Management of Sepsis and Septic Shock 2026

This Guideline deals with the recommendations of Management of Sepsis and Septic Shock.

➡️ SCREENING AND EARLY MANAGEMENT

1.   Performance Improvement Programs

For hospitals and health systems, we “recommend” using a performance improvement program for sepsis, including sepsis screening for acutely ill, high-risk patients; standard operating procedures for treatment; and implementation of sepsis quality improvement strategies. (Strong)

2.    Implementation Strategies

For hospitals and health systems, we “suggest” using a “code sepsis” or “sepsis huddle” protocol over not using such a protocol. (Conditional)

3.   Screening for Sepsis

3.1   In acutely ill adults en route to hospital by ambulance or flight, we “suggest” using a standard sepsis screening tool over not using a screening tool. (Conditional)

3.2   For acutely ill patients in hospital, we “recommend” using NEWS, NEW2, MEWS, or SIRS over qSOFA as a single tool to screen for sepsis.  (Strong)

4.   Biomarkers and Rapid Diagnostic Tests for Sepsis

4.1   Sepsis is a clinical diagnosis and should not be ruled in or ruled out using a single biomarker or diagnostic test. (GPS)

4.2   There is “insufficient evidence” to make a recommendation regarding use of novel rapid host response diagnostics. (GPS)

5.  Blood Cultures

For adults with possible, probable, or definite sepsis or septic shock, we “recommend” collecting blood cultures as soon as possible and ideally before the administration of antimicrobial therapy. (Strong)

6.  Blood Lactate Measurement

For adults with possible, probable, or definite sepsis or septic shock, we “suggest” measuring blood lactate. (Conditional)

7.   Initial Fluid Resuscitation

7.1   Sepsis and septic shock are medical emergencies; treatment and resuscitation should begin immediately. (Conditional)

7.2   For adults with sepsis-induced hypoperfusion or septic shock, we “suggest” administering at least 30 mL/kg of IV crystalloid in the first 3 hr. (Conditional)

8.   Timing of Vasopressor Initiation Relative to Fluid Resuscitation

For adults with sepsis-induced hypotension, we “suggest” initial IV crystalloid fluid bolus resuscitation followed by vasopressor support if hypotension persists. (Conditional)

9.   Route of Vasopressor Administration

In adults with septic shock, we “suggest” starting vasopressors peripherally to restore mean arterial pressure rather than delaying initiation until central venous access is secured. (Conditional)

10.  Mean Arterial Pressure (MAP) Targets

10.1   For adults with septic shock, we “recommend” an initial MAP target of 65 mm Hg over higher MAP targets. (Strong)

10.2   For adults with septic shock 65 years old or older, we “suggest” an initial MAP range of 60–65 mm Hg over higher ranges. (Conditional)

11.  Admission to Intensive Care: For adults with sepsis or septic shock who require ICU admission, we “suggest” admitting the patients to the ICU within 6 hr. (Conditional)

➡️INFECTION

12.  Timing of Antibiotic Initiation in Hospital and En Route to Hospital

12.1   For adults with possible, probable, or definite septic shock, we “recommend” administering antimicrobial therapy immediately, ideally within 1 hr of recognition. (Strong)

12.2  For adults with probable or definite sepsis without shock, we “recommend” administering antimicrobial therapy immediately, ideally within 1 hr of recognition. (Strong)

12.3  For adults with possible sepsis without shock, we “suggest” a time-limited course of rapid investigation and if concern for infection persists, the administration of antimicrobial therapy within 3 hours from the time when sepsis was first suspected. (Conditional)

12.4   Clinicians should perform a rapid assessment of the likelihood of infectious vs. non-infectious causes of acute illness in adults with possible sepsis without shock. (GPS)

12.5   For adults with a low likelihood of infection and without shock, we “suggest” deferring antimicrobial therapy while continuing to closely monitor the patient. (Conditional)

12.6  For adults with definite or probable sepsis and hypotension (i.e., septic shock) and who have an anticipated time to in-hospital medical evaluation of over 60 min, we “suggest” administering antimicrobial therapy in ambulance or flight. (Conditional)

13.  Biomarker-Guided Initiation of Antimicrobial Therapy

For adults with possible or probable sepsis or septic shock, we “suggest” using clinical evaluation alone over procalcitonin plus clinical evaluation to decide whether to start antimicrobial therapy. (Conditional)

14.  Source Control

14.1  Adults with sepsis or septic shock should be rapidly evaluated for specific anatomical diagnoses or sources of infection that require emergent source control. (GPS)

