Surviving Sepsis Campaign Adult Guidelines

Guidance for clinicians caring for adult patients with sepsis or septic shock

Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2026

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Critical Care Medicine | Intensive Care Medicine

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These guidelines are intended to support clinicians caring for adult patients with sepsis, focusing on management in the hospital, the immediate prehospital setting, and the immediate post-hospital setting. These guidelines incorporate principles of antimicrobial stewardship through responsible antimicrobial use, proper diagnostic strategies, and de-escalation of antimicrobial therapy.

The 2026 adult guidelines update recommendations from the 2021 SSC guidelines and include 129 statements, with 46 being new statements not previously addressed and more definitive recommendations. The 69-person guidelines panel had broad geographic diversity, representing 23 countries, with 38% of panelists currently or previously practicing in a low- or middle-income country.

These recommendations reinforce the core pillars of sepsis care—early recognition, timely treatment of infection, and hemodynamic resuscitation—while adding more detail, clarity, and nuance to guide real-world clinical decisions.

Related Resources

Infographics

What's New and Different in the Surviving Sepsis Campaign 2026

Hallie Prescott, MD, MSc, FACP, FCCM, Massimo Antonelli, MD, Waleed Alhazzani, MD, MSc, FRCPC, and Mervyn Mer, MD, PhD, discussed the updated Surviving Sepsis Campaign guidelines for adults, including new and revised recommendations, the evidence behind them, knowledge gaps, and application in low- and middle-income countries.

Filterable Recommendations

Review the recommendations from the guidelines below. Filter recommendations based on section, strength, or identifier. 

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Strength:




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.
Certainty of evidence: moderate for screening and quality improvement strategies, very low for standard operating procedures

Performance improvement programs and quality improvement strategies may vary by setting and in accordance with a hospital/healthcare system’s ability to implement.
Strong Performance Improvement

For hospitals and health systems, we “suggest” using a “code sepsis” or “sepsis huddle” protocol over not using such a protocol.
Certainty of evidence: Low

“Code sepsis” or “sepsis huddle” protocols involve a multidisciplinary team huddle at bedside to discuss and expedite sepsis diagnosis and treatment following a positive sepsis screen.
Conditional Implementation

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.
Certainty of evidence: Very low

Conditional Screening

For acutely ill patients in hospital, we “recommend” using NEWS, NEW2, MEWS, or SIRS over qSOFA as a single tool to screen for sepsis.
Certainty of evidence: Moderate

Strong Screening

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

Good practice statement Biomarkers

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

hide Diagnostics

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.
Certainty of evidence: Low

Strong Blood culture

For adults with possible, probable, or definite sepsis or septic shock, we “suggest” measuring blood lactate.
Certainty of evidence: Low

Conditional Blood lactate

Sepsis and septic shock are medical emergencies; treatment and resuscitation should begin immediately.

Good practice statement Fluid resuscitation

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.
Certainty of evidence: Low

Consideration should be given to individual patient characteristics and context when selecting initial fluid volume.

Clinicians prescribing fluids should perform frequent, ongoing reassessment and closely monitor patients to avoid harms of under- or over-resuscitation.

Weight-based fluid volume should be calculated based on actual body weight, or by adjusted or ideal body weight in patients with body mass index > 30 kg/m2.
Conditional Fluid resuscitation

For adults with sepsis-induced hypotension, we “suggest” initial IV crystalloid fluid bolus resuscitation followed by vasopressor support if hypotension persists.
Certainty of evidence: Very low

In patients with unstable septic shock, immediate concurrent administration of vasopressors together with IV crystalloid fluid may be warranted on a case-by-case basis. Presence of unstable shock should be determined by physical examination. Suggestive clinical features of unstable shock include severely reduced blood pressure, mottled skin, ashen appearance, cyanosis/decreased oxygen saturation, tachycardia, and altered mentation.
Conditional Fluid resuscitation

In adults with septic shock, we “suggest” starting vasopressors peripherally to restore MAP rather than delaying initiation until central venous access is secured.
Certainty of evidence: Very low

Data are insufficient to recommend a duration of use, dose, or access route (size of peripheral IV line or anatomic location). Midline catheters were not considered.
Conditional Vasopressor administration

