using empiric antimicrobials with MRSA coverage, as compared with using antimicrobials without MRSA coverage.

We suggest using two antimicrobials with gram-negative coverage for empiric treatment over one gram-negative agent.

We suggest against using two gram-negative agents for empiric treatment, as compared to one gram-negative agent.

We suggest against using double gram-negative coverage once the causative pathogen and the susceptibilities are known.

We suggest using empiric antifungal therapy over no antifungal therapy.

We suggest against empiric use of antifungal therapy

We suggest using prolonged infusion of beta-lactams for maintenance (after an initial bolus) over conventional bolus infusion.

We recommend optimising dosing strategies of antimicrobials based on accepted pharmacokinetic/pharmacodynamic (PK/PD) principles and specific drug properties.

We recommend rapidly identifying or excluding a specific anatomical diagnosis of infection that requires emergent source control and implementing any required source control intervention as soon as medically and logistically practical.

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.

We suggest daily assessment for de-escalation of antimicrobials over using fixed durations of therapy without daily reassessment for de-escalation.

We suggest using shorter over longer duration of antimicrobial therapy.

We suggest using procalcitonin AND clinical evaluation to decide when to discontinue antimicrobials over clinical evaluation alone.

We recommend using crystalloids as first-line fluid for resuscitation.

We suggest using balanced crystalloids instead of normal saline for resuscitation.

We suggest using albumin in patients who received large volumes of crystalloids.

We recommend against using starches for resuscitation.

We suggest against using gelatin for resuscitation.

There is insufficient evidence to make a recommendation on the use of restrictive versus liberal fluid strategies in the first 24 hr of resuscitation.

There is insufficient evidence to make a recommendation on the use of conservative oxygen targets.

We suggest the use of high flow nasal oxygen over noninvasive ventilation.

There is insufficient evidence to make a recommendation on the use of noninvasive ventilation in comparison to invasive ventilation.

We recommend using a low tidal volume ventilation strategy (6 mL/kg), over a high tidal volume strategy (> 10 mL/kg).

We recommend using an upper limit goal for plateau pressures of 30 cm H2O, over higher plateau pressures.

We suggest using higher PEEP over lower PEEP.

We suggest using low tidal volume as compared with high tidal volume ventilation.

We suggest using traditional recruitment maneuvers.

We recommend against using incremental PEEP titration/strategy.

We recommend using prone ventilation for greater than 12 hr daily.

We suggest using intermittent NMBA boluses, over NMBA continuous infusion.

We suggest using Veno-venous (VV) ECMO when conventional mechanical ventilation fails in experienced centers with the infrastructure in place to support its use.

We suggest using IV corticosteroids.

We suggest against using polymyxin B hemoperfusion.

There is insufficient evidence to make a recommendation on the use of other blood purification techniques.

We recommend using a restrictive (over liberal) transfusion strategy.

We suggest against using IV immunoglobulins.

We suggest using stress ulcer prophylaxis.

We recommend using pharmacologic venous thromboembolism (VTE) prophylaxis unless a contraindication to such therapy exists.

We recommend using low molecular weight heparin over unfractionated heparin for VTE prophylaxis

We suggest against using mechanical VTE prophylaxis, in addition to pharmacological prophylaxis, over pharmacologic prophylaxis alone.

We suggest using either continuous or intermittent renal replacement therapy.

We suggest against using renal replacement therapy.

We recommend initiating insulin therapy at a glucose level of ≥ 180mg/dL (10 mmol/L).

We suggest against using IV vitamin C.

We suggest against using sodium bicarbonate therapy to improve hemodynamics or to reduce vasopressor requirements.

We suggest using sodium bicarbonate therapy

We suggest early (within 72 hr) initiation of enteral nutrition.