14.2 For adults with sepsis or septic shock and a specific anatomical diagnosis or source of infection that requires source control, we “suggest” early source control over late source control, ideally within 6 hr of diagnosis of sepsis or septic shock requiring source control. (Conditional)

15.  Empiric Multidrug Resistant (MDR) Pathogen Coverage, Empiric Antifungal Coverage, and Empiric Anaerobic Coverage

15.1  For adults with sepsis or septic shock at high risk of infection with a specific multidrug resistant (MDR) pathogen, we “suggest” using empirical antimicrobial therapy with coverage for this MDR pathogen. (Conditional)

15.2  For adults with sepsis or septic shock at low risk of infection with a specific MDR pathogen, we “suggest against” using empirical antimicrobial therapy with coverage for this MDR pathogen. (Conditional)

15.3   For adults with sepsis or septic shock, we “suggest against” using empirical antifungal therapy. (Conditional)

15.4  For adults with sepsis or septic shock without risk factors for anaerobic infection, we “suggest” using an empiric antibiotic regimen without anaerobic coverage. (Conditional)

15.5  For adults with sepsis or septic shock with specific risk factors for anaerobic infection, we “suggest” using an empiric antibiotic regimen that includes anaerobic coverage. (Conditional)

16.  Pathogen-Specific Rapid Diagnostic Tests

For adults with sepsis or septic shock, we “suggest” using pathogen-specific rapid diagnostic tests on a case-by-case basis in selected patients based on clinical features, local pathogen- and resistance patterns, seasonality, and availability of tests and antibiotic stewardship guidance. (Conditional)

17.  Prolonged Infusion of β-Lactam Antibiotics

For adults with sepsis or septic shock, we “recommend” using prolonged infusion of beta-lactams for maintenance (after an initial loading dose) over bolus administration. (Strong)

18.  Therapeutic Drug Monitoring (TDM) of Antimicrobial Therapy

For adults with sepsis or septic shock, we “suggest” using antimicrobial therapeutic drug monitoring (TDM) on a case-by-case basis in selected patients, based on clinical features, local pathogen- and resistance patterns, drug class, and availability of TDM. (Conditional)

19.   Antimicrobial De-escalation and Discontinuation

19.1  Clinicians should continuously reevaluate patients, search for alternative diagnoses, and discontinue empiric antimicrobial therapy if an alternative cause of illness is demonstrated or strongly suspected in adults with suspected sepsis or septic shock but unconfirmed infection. (GPS)

19.2    For adults with sepsis or septic shock, we “recommend” de-escalation of antimicrobial therapy over no de-escalation when a confirmed microbiological diagnosis and susceptibility profile is available. (Strong)

19.3   For adults with sepsis or septic shock, we “suggest” de-escalation of antimicrobial therapy over no de-escalation when no pathogens are identified on final culture results. (Conditional)

19.4   For adults with an initial diagnosis of sepsis or septic shock and adequate source control where optimal duration of therapy is unclear, we “suggest” using procalcitonin AND clinical evaluation to decide when to discontinue antimicrobial therapy over clinical evaluation alone. (Conditional)

➡️HEMODYNAMIC MANAGEMENT

20.  Blood Pressure Monitoring

For adults with septic shock, we “suggest” using either invasive or noninvasive blood pressure monitoring.  (Conditional)

21.  Fluid Type

21.1  For adults with sepsis or septic shock, we “recommend” using crystalloids as first-line fluid for resuscitation. (Strong)

21.2  For adults with sepsis or septic shock undergoing initial resuscitation, we “suggest” using balanced crystalloids over 0.9% saline. (Conditional)

21.3       For adults with sepsis or septic shock, we “suggest” using crystalloids alone over crystalloids with supplemental albumin for fluid resuscitation. (Conditional)

21.4    For adults with sepsis or septic shock, we “recommend against” using starches for resuscitation. (Strong)

21.5  For adults with sepsis and septic shock, we “suggest against” using gelatin for resuscitation. (Conditional)

22.  Liberal Vs. Conservative Approach to Resuscitation

For adults with sepsis or septic shock who have already received fluid resuscitation with 30 mL/kg and have persistent hypoperfusion, we “suggest” using either a liberal or a restrictive fluid resuscitation strategy based on individual patient and health system factors. (Conditional)

23.  Fluid Resuscitation Guided by Dynamic Measures, Capillary Refill Time & Cardiac Output Monitoring Devices

23.1  For adults with sepsis or septic shock, we “suggest” using dynamic measures to guide fluid resuscitation over physical examination or static measures alone. (Conditional)

23.2  For adults with sepsis or septic shock, we “suggest” using capillary refill time to guide resuscitation as an adjunct to other measures of perfusion. (Conditional)

23.3  For adults with septic shock, there is “insufficient evidence” to make a recommendation on using minimally invasive or noninvasive cardiac output monitoring in addition to usual care.