For adults with septic shock, we “recommend” an initial MAP target of 65 mm Hg over higher MAP targets.
Certainty of evidence: Moderate

In practice, it is not feasible to maintain MAP at exactly 65 mm Hg, so a reasonable range (e.g., within 5 mm Hg) should be used. Vasopressors should be titrated to maintain MAP within this range.
Strong Mean arterial pressure

For adults with septic shock 65 years old or older, we “suggest” an initial MAP range of 60-65 mm Hg over higher ranges.
Certainty of evidence: Low

Conditional Mean arterial pressure

For adults with sepsis or septic shock who require ICU admission, we “suggest” admitting the patients to the ICU within 6 hr.
Certainty of evidence: Low

Conditional ICU admission

For adults with possible, probable, or definite septic shock, we “recommend” administering antimicrobial therapy immediately, ideally within 1 hr of recognition.
Certainty of evidence: Very low

Strong Antibiotic initiation

For adults with probable or definite sepsis without shock, we “recommend” administering antimicrobial therapy immediately, ideally within 1 hr of recognition.
Certainty of evidence: Very low

Strong Antibiotic initiation

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.
Certainty of evidence: Very low

Conditional Antibiotic initiation

Clinicians should perform a rapid assessment of the likelihood of infectious vs. noninfectious causes of acute illness in adults with possible sepsis without shock.

Good practice statement Antibiotic initiation

For adults with a low likelihood of infection and without shock, we “suggest” deferring antimicrobial therapy while continuing to closely monitor the patient.
Certainty of evidence: Very low

Conditional Antibiotic initiation

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.
Certainty of evidence: Very low

Prehospital antibiotic delivery should be implemented only after having a structured process in place to screen for sepsis in ambulance or flight, as discussed in recommendation 3.
Conditional Antibiotic initiation

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.
Certainty of evidence: Very low

Conditional Antibiotic initiation

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

Good practice statement Source control

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.
Certainty of evidence: Very low

Conditional Source control

For adults with sepsis or septic shock at high risk of infection with a specific MDR pathogen, we “suggest” using empirical antimicrobial therapy with coverage for this MDR pathogen.
Certainty of evidence: Very low

Risk factors for MDR pathogens include colonization with the MDR pathogen of concern, previous infection with the MDR pathogen of concern, prolonged use of broad-spectrum antibiotics, and prolonged hospitalization in a unit with a high prevalence of the MDR pathogen of concern.
Conditional Multidrug resistance

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.
Certainty of evidence: Very low

Conditional Multidrug resistance

For adults with sepsis or septic shock, we “suggest against” using empirical antifungal therapy.
Certainty of evidence: Low

Empiric antifungal therapy should be considered on a case-by-case basis in selected patients with sepsis or septic shock and risk factors for fungal infection, including immunosuppression, prolonged use of antibiotics, prolonged hospitalization, and intra-abdominal sources of infection.
Conditional Antifungal coverage

For adults with sepsis or septic shock without risk factors for anaerobic infection, we “suggest” using an empiric antibiotic regimen without anaerobic coverage.
Certainty of evidence: Very low

When coverage of potential MDR pathogens is required, agents with anaerobic activity (e.g., piperacillin–tazobactam or carbapenems) are appropriate when alternative agents lacking anaerobic coverage are insufficient.
Conditional Anaerobic coverage

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.
Certainty of evidence: Very low

Risk factors for anaerobic infection include intra-abdominal or deep-seated gynecological/obstetric source of infection, necrotizing soft-tissue infection, head and neck infection, and CNS abscesses or empyema.
Conditional Anaerobic coverage

There is “insufficient evidence” to make a recommendation regarding use of departmental (i.e., ICU-wide) microbiological surveillance samples of the upper respiratory tract to guide empirical antimicrobial therapy.

hide Microbiological surveillance

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.
Certainty of evidence: Low

Conditional Pathogen tests

For adults with sepsis or septic shock, we “suggest against” using Candida fungal biomarkers to guide initiation of empiric antifungal therapy.
Certainty of evidence: Low

Use of Candida biomarkers to guide initiation of empiric antifungal therapy may be considered on a case-by-case basis in selected patients at high risk of Candida infection, including those with immunosuppression, prolonged exposure to antibiotics, prolonged hospitalization, and intra-abdominal source of infection.
Conditional Antifungal therapy

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.
Certainty of evidence: Moderate

Strong Beta-lactam antibiotics

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.
Certainty of evidence: Very low

Conditional Drug monitoring

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.

