Sepsis and septic shock

Recognise sepsis early with Sepsis-3 and SOFA, deliver the first-hour bundle, choose and time empirical antibiotics for Indian resistance patterns, achieve source control, use steroids and vasopressin in refractory shock, and de-escalate safely. Updated to the Surviving Sepsis Campaign 2026 adult guidelines.

6 topics

01
Recognition: Sepsis-3, SOFA and screening
Sepsis is infection plus organ dysfunction (acute SOFA rise ≥ 2). Septic shock is sepsis needing vasopressors for MAP ≥ 65 with lactate > 2 mmol/L despite adequate fluids.
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02
Hour-1 bundle and initial resuscitation
Measure lactate, take blood cultures, give antibiotics, give at least 30 mL/kg crystalloid for hypotension or lactate ≥ 4, and start noradrenaline if MAP stays < 65, all begun within the first hour (SSC 2026).
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03
Antibiotics: timing, choice and dosing
Give the right empirical antibiotics immediately (ideally within 1 h) in shock, chosen by source, MDR risk and the local antibiogram, with full loading doses and prolonged-infusion beta-lactams (now a strong SSC 2026 recommendation).
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04
Source control
Find the anatomical source fast, then drain, debride, decompress or remove infected devices as soon as medically and logistically practical, ideally within 6 h (SSC 2026).
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05
Refractory shock: vasopressin, steroids and adjuncts
As noradrenaline doses escalate (commonly about 0.25-0.5 mcg/kg/min), add vasopressin; give IV hydrocortisone for ongoing vasopressor need; add dobutamine or use adrenaline for cardiac dysfunction; avoid vitamin C, beta-blockers, terlipressin and levosimendan.
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06
De-escalation, duration and stewardship
Review antibiotics daily, narrow once cultures return, use procalcitonin with clinical judgement to stop, and prefer short courses (often 5-7 days).
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Drugs in this module

Doses written for this module's context. The same drug may read differently in another module.

Noradrenaline (norepinephrine)

Catecholamine vasopressor (alpha-1 > beta-1)

Indications: First-line vasopressor in septic and most vasodilatory shock.
Adult dose: Start 0.05-0.1 mcg/kg/min and titrate every 5-10 min to MAP 65 mmHg (60-65 if aged ≥ 65). Usual range 0.05-0.5 mcg/kg/min. When doses are escalating (commonly 0.25-0.5 mcg/kg/min) add vasopressin; above ~0.5-1 mcg/kg/min = refractory shock.
Preparation (India): Ampoules 2 mg/2 mL. Common ICU syringe: 4 mg in 50 mL NS or D5 (80 mcg/mL), or 8 mg in 50 mL (160 mcg/mL) for fluid-restricted patients.
Cautions: Extravasation causes tissue necrosis (infiltrate phentolamine 5-10 mg in 10 mL NS if available). Digital and mesenteric ischaemia at high doses. Can be started via a good proximal peripheral cannula while central access is arranged.
Monitoring: Arterial line once on a vasopressor; MAP, lactate, capillary refill, urine output; peripheral site checks every hour if peripheral.

Vasopressin

V1 receptor agonist (non-catecholamine vasopressor)

Indications: Second vasopressor in septic shock when noradrenaline doses are escalating (commonly 0.25-0.5 mcg/kg/min).
Adult dose: Fixed 0.03 units/min (range 0.01-0.03, up to 0.04). Not titrated like noradrenaline.
Preparation (India): 20 units/mL ampoules. 20 units in 50 mL NS = 0.4 units/mL; 0.03 units/min = 4.5 mL/h.
Cautions: Digital, mesenteric and myocardial ischaemia; hyponatraemia. Avoid in low cardiac output states without inotropic support. Terlipressin is sometimes substituted in India but is not equivalent (longer acting, more ischaemia), and SSC 2026 suggests against it in septic shock.
Monitoring: Peripheral perfusion, ECG, sodium. When weaning, taper noradrenaline first, then vasopressin once noradrenaline is low.

Adrenaline (epinephrine)

Catecholamine (beta-1, beta-2, alpha-1)

Indications: Add-on when MAP is inadequate despite noradrenaline plus vasopressin (or noradrenaline alone if vasopressin is unavailable); inotropic alternative to dobutamine; a first-line option with cardiac dysfunction, especially with bradycardia (SSC 2026).
Adult dose: 0.05-0.3 mcg/kg/min titrated to MAP and perfusion; higher in refractory shock.
Preparation (India): 1 mg/mL ampoules. 4 mg in 50 mL = 80 mcg/mL.
Cautions: Raises lactate (beta-2 aerobic glycolysis), which can mask perfusion assessment; tachyarrhythmias; hyperglycaemia.
Monitoring: Arterial line, ECG, glucose; interpret lactate with care.