24.  Serial Lactate Measurement

For adults with sepsis and elevated lactate or septic shock, we “suggest” using serial lactate measurements to guide resuscitation. (Conditional)

25.  Vasopressors

25.1   For adults with septic shock, we “recommend” using norepinephrine as the first-line agent over dopamine, epinephrine, or selepressin. (Strong)

25.2  For adults with septic shock, we “suggest against” using terlipressin. (Conditional)

25.3   For adults with septic shock, we “suggest” using norepinephrine as the first-line agent over vasopressin or angiotensin II. (Conditional)

25.4  For adults with septic shock on escalating doses of norepinephrine, we “suggest” adding vasopressin. (Conditional)

25.5   For adults with septic shock and inadequate MAP levels despite norepinephrine and vasopressin, we “suggest” adding epinephrine. (Conditional)

25.6   For adults with septic shock with concomitant cardiac dysfunction, we “suggest” using either norepinephrine or epinephrine as first line vasopressor. (Conditional)

26.  Inotropes

26.1  For adults with septic shock and cardiac dysfunction with persistent hypoperfusion despite adequate fluid status and arterial blood pressure, we “suggest” using inotropes over no inotropes.(Conditional)

26.2  For adults with septic shock with persistent hypoperfusion and cardiac dysfunction despite adequate fluid resuscitation and arterial blood pressure, we “suggest” adding dobutamine to norepinephrine or using epinephrine alone. (Conditional)

26.3   For adults with septic shock and cardiac dysfunction with persistent hypoperfusion despite adequate volume status and arterial blood pressure, we “suggest against” using levosimendan. (Conditional)

27.  Beta-Blockers, Oral Midodrine and Methylene Blue

27.1   For adults with septic shock, we “suggest against” using beta-blockers as a treatment for septic shock. (Conditional)

27.2   For adults with septic shock and ongoing requirement for vasopressors, there is “insufficient evidence” to make a recommendation on use of oral midodrine.

27.3   For adults with refractory septic shock and escalating vasopressor requirements, there is “insufficient evidence” to make a recommendation on IV methylene blue.

➡️RESPIRATORY SUPPORT

28.  Monitoring of Hypoxemia

For adults with sepsis, we “suggest” measuring oxygenation by either pulse oximeter (Spo2) or arterial blood gas (Sao2) in conjunction with physical examination and clinical acumen. (Conditional)

29.  Oxygen Targets

For adults with sepsis and acute hypoxemic respiratory failure, we “suggest” titrating Fio2 to target either higher, more liberal oxygen levels or lower, conservative oxygen levels depending on patient factors and resource limitations. (Conditional)

30.  Noninvasive Respiratory Support & Awake Proning

30.1  For adults with sepsis and acute hypoxemic respiratory failure, we “suggest” using high flow nasal cannula (HFNC) therapy over conventional oxygen therapy. (Conditional)

30.2   For adults with sepsis and acute hypoxemic respiratory failure, we “suggest” using HFNC as the initial therapy over noninvasive positive pressure ventilation. (Conditional)

30.3   For adults with sepsis and acute hypoxemic respiratory failure, we “suggest” using HFNC over high flow alternating with noninvasive positive pressure ventilation. (Conditional)

30.4    For adults with sepsis and acute hypoxemic respiratory failure who are not intubated, we “suggest” a trial of awake proning. (Conditional)

31.  Invasive Mechanical Ventilation

31.1   For adults with sepsis and ARDS, we “recommend” using a low tidal volume ventilation strategy (6 mL/kg) over a high tidal volume strategy (> 10 mL/kg). (Strong)

31.2  For adults with sepsis-associated hypoxemic respiratory failure without ARDS, we “suggest” using a tidal volume of 6—8 mL/kg ideal body weight (IBW) over a lower (4 to < 6 mL/kg IBW) tidal volume. (Conditional)

31.3   For adults with sepsis and ARDS, we “recommend” using an upper limited goal for plateau pressure of 30 cm H2o) over higher plateau pressures. (Strong)

31.4  For adults with sepsis and moderate-severe ARDS, we “suggest” using higher positive end-expiratory pressure (PEEP) over lower PEEP. (Conditional)