Good practice statement Antimicrobial therapy

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.
Certainty of evidence: Very low

De-escalation involves discontinuing unnecessary antimicrobial therapy or narrowing the spectrum of antimicrobial agents where appropriate.
Strong Antimicrobial therapy

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.
Certainty of evidence: Very low

Conditional Antimicrobial therapy

For adults with sepsis or septic shock who are receiving empiric antifungal therapy, we “suggest against” use of Candida fungal biomarkers to guide discontinuation of empiric antifungal therapy.
Certainty of evidence: Low

Use of Candida biomarkers to guide discontinuation of empiric antifungal therapy may be considered on a case-by-case basis in clinically improving selected patients at high risk of Candida infection, including patients with immunosuppression, prolonged use of antibiotics, prolonged hospitalization, and intra-abdominal source of infection.
Conditional Antifungal therapy

For adults with an initial diagnosis of sepsis or septic shock and adequate source control, we “suggest” using shorter over longer duration of antimicrobial therapy.
Certainty of evidence: Very low

Conditional Antimicrobial therapy

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.
Certainty of evidence: Low

Conditional Antimicrobial therapy

In mechanically ventilated adults with sepsis or septic shock in units with a low prevalence of antimicrobial resistance, we “suggest” using selective decontamination of the digestive tract.
Certainty of evidence: Moderate

Conditional Digestive tract decontamination

For adults with septic shock, we “suggest” using either invasive or noninvasive blood pressure monitoring.
Certainty of evidence: Very low

Invasive blood pressure monitoring is advised in patients with shock who: require intermediate-to-high dose vasopressors, escalating doses of vasopressor, or multiple vasopressors; are receiving frequent arterial blood sampling; or have noninvasive blood pressure measurements which are inconsistent on repeated assessments.
Conditional Blood pressure monitoring

For adults with sepsis or septic shock, we “recommend” using crystalloids as first-line fluid for resuscitation.
Certainty of evidence: Moderate

Strong Fluid type

For adults with sepsis or septic shock undergoing initial resuscitation, we “suggest” using balanced crystalloids over 0.9% saline.
Certainty of evidence: Moderate

For patients with sepsis and traumatic brain injury, we suggest using 0.9% saline.
Conditional Fluid type

For adults with sepsis or septic shock, we “suggest” using crystalloids alone over crystalloids with supplemental albumin for fluid resuscitation.
Certainty of evidence: Moderate

Use of supplemental albumin may be appropriate for patients who already received large crystalloid volumes or have cirrhosis. Supplemental albumin should be avoided in patients with traumatic brain injury.
Conditional Fluid type

For adults with sepsis or septic shock, we “recommend against” using starches for resuscitation.
Certainty of evidence: High

Strong Fluid type

For adults with sepsis and septic shock, we “suggest against” using gelatin for resuscitation.
Certainty of evidence: Moderate

Conditional Fluid type

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.
Certainty of evidence: Low

There was wide variability in the protocols used and the volume of fluids received in the liberal vs. restrictive arms across trials. Patient and health system factors to be considered include patients’ current clinical conditions and chronic illnesses (e.g., heart failure) and the availability of monitored beds (i.e., if a restrictive approach necessitates vasopressor use).
Conditional Resuscitation

For adults with sepsis or septic shock, we “suggest” using dynamic measures to guide fluid resuscitation over physical examination or static measures alone.
Certainty of evidence: Low

Dynamic measures include response to a passive leg raise or a fluid bolus using stroke volume (SV), stroke volume variation (SVV), pulse pressure (PP), or pulse pressure variation (PPV).
Conditional Resuscitation

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.