Dobutamine

Inotrope (beta-1 > beta-2)

Indications: Septic shock with cardiac dysfunction and persistent hypoperfusion despite adequate volume and MAP.
Adult dose: 2.5-10 mcg/kg/min (max 20).
Preparation (India): 250 mg/20 mL vials. 250 mg in 50 mL = 5000 mcg/mL.
Cautions: Vasodilatation and hypotension; tachyarrhythmias. Support MAP with a vasopressor first.

Hydrocortisone

Corticosteroid

Indications: Septic shock with ongoing vasopressor need (SSC 2026 suggests IV corticosteroids). Common unit trigger: noradrenaline or adrenaline ≥ 0.25 mcg/kg/min for ≥ 4 h.
Adult dose: 200 mg/day: 50 mg IV every 6 h, or 200 mg/24 h continuous infusion. Usually 5-7 days; stop when off vasopressors (taper optional).
Preparation (India): 100 mg vial (sodium succinate) reconstituted in 2 mL water for injection. Infusion: 200 mg in 50 mL NS at ~2.1 mL/h.
Cautions: Hyperglycaemia, hypernatraemia, ICU-acquired weakness, possible superinfection.
Monitoring: Glucose every 4-6 h, sodium.

Fludrocortisone

Mineralocorticoid

Indications: Optional add-on to hydrocortisone in septic shock (APROCCHSS regimen). Not specifically recommended in SSC 2026.
Adult dose: 50 mcg orally or by nasogastric tube once daily for 7 days, with hydrocortisone 50 mg IV every 6 h.
Preparation (India): 0.1 mg tablets are the common strength; 50 mcg = half tablet.

Balanced crystalloid (Ringer's lactate / Plasma-Lyte)

Isotonic crystalloid

Indications: Initial resuscitation fluid in sepsis-induced hypoperfusion.
Adult dose: At least 30 mL/kg IV within the first 3 h for hypotension or hypoperfusion (lactate ≥ 4, consider 2-4), as 250-500 mL boluses with reassessment after each. Use actual body weight; adjusted or ideal body weight if BMI > 30.
Preparation (India): Ringer's lactate 500 mL bottles are cheap and widely available. Plasma-Lyte A or Sterofundin in larger hospitals.
Cautions: Fluid overload and worsening oxygenation. Stop boluses when no longer fluid responsive or overloaded. Use 0.9% saline rather than balanced fluid in traumatic brain injury. Starches: recommend against; gelatin: suggest against (SSC 2026).

Human albumin 20%

Colloid

Indications: Not routine. SSC 2026 suggests crystalloid alone over added albumin; consider case by case after large crystalloid volumes or in cirrhosis.
Adult dose: Commonly 100 mL of 20% (20 g) per dose; ALBIOS targeted serum albumin ≥ 30 g/L.
Preparation (India): 20% in 50 mL and 100 mL vials; expensive.
Cautions: Cost. Avoid in traumatic brain injury (SAFE-TBI signal; SSC 2026).

Piperacillin-tazobactam

Antipseudomonal penicillin + beta-lactamase inhibitor

Indications: Empirical cover for sepsis with lower ESBL risk; intra-abdominal and many hospital-onset infections if the local antibiogram allows.
Adult dose: 4.5 g IV every 6 h. First dose over 30 min, then extended infusion over 3-4 h (SSC 2026: strong recommendation) (or continuous infusion 18 g/24 h after a loading dose).
Preparation (India): 4.5 g vials; reconstitute and dilute in 50-100 mL NS.
Renal / hepatic: Reduce frequency when CrCl < 40 mL/min (e.g. 4.5 g every 8 h; every 12 h if < 20). Always give a full first dose.
Cautions: Not for ESBL (ceftriaxone-resistant) bacteraemia (MERINO). ICMR advises avoiding it in septic shock until such bacteraemia is excluded. Hypokalaemia; more AKI when combined with vancomycin.

Meropenem

Carbapenem

Indications: Empirical therapy for septic shock with unclear focus (ICMR preferred, with imipenem), or high ESBL risk.
Adult dose: 1 g IV every 8 h as a 3-h extended infusion (2 g every 8 h for CNS infection or higher-MIC organisms). First dose over 30 min.
Preparation (India): 500 mg and 1 g vials. Dilute in 50-100 mL NS; limited stability at room temperature, so prepare each dose fresh.
Renal / hepatic: CrCl 26-50: 1 g every 12 h; 10-25: 500 mg every 12 h; < 10: 500 mg every 24 h.
Cautions: Overuse drives carbapenem resistance: de-escalate. Sharply lowers valproate levels.

