International societies release historic guidelines for treating sepsis

Goal is to reduce mortality rate by 25% in five years

An international group of critical care professionals has developed the first evidence-based recommendations ever to address the treatment of patients with sepsis.

"There is now a gold standard of care for the management of sepsis," says Mitchell M. Levy, MD, FCCP, FCCM, associate professor of medicine at Brown University School of Medicine in Providence, RI, and medical director of the Medical Intensive Care Unit at Rhode Island Hospital. Levy is one of the guidelines’ authors.

The guidelines are the result of a collaboration that began in 2002, when the European Society of Intensive Care Medicine, the Society of Critical Care Medicine, and the International Sepsis Forum came together to form the "Surviving Sepsis Campaign." Data in the literature, both specific for sepsis and for general disease management in the intensive care unit, suggested that the societies could improve survival in sepsis by creating guidelines and an international standard of care, Levy says. The campaign has been endorsed by 11 of the world’s leading critical care and infectious disease societies. Eli Lilly & Co., Baxter International, and Edwards Lifesciences Corp. added support with unrestricted educational grants.

The guidelines are remarkable for several reasons, Levy reports. First, there has never been a comprehensive set of guidelines for the overall treatment of sepsis. Second, and probably even more important, is the number of international infectious disease and critical care societies that have endorsed it, he adds. "It is historic that we have such a broad consensus of disciplines internationally signing on to a single set of guidelines."

The campaign has a threefold goal, Levy explains. The societies first wanted to increase public and clinician awareness of sepsis. Next, they wanted to create the set of consensus guidelines for sepsis management.

To accomplish this, the group held a consensus conference of about 45 opinion leaders in critical care and infectious diseases. The leaders came to the conference prepared, Levy says. "They did a thorough evidence-based review of the literature for each of their topics." The group went from the meeting to publication of their recommendations in a few short months. "We were determined not to sit on this because we think it is highly important."

The guidelines are detailed and comprehensive. Some of the recommendations include:

  • More aggressive recognition and diagnosis of sepsis in all hospital departments.
  • Monitoring of central venous oxygen saturation levels.
  • Empiric, timely antibiotic therapy to fight the underlying infection.
  • Maintenance of adequate blood pressure through intravenous fluids and/or medications.
  • When localizable, removal or reduction of the source of the infection (for instance, removal of a potentially infected catheter or drainage of an abscess).

One of the highest impact points in the guidelines for pharmacists is the early institution of antibiotics, Levy says. "We have always said that. Now we are saying that within the first hour or two, the right antibiotics — or at least antibiotics — should be given to patients who are septic." Guidelines also exist for the number of blood cultures and for the use of steroids. "It is important for pharmacists to know which drugs are being recommended in the guidelines and [when to give them]."

The guidelines were initially presented at the 33rd Annual Critical Care Congress of the Society for Critical Care Medicine (SCCM) in Orlando, FL. They were next published in the March issues of both Critical Care Medicine and Intensive Care Medicine. The guidelines also will be posted on-line, free of charge, at the SCCM site and the sites of participating organizations.

Reaction among critical care professionals has been more positive than expected, Levy says. "We thought we would get a lot of I don’t know if I agree with this and that.’ Instead, we have run into a very high level of acceptance."

The third facet of the goal, and next step, is to put these guidelines into practice and change clinician behavior. The campaign hopes to reduce the sepsis mortality rate by at least 25% over the next five years, Levy reports. Sepsis now kills about 1,400 Americans daily.

"Phase III is moving into a collaborative of different hospitals where we are going to take the guidelines, turn them into what are called change bundles,’ and find a way to bring them to the bedside of critically ill patients," he says. Chart review will identify and track change in practice and clinical outcomes.

These guidelines are subject to change, the authors say. "New interventions will be proven and established interventions, as stated in the current recommendations, may need modification." The authors expect to formally update the guidelines yearly.