Minimally invasive cardiac output monitoring refers to devices requiring an arterial catheter. Noninvasive cardiac output monitoring refers to devices using bioreactance. Usual care refers to care without a pulmonary artery catheter. The use of critical care ultrasound was not evaluated.
hide Cardiac output monitoring

For adults with sepsis and elevated lactate or septic shock, we “suggest” using serial lactate measurements to guide resuscitation.
Certainty of evidence: Low

Fluid administration should be individualized after initial fluid bolus and monitoring of lactate decrement, rather than continuing fluids until lactate normalization is achieved.
Conditional Serial lactate

For adults with sepsis or septic shock, we “suggest” using capillary refill time to guide resuscitation as an adjunct to other measures of perfusion.
Certainty of evidence: Low

Conditional Capillary refill

For adults with septic shock, we “recommend” using norepinephrine as the first-line agent over dopamine, epinephrine, or selepressin.
Certainty of evidence: High for dopamine, low for epinephrine and selepressin

Strong Vasopressors

For adults with septic shock, we “suggest against” using terlipressin.
Certainty of evidence: Low

Conditional Vasopressors

For adults with septic shock, we “suggest” using norepinephrine as the first-line agent over vasopressin or angiotensin II.
Certainty of evidence: Low for vasopressin, very low for angiotension II

Conditional Vasopressors

For adults with septic shock on escalating doses of norepinephrine, we “suggest” adding vasopressin.
Certainty of evidence: Moderate

Conditional Vasopressors

For adults with septic shock and inadequate MAP levels despite norepinephrine and vasopressin, we “suggest” adding epinephrine.
Certainty of evidence: Very low

In settings where vasopressin is not available, epinephrine can be added to norepinephrine alone.
Conditional Vasopressors

For adults with septic shock with concomitant cardiac dysfunction, we “suggest” using either norepinephrine or epinephrine as first line vasopressor.
Certainty of evidence: Very low

Norepinephrine may be preferred in patients with tachyarrhythmia or significant sinus tachycardia. Conversely, epinephrine may be preferred in patients with bradyarrhythmia or significant sinus bradycardia.
Conditional Vasopressors

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

Although methylene blue may improve blood pressure, there is insufficient evidence to determine if its use as rescue therapy improves survival; some patients with potentially treatable disease may value a trial.

“In our practice,” 69% of panelists “never” or “almost never” use methylene blue as rescue therapy, 23% “sometimes” use it, 6% “usually” use it, and 1.5% “almost always” use it.
hide Methylene blue

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.
Certainty of evidence: Very low

For patients requiring vasopressors to maintain MAP at target, inotropes should be used in addition to (not instead of) vasopressors.
Conditional Inotropes

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.
Certainty of evidence: Very low

Data were insufficient to make a recommendation for dobutamine vs. milrinone.
Conditional Inotropes

For adults with septic shock and cardiac dysfunction with persistent hypoperfusion despite adequate volume status and arterial blood pressure, we “suggest against” using levosimendan.
Certainty of evidence: Low

Conditional Inotropes

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

hide Midodrine

For adults with septic shock, we “suggest against” using beta-blockers as a treatment for septic shock.
Certainty of evidence: Very low

This recommendation is based on evidence for short-acting, IV beta-blockers (esmolol and landiolol) prescribed for treatment of septic shock.
Conditional Beta-blockers

For adults with sepsis, we “suggest” measuring oxygenation by either pulse oximeter (SpO2) or arterial blood gas (Sa O2) in conjunction with physical examination and clinical acumen.
Certainty of evidence: Very low

Arterial blood gas measurements are the gold standard for assessing oxygenation; include other important information such as pH, PacO2, lactate, and bicarbonate; and are preferable when available. SpO2/FIO2 by pulse oximeter may substitute for PaO2/FIO2 ratio but is less accurate in patients in shock, with darker skin tones, and/or with oxygen saturations < 90% or > 97%.
Conditional Hypoxemia monitoring

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.
Certainty of evidence: Low

Although there was variability across trials informing this recommendation, most used a lower target of approximately 90-93% SpO2 and a higher target of SpO2 ≥ 96.