Vancomycin

Glycopeptide

Indications: Add when MRSA risk is high (known colonisation, prior MRSA, line or skin source, post-operative or dialysis patients).
Adult dose: Loading 20-35 mg/kg actual body weight (max 3 g), then 15-20 mg/kg every 8-12 h, adjusted to AUC 400-600 (trough 15-20 mg/L if AUC monitoring is unavailable).
Preparation (India): 500 mg and 1 g vials. Infuse at ≤ 1 g/h in 200-250 mL NS.
Renal / hepatic: Keep the loading dose; extend the interval and use levels in AKI.
Cautions: Nephrotoxicity (more with pip-taz or aminoglycosides); infusion (flushing) reaction.
Monitoring: Level before the 4th dose; creatinine daily.

Teicoplanin

Glycopeptide

Indications: Alternative to vancomycin for MRSA; widely used in India.
Adult dose: Loading 12 mg/kg (≈ 800 mg) IV every 12 h for 3-5 doses, then 12 mg/kg once daily (6 mg/kg for less severe infection).
Preparation (India): 200 mg and 400 mg vials; slow IV bolus or 30-min infusion.
Renal / hepatic: Keep loading doses; reduce maintenance frequency from day 4 in renal impairment.

Colistin (colistimethate sodium)

Polymyxin

Indications: Carbapenem-resistant Acinetobacter, Pseudomonas or Enterobacterales when better options are unavailable; preferred polymyxin for lower UTI.
Adult dose: Loading 9 million units (MU) IV, then 4.5 MU every 12 h (or 3 MU every 8 h), starting 12-24 h after the load. Use in combination.
Preparation (India): 1 MU and 2 MU vials (1 MU ≈ 33 mg colistin base activity).
Renal / hepatic: Loading dose unchanged; maintenance reduced by creatinine clearance; supplement after dialysis.
Cautions: Nephrotoxicity and neurotoxicity.

Polymyxin B

Polymyxin

Indications: Preferred polymyxin for systemic carbapenem-resistant infection (not lower UTI).
Adult dose: Loading 2-2.5 mg/kg (20,000-25,000 units/kg) over 1 h, then 1.25-1.5 mg/kg (12,500-15,000 units/kg) every 12 h. No renal adjustment.
Preparation (India): 500,000-unit vials (1 mg = 10,000 units).
Cautions: Nephrotoxicity, neurotoxicity, skin hyperpigmentation.

Ceftazidime-avibactam

Cephalosporin + novel beta-lactamase inhibitor

Indications: CRE producing KPC or OXA-48-like enzymes (OXA-48-like are common in India). With aztreonam for metallo-beta-lactamase (NDM) producers.
Adult dose: 2.5 g IV every 8 h over 2 h. For NDM: plus aztreonam 2 g IV every 8 h, given together.
Preparation (India): 2.5 g vials (costly). Aztreonam 1 g vials.
Renal / hepatic: Reduce when CrCl ≤ 50 mL/min (e.g. 1.25 g every 8 h for CrCl 31-50).
Cautions: Use with susceptibility data or strong local epidemiology; involve microbiology.

Amikacin

Aminoglycoside

Indications: Second gram-negative agent in septic shock with unclear focus (ICMR), or urinary sepsis in high-resistance settings.
Adult dose: 15-20 mg/kg IV once daily (up to 25-30 mg/kg once daily in septic shock per some protocols), over 30-60 min.
Preparation (India): 100 mg, 250 mg and 500 mg vials.
Renal / hepatic: Extend interval in AKI and use levels; avoid prolonged courses.
Cautions: Nephrotoxicity and ototoxicity; stop after 48-72 h when susceptibilities are known.

Doxycycline

Tetracycline

Indications: Add empirically in Indian febrile sepsis when scrub typhus, rickettsia or leptospirosis is plausible.
Adult dose: 100 mg orally or by NG tube every 12 h (IV where available).
Preparation (India): 100 mg capsules or tablets; IV form has limited availability. Azithromycin 500 mg IV daily is an alternative.

6 topics

Recognition: Sepsis-3, SOFA and screening

Hour-1 bundle and initial resuscitation

Antibiotics: timing, choice and dosing

Source control

Refractory shock: vasopressin, steroids and adjuncts

De-escalation, duration and stewardship

Drugs in this module

Module references (29)