31.5  For adults with sepsis and moderate-severe ARDS, we “recommend against” using an incremental PEEP titration strategy. (Strong)

31.6    For adults with sepsis and moderate-severe ARDS, we “suggest” using prone ventilation for greater than 12 hr daily. (Conditional)

31.7    For adults with sepsis and moderate-severe ARDS, we “suggest” using intermittent NMBA boluses over continuous NMBA infusion. (Conditional)

32.  Venovenous ECMO

 For adults with severe ARDS due to sepsis, we “suggest” using veno-venous ECMO    when conventional mechanical ventilation fails in experienced centers with infrastructure to support its use. (Conditional)

➡️ADJUNCTIVE THERAPIES FOR THE MANAGEMENT OF SEPSIS

33.  Adjunctive Therapies for the Management of Sepsis

33.1    IV Corticosteroids: For adults with septic shock, we “suggest” using IV corticosteroids. (Conditional)

33.2      Antipyretics: For adults with sepsis or septic shock, we “suggest against” the use of antipyretic therapy, either pharmacologic or surface cooling, for the purpose of improving clinical outcomes. (Conditional)

33.3   IV Vitamin C: For adults with sepsis or septic shock, we “suggest against” using IV vitamin C in patients with sepsis or septic shock. (Conditional)

33.4     IV Immunoglobulin (IVIG): For adults with sepsis or septic shock, we “suggest against” using IV immunoglobulins. (Conditional)

33.5    Vitamin D: For adults with sepsis and septic shock, we “suggest against” using Vitamin D therapy for sepsis treatment. (Conditional)

33.6  IV XueBiJing: For adults with sepsis or septic shock, we “suggest against” using XueBiJing injection outside of jurisdictions where it has regulatory approval. (Conditional)

33.7  Blood Purification:

33.7.1 For adults with sepsis or septic shock, we “suggest against” using blood purification techniques, including hemoperfusion, high- dose hemofiltration, or plasma exchange. (Conditional)

33.7.2 For adults with sepsis or septic shock we “suggest against” using polymyxin B hemoperfusion. (Conditional) 

➡️ADDITIONAL SUPPORTIVE THERAPIES IN PATIENTS WITH SEPSIS

34.  Insulin Therapy

For adults with sepsis or septic shock, we “recommend” initiating insulin therapy at a glucose level of ≥180 mg/dL (10 mmol/L). (Strong)

35.  Blood Transfusion

For adults with sepsis or septic shock, we “recommend” using a restrictive transfusion strategy over a liberal transfusion strategy. (Strong)

36.  Stress Ulcer Prophylaxis

For adults with sepsis or septic shock, and who have risk factors for GI bleeding, we “suggest” using stress ulcer prophylaxis with proton-pump inhibitors over not using stress ulcer prophylaxis. (Conditional)

37.  Renal Replacement Therapy

37.1   For adults with sepsis or septic shock and acute kidney injury, with no definitive indication for renal replacement therapy, we “suggest against” using renal replacement therapy. (Conditional)

37.2     For adults with sepsis or septic shock and acute kidney injury warranting renal replacement therapy, we “suggest” either continuous or intermittent renal replacement therapy. (Conditional)

38.  Enteral Nutrition

For adults with sepsis or septic shock, we “suggest” early (within 72 h) initiation of enteral nutrition. (Conditional)

39.  Sodium Bicarbonate

38.1  For adults with septic shock and hypoperfusion-induced lactic acidemia, we “suggest against” using sodium bicarbonate therapy to improve hemodynamics or to reduce vasopressor requirements. (Conditional)

38.2  For adults with septic shock, severe metabolic acidemia (pH ≤7.2), & acute kidney injury (AKIN score 2 or 3), we “suggest” using sodium bicarbonate therapy. (Conditional)

40.  Active Fluid Removal

For adults with septic shock after the acute resuscitation phase, we “suggest” using active fluid removal. (Conditional)

41.  Probiotics

For adults with sepsis or septic shock, we “suggest against” using probiotics. (Conditional)

42.  Venous Thromboembolism Prophylaxis

42.1   For adults with sepsis or septic shock, we “recommend” using pharmacologic venous thromboembolism (VTE) prophylaxis unless a contraindication exists. (Strong)

42.2   For adults with sepsis or septic shock, we “recommend” using low molecular weight heparin over unfractionated heparin for VTE prophylaxis. (Strong)

For adults with sepsis or septic shock, we “suggest” using pharmacological VTE prophylaxis alone over pharmacological VTE prophylaxis plus mechanical VTE prophylaxis. (Conditional)