“In our practice”, panelists target SpO2 between 90% (IQR 90-92%) to 96% (IQR 94-98%) for patients with sepsis and acute hypoxemic respiratory failure.
Conditional Oxygen targets

For adults with sepsis and acute hypoxemic respiratory failure, we “suggest” using HFNC therapy over conventional oxygen therapy.
Certainty of evidence: Very low

This recommendation pertains to patients with a PaO2/FIO2 ratio < 200 or SpO2/FIO2 ratio < 235.
Conditional Respiratory support

For adults with sepsis and acute hypoxemic respiratory failure, we “suggest” using HFNC as the initial therapy over noninvasive positive pressure ventilation.
Certainty of evidence: Low

Conditional Respiratory support

For adults with sepsis and acute hypoxemic respiratory failure, we “suggest” using HFNC over high flow alternating with noninvasive positive pressure ventilation.
Certainty of evidence: Very low

Conditional Respiratory support

For adults with sepsis and acute hypoxemic respiratory failure who are not intubated, we “suggest” a trial of awake proning.
Certainty of evidence: Very low

The duration and frequency of proning will depend on patient tolerance. Sedation should not be used for the purposes of promoting tolerance of proning in non-intubated patients.
Conditional Awake proning

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).
Certainty of evidence: High

Strong Mechanical ventilation

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.
Certainty of evidence: Low

Patients should be screened regularly for development of ARDS, as ARDS diagnosis is often missed or delayed in clinical practice.
Conditional Mechanical ventilation

For adults with sepsis and ARDS, we “recommend” using an upper limited goal for plateau pressure of 30 cm H2O) over higher plateau pressures.
Certainty of evidence: High

Strong Mechanical ventilation

For adults with sepsis and moderate-severe ARDS, we “suggest” using higher PEEP over lower PEEP.
Certainty of evidence: Moderate

Conditional Mechanical ventilation

For adults with sepsis and moderate-severe ARDS, we “recommend against” using an incremental PEEP titration strategy.
Certainty of evidence: Moderate

Strong Mechanical ventilation

For adults with sepsis and moderate-severe ARDS, we “suggest” using prone ventilation for greater than 12 hr daily.
Certainty of evidence: Moderate

Conditional Mechanical ventilation

For adults with sepsis and moderate-severe ARDS, we “suggest” using intermittent NMBA boluses over continuous NMBA infusion.
Certainty of evidence: Moderate

Conditional Mechanical ventilation

For adults with severe ARDS due to sepsis, we “suggest” using venovenous ECMO when conventional mechanical ventilation fails in experienced centers with infrastructure to support its use.
Certainty of evidence: Low

Conditional Venovenous ECMO

For adults with septic shock, we “suggest” using IV corticosteroids.
Certainty of evidence: Low

Conditional IV Corticosteroids

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.
Certainty of evidence: Very low

This recommendation does not apply to using antipyretic therapy for pain control, patient symptom control, or for patients with other indications for temperature control, such as neurocritical care patients or patients after cardiac arrest.
Conditional Antipyretics

For adults with sepsis or septic shock, we “suggest against” using IV vitamin C in patients with sepsis or septic shock.
Certainty of evidence: Low

Conditional IV Vitamin C

For adults with sepsis or septic shock, we “suggest against” using IV immunoglobulins.
Certainty of evidence: Low

Conditional IV Immunoglobulin

For adults with sepsis or septic shock, we “suggest against” using blood purification techniques, including hemoperfusion, high- dose hemofiltration, or plasma exchange.
Certainty of evidence: Very low

Conditional Blood purification

For adults with sepsis or septic shock we “suggest against” using polymyxin B hemoperfusion.
Certainty of evidence: Low

Conditional Blood purification

For adults with sepsis and septic shock, we “suggest against” using vitamin D therapy for sepsis treatment.
Certainty of evidence: Very low

This recommendation does not pertain to patients who are on lower doses of vitamin D supplement for other indication or receiving it as part of standard nutritional practice.
Conditional Vitamin D

For adults with sepsis or septic shock, we “suggest against” using XueBiJing injection outside of jurisdictions where it has regulatory approval.
Certainty of evidence: Very low

Conditional XueBiJing

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.
Certainty of evidence: Moderate

Conditional Stress ulcer prophylaxis

For adults with sepsis or septic shock, we “suggest against” using probiotics.
Certainty of evidence: Very low

Conditional Probiotics

For adults with septic shock after the acute resuscitation phase, we “suggest” using active fluid removal.
Certainty of evidence: Very low

