---

Sepsis Guidelines 2026 - Surviving Sepsis Campaign (SSC)

---

1. DEFINITIONS (Sepsis-3, Still Current)

• Current Surgical Therapy 14e, p.1615; Goldman-Cecil Medicine, Vol.1

---

2. SCREENING & EARLY RECOGNITION (NEW in 2026)

• RECOMMEND using a performance improvement program for sepsis at all hospitals - includes sepsis screening tools, standard operating procedures, and quality improvement strategies (moderate evidence for screening; very low for SOPs).
• SUGGEST using a "code sepsis" or "sepsis huddle" protocol over not using one (low evidence).
• NEW: For patients arriving by ambulance or air transport, SUGGEST using a standardized sepsis screening tool in the prehospital setting (very low evidence).
• The focus on early prehospital screening is a key change from 2021.

---

3. DIAGNOSTICS

• Blood cultures before antibiotics - obtain at least 2 sets; one peripheral, one from each vascular access device. Do not delay antibiotics >45 minutes just to get cultures.
• Serum lactate: Measure in all suspected sepsis - lactate ≥ 2 mmol/L supports diagnosis and is a resuscitation target.
• Procalcitonin (PCT): Useful for antibiotic de-escalation decisions; not reliable as a standalone diagnostic.
• Imaging: Obtain promptly to identify source. CT with contrast preferred for intra-abdominal sources.
• 2026 NEW - POCUS (Point-of-Care Ultrasound): Conditional recommendation to use cardiac and lung POCUS to guide resuscitation, particularly when local training and resources allow (addresses fluid responsiveness assessment).

---

4. HEMODYNAMICS & FLUID RESUSCITATION (Major Updates)

Initial Resuscitation

• SUGGEST initial IV crystalloid fluid bolus (balanced crystalloids preferred - e.g., Ringer's lactate, Plasmalyte) for sepsis-induced hypotension.
• Start with 30 mL/kg IV crystalloid in the first 3 hours as a reasonable initial target, but this is now individualized - reassess frequently using dynamic markers of fluid responsiveness (pulse pressure variation, passive leg raise, stroke volume variation, POCUS).
• SUGGEST initiating vasopressors early, including for persistent hypotension during initial crystalloid - do not delay vasopressors while waiting to finish fluid loading.

MAP Targets (2026 Update)

• The lower MAP target in older adults is a new 2026 recommendation - older patients may not benefit from targeting higher MAP and may be harmed by excess vasopressors.

Fluid Removal (NEW in 2026)

• After initial resuscitation, actively pursue fluid removal (de-resuscitation) once the patient is hemodynamically stable - this includes judicious use of diuretics or ultrafiltration. Fluid overload worsens outcomes.

Vasopressors

• For septic shock with concomitant cardiac dysfunction: SUGGEST norepinephrine or epinephrine as first-line (patient-specific cardiac rhythm guides choice).
• Methylene blue and midodrine are mentioned as adjunctive agents in refractory cases (emerging, not strongly recommended).

---

5. ANTIMICROBIALS (Significant Updates)

Timing

• RECOMMEND IV antibiotics within 1 hour of recognition in septic shock.
• For sepsis without shock: SUGGEST antibiotics within 3 hours (1 hour if high suspicion; hourly reassessment if uncertain).
• NEW 2026 - Prehospital antibiotics: For patients in areas where hospital access takes >1 hour, SUGGEST administering antibiotics in the prehospital setting.

Empirical Coverage

• Use broad-spectrum empirical therapy covering the most likely pathogens based on:
  • Clinical syndrome and likely source (pneumonia, abdominal, urosepsis, etc.)
  • Local epidemiology and resistance patterns
  • Patient risk factors for resistant organisms (prior MRSA, MDR gram-negatives, Candida)
• MRSA coverage: Add vancomycin or alternative if MRSA risk is high.
• Anti-fungal: Consider empirical antifungal therapy in immunocompromised patients or patients with known Candida colonization.

De-escalation & Duration (Stewardship - Emphasized in 2026)

• De-escalate antibiotics based on culture results - narrow spectrum as soon as clinically safe.
• Stop antibiotics if infection is ruled out (procalcitonin can guide this).
• Duration: Typically 5-7 days for most infections; longer only if immunocompromised, inadequate source control, or slow clinical response.
• Procalcitonin-guided de-escalation: The 2026 guidelines endorse using PCT to guide shortening antibiotic duration.

Source Control

• RECOMMEND source control as soon as feasible after identification - drainage, debridement, or removal of infected hardware.
• If infected intravascular device is the source, remove it promptly after establishing alternative IV access.

---

6. RESPIRATORY SUPPORT (Updated)

---

7. ADJUNCTIVE THERAPIES

Corticosteroids

• SUGGEST IV hydrocortisone in septic shock not responding to vasopressors - 200 mg/day continuous infusion or 50 mg every 6 hours.
• Do not use corticosteroids routinely in sepsis without shock.
• The HAT protocol (hydrocortisone + ascorbic acid + thiamine) is not recommended - RCTs failed to show mortality benefit.

Glucose Control

• Target blood glucose 140-180 mg/dL using insulin infusion in ICU patients.
• Avoid hypoglycemia - blood glucose < 70 mg/dL worsens outcomes.

DVT Prophylaxis

• RECOMMEND pharmacological VTE prophylaxis (LMWH preferred) in all sepsis patients unless contraindicated.
• Mechanical prophylaxis when pharmacological is contraindicated.

Stress Ulcer Prophylaxis

• SUGGEST using stress ulcer prophylaxis in sepsis patients with high GI bleeding risk (on vasopressors, coagulopathic, mechanically ventilated > 48h).

Blood Transfusion

• Transfuse RBCs if Hgb < 7 g/dL (in absence of active hemorrhage, MI, or severe anemia).
• Transfuse platelets if < 50,000/mm³ with active bleeding or surgery; can observe down to 20,000/mm³ without bleeding.

What is NOT Recommended (New 2026 Statements)

• Against routine use of antipyretics to improve clinical outcomes (can use for symptom relief only).
• Against routine use of probiotics in sepsis/septic shock.
• Against use of beta-blockers for treatment of septic shock.
• Against routine use of IVIG (intravenous immunoglobulin).
• Against routine use of selenium, glutamine, or omega-3 fatty acids.

---

8. MONITORING & TARGETS

---

9. POST-SEPSIS CARE (NEW Focus in 2026)

• Advance care planning: Discuss goals of care early and revisit regularly.
• Pharmacist-led medication reconciliation at ICU discharge and hospital discharge.
• Structured post-discharge follow-up: Sepsis survivors have high rates of rehospitalization, PTSD, cognitive impairment, and physical deconditioning ("Post-Intensive Care Syndrome" or PICS).
• Psychological support: Cognitive behavioral therapy and mental health services for survivors.
• Physical rehabilitation: Early mobilization in ICU; structured outpatient rehabilitation after discharge.
• 30-40% of pediatric sepsis survivors face long-term morbidity - emphasized in the pediatric guidelines as well.

---

10. KEY 2026 vs 2021 DIFFERENCES AT A GLANCE

---

Citation

Prescott H, Antonelli M, Alhazzani W, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2026. Crit Care Med. 2026 Mar. doi:10.1097/CCM.0000000000007075

• Sabiston Textbook of Surgery, p. 1615-1617
• Current Surgical Therapy 14e, p. 1615-1618
• SCCM 2026 SSC Guidelines | ESICM Announcement