The time to administration of broad-spectrum antibiotics and (secondarily) to the initiation of hemodynamic stabilization are the most important factors influencing survival of patients with sepsis and septic shock; however, the basic prerequisite for the initiation of an adequate treatment is that a suspected diagnosis of sepsis is made first. Therefore, the treatment of sepsis, even before it has begun, is an interdisciplinary and interprofessional task. This article provides an overview of the current state of the art in sepsis treatment and points towards new evidence that has the potential to change guideline recommendations in the coming years. In summary, the following points are critical: (1) sepsis must be diagnosed as soon as possible and the implementation of a source control intervention (in case of a controllable source) has to be implemented as soon as (logistically) possible. (2) In general, intravenous broad-spectrum antibiotics should be given within the first hour after diagnosis if sepsis or septic shock is suspected. In organ dysfunction without shock, where sepsis is a possible but unlikely cause, the results of focused advanced diagnostics should be awaited before a decision to give broad-spectrum antibiotics is made. If it is not clear within 3 h whether sepsis is the cause, broad-spectrum antibiotics should be given when in doubt. Administer beta-lactam antibiotics as a prolonged (or if therapeutic drug monitoring is available, continuous) infusion after an initial loading dose. (3) Combination treatment with two agents for one pathogen group should remain the exception (e.g. multidrug-resistant gram-negative pathogens). (4) In the case of doubt, the duration of anti-infective treatment should rather be shorter than longer. Procalcitonin can support the clinical decision to stop (not to start!) antibiotic treatment! (5) For fluid treatment, if hypoperfusion is present, the first (approximately) 2L (30 ml/kg BW) of crystalloid solution is usually safe and indicated. After that, the rule is: less is more! Any further fluid administration should be carefully weighed up with the help of dynamic parameters, the patient's clinical condition and echo(cardio)graphy.
Die Zeiten bis zur Gabe eines Breitbandantibiotikums und (nachgeordnet) bis zum Beginn der hämodynamischen Stabilisierung sind die wichtigsten Einflussfaktoren für das Überleben von Patienten mit Sepsis und septischem Schock. Grundvoraussetzung für den Beginn einer adäquaten Therapie ist jedoch zunächst, dass die Verdachtsdiagnose „Sepsis“ gestellt wird. Die Behandlung der Sepsis ist daher, noch bevor sie begonnen hat, eine interdisziplinäre und interprofessionelle Aufgabe. Der vorliegende Artikel gibt eine Übersicht über den aktuellen „State of the Art“ der Sepsistherapie und weist auf neue Evidenz hin, die das Potenzial hat, die Leitlinienempfehlungen in den nächsten Jahren zu verändern.
Keywords: Antiinfective therapy; Hemodynamic stabilization; Prolonged antibiotic administration; Septic shock; Supportive therapy.
© 2023. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.