Acute resuscitation refers to escalating doses of vasopressors, ongoing high doses of vasopressors, or needing ongoing volume expansion. Active fluid removal refers to diuretics and, if diuretics are insufficient, ultrafiltration or extracorporeal fluid removal. Factors to be considered when deciding to initiate active fluid removal include cardiorespiratory function, vasopressor dose, clinical course, peripheral edema, weight, and fluid balance.
Conditional Active fluid removal

For adults with sepsis or septic shock, we “recommend” using a restrictive transfusion strategy over a liberal transfusion strategy.
Certainty of evidence: Moderate

Strong Blood transfusion

For adults with sepsis or septic shock, we “suggest” early (within 72h) initiation of enteral nutrition.
Certainty of evidence: Very low

Conditional Enteral nutrition

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

Strong Insulin therapy

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.
Certainty of evidence: Moderate

Conditional Renal replacement therapy

For adults with sepsis or septic shock and acute kidney injury warranting renal replacement therapy, we “suggest” either continuous or intermittent renal replacement therapy.
Certainty of evidence: Low

Conditional Renal replacement therapy

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.
Certainty of evidence: Low

Conditional Sodium bicarbonate

For adults with septic shock, severe metabolic acidemia (pH ≤ 7.2), and acute kidney injury (AKIN score 2 or 3), we “suggest” using sodium bicarbonate therapy.
Certainty of evidence: Very low

Conditional Sodium bicarbonate

For adults with sepsis or septic shock, we “recommend” using pharmacologic VTE prophylaxis unless a contraindication exists.
Certainty of evidence: Moderate

Strong VTE prophylaxis

For adults with sepsis or septic shock, we “recommend” using low molecular weight heparin over unfractionated heparin for VTE prophylaxis.
Certainty of evidence: Moderate

Strong VTE prophylaxis

For adults with sepsis or septic shock, we “suggest” using pharmacological VTE prophylaxis alone over pharmacological VTE prophylaxis plus mechanical VTE prophylaxis.
Certainty of evidence: Moderate

Conditional VTE prophylaxis

For adults with sepsis or septic shock, clinicians should discuss goals of care and prognosis with patients and/or families.

Good practice statement Goals of care

For adults with sepsis or septic shock, we “suggest” addressing goals of care early (within 72 h) over late (72 h or later).
Certainty of evidence: Low

Conditional Goals of care

For adult patients with sepsis or septic shock, there is “insufficient evidence” to issue a recommendation regarding the use of a specific standardized criterion to identify patients for goals of care discussions.

hide Goals of care

Health systems should implement strategies to ensure that patients being discharged from hospital after sepsis or septic shock have the opportunity to execute advanced directives.

Good practice statement Advanced directives

For adults with sepsis or septic shock, there is “insufficient evidence” to issue a recommendation on the systematic establishment of advanced care directives before hospital discharge.

hide Advanced directives

For adults with sepsis or septic shock, there is “insufficient evidence” to issue a recommendation regarding formal time-limited trials (TLTs) of critical care.

A TLT is a collaborative plan to use life-sustaining therapy for a defined duration, after which response to therapy informs the decision as to whether to continue or escalate curative intent ICU care or to instead focus care on other goals.
hide Time-limited trials

The principles of palliative care (which may include palliative care consultation based on clinician judgement) should be integrated into the treatment plan, when appropriate, to address patient and family symptoms and suffering.

Good practice statement Palliative care

For adults with sepsis or septic shock, we “suggest against” routine formal palliative care.
Certainty of evidence: Low

Conditional Palliative care

For adults with sepsis and septic shock admitted to ICU, we “suggest” using a critical care transition program, compared with usual care, upon transfer to the floor.
Certainty of evidence: Very low

Conditional Transitions of care

For adults with sepsis or septic shock, we “suggest” using a handoff process of critically important information at transitions of care over no such handoff process.
Certainty of evidence: Very low

Conditional Transitions of care

Hospitals and health systems should screen patients with sepsis or septic shock for economic and social support needs (including housing, nutritional, financial, and spiritual support), and make referrals where available to meet these needs.

Good practice statement Patient support

For adults with sepsis or septic shock, comprehensive medication reconciliation should be performed at transitions in care, including at ICU and hospital discharge.

