Current Management of Gram-Negative Septic Shock

Jean-Louis Vincent; Wasineenart Mongkolpun

Disclosures

Curr Opin Infect Dis. 2018;31(6):600-605. 

In This Article

Infection Control

Antibiotic therapy must be both appropriate, in terms of effectiveness against the causative microorganism(s), and adequate, in terms of dose and duration. Results from microbiological cultures, which should be taken prior to starting antibiotics whenever possible, without delaying antibiotic administration, still take several days to become available. Broad-spectrum empiric therapy is thus indicated in the majority of patients to insure that all likely microorganisms are covered. When deciding which empiric antibiotic(s) to use, various factors should be taken into account, including the most likely focus of infection, knowledge of local microbiological flora and resistance patterns, any recent or ongoing antimicrobial therapy, the immune status and the origin of the patient (nursing home, other hospital, home), and disease severity. Specific antimicrobial choices, dosing, and duration of treatment for Gram-negative sepsis have been covered in other manuscripts in this issue.

The need for early antibiotic administration is particularly important in septic shock. This logical statement is supported by epidemiological data. For example, in a large series of 18 000 patients included in the Surviving Sepsis Campaign database,[14] mortality increased from about 25% when antibiotics were administered within 1 h to about 33% when they were administered more than 6 h after recognition of the sepsis syndrome. Admittedly, this may not seem to be a large difference and other factors, including difficulty recognizing sepsis in some patients with atypical presentation and/or comorbidities, may complicate the picture, but the effect is clinically relevant and appropriate antibiotics should be administered as soon as possible after diagnosis.

Source control, when necessary, must also be accomplished rapidly. Source control is a heterogeneous problem because it can range from relatively simple catheter removal to more complex percutaneous drainage for an intra-abdominal abscess. It is, therefore, difficult to specify a time limit that could apply to every patient and situation, but care needs to be taken to insure that time is not lost waiting for source control interventions; for example, if surgery is needed for an acute abdomen, the procedure should be performed without delay. Importantly, although trying to find a source of infection is of paramount importance because it can influence management, one should recognize that in roughly 20–25% of cases, no source will be identified.

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