Good practice statement Medication reconciliation

For adults with sepsis or septic shock, we “suggest” comprehensive medication reconciliation using a pharmacist-based approach at transitions in care.
Certainty of evidence: Very low

Conditional Medication reconciliation

Clinical teams should provide adults with sepsis or septic shock and their families the opportunity to participate in shared decision making in post-ICU and hospital discharge planning to ensure discharge plans are acceptable and feasible.

Good practice statement Hospital discharge

For adult survivors of sepsis or septic shock and their families, clinicians should provide information about the hospital stay, sepsis and related diagnoses, treatments, and common impairments after sepsis in the written and verbal discharge summary.

Good practice statement Hospital discharge

For adults with sepsis or septic shock who developed new impairments, hospital discharge plans should include follow-up with clinicians able to support and manage new and long-term sequelae.

Good practice statement Hospital discharge

Healthcare systems should implement strategies to ensure that patients, their families, and their primary care providers are provided with adequate information to navigate the transition out of hospital.

Good practice statement Hospital discharge

For adults who survive hospitalization with sepsis or septic shock, there is “insufficient evidence” to issue a recommendation regarding a specific structured multi-component discharge planning process.

hide Hospital discharge

For adult survivors of sepsis or septic shock and their families, clinicians should provide information about the hospital stay, sepsis and related diagnoses, treatments, and common impairments after sepsis in the written and verbal discharge summary.

Good practice statement Patient family education

For adults with sepsis and septic shock and their families, we “suggest” offering written and verbal sepsis education (diagnosis, treatment, post-ICU/sepsis syndrome) before hospital discharge and in the follow-up setting.
Certainty of evidence: Very low

Conditional Patient family education

Health systems should implement strategies to ensure clinicians have the knowledge and competency to support sepsis survivors and their families during the post-hospital recovery.

Good practice statement PCP education

There is “insufficient evidence” to issue a recommendation regarding providing sepsis-focused educational material to primary care providers as compared with usual care.

hide PCP education

Health systems should implement strategies to support sepsis survivors and their families during the post-hospital recovery.

Good practice statement Post-discharge care

There is “insufficient evidence” to make a recommendation on early post-hospital discharge follow-up vs. routine post-hospital discharge follow-up.

hide Post-discharge care

Health systems should facilitate assessment and follow-up for physical, cognitive, and emotional problems after hospital discharge for sepsis or septic shock.

Good practice statement Post-hospital evaluation

For adult survivors of hospitalization for sepsis or septic shock, we “suggest” offering post critical illness follow-up services.
Certainty of evidence: Low

Follow-up services may vary in format, intensity, and duration, depending on locally available resources and patient needs.
Conditional Post-hospital evaluation

For adult survivors of hospitalization for sepsis or septic shock who received invasive mechanical ventilation > 48hr, we “suggest” offering physical rehabilitation services after hospital discharge.
Certainty of evidence: Low

Physical rehabilitation services may vary in format, intensity, and duration, depending on locally available resources and patient needs.
Conditional Physical rehabilitation

For adult survivors of hospitalization for sepsis or septic shock, we “suggest” offering services that support mental health after hospital discharge.
Certainty of evidence: Low

Conditional Mental health services

Adult survivors of hospitalization for sepsis or septic shock who demonstrate clinical symptoms of mental health disorders should be referred to appropriate healthcare professionals for evaluation and management.

Good practice statement Mental health services

For adult survivors of hospitalization for sepsis or septic shock, there is “insufficient evidence” to issue a recommendation regarding cognition-targeted therapies vs. usual care.

Where cognitive-targeted therapies are being used, it is reasonable to continue using them as they are likely acceptable and feasible.
hide Cognitive therapy

ARDS, acute respiratory distress syndrome, ECMO = extracorporeal membrane oxygenation, HFNC = high-flow nasal cannula, MAP = mean arterial pressure, MDR = multidrug-resistant, NMBA = neuromuscular blockade, PEEP =  positive end-expiratory pressure, VTE = venous thromboembolism.

A complete list of the guidelines authors and contributors is available within the published manuscript.

Knowledge Area:
Guidelines Quality and Patient Safety Sepsis Surviving Sepsis Campaign
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