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).
At the bedside
Timed steps- 1
Look for a drainable source
0-1 hHistory and examination (wounds, abdomen, lines, catheters, skin crepitus), plus bedside POCUS: pleural effusion, hydronephrosis, gallbladder, free fluid, abscess.
- 2
Image the likely source
1-6 hCT when the patient is stable enough to travel; ultrasound at the bedside if not.
- 3
Least invasive effective procedure
ASAP, ideally ≤ 6 hPercutaneous drainage (abscess, empyema), nephrostomy or DJ stent for an obstructed kidney, cholecystostomy, ERCP for cholangitis, before open surgery when that will work. SSC 2026 suggests early source control, ideally within 6 h of diagnosis; sooner is better when feasible.
- 4
Remove infected devices
ImmediatelyRemove intravascular lines that may be the source once other access is in place (SSC 2021 best practice; source control guidance reaffirmed in 2026).
- 5
Surgical emergencies
NowNecrotising fasciitis, perforated viscus, ischaemic bowel: operate as part of resuscitation; do not wait for stability.
- 6
Short antibiotic course
After controlWith adequate source control, about 4 days of antibiotics after the procedure is as good as longer courses for intra-abdominal infection (STOP-IT).
Common sources and their control
| Source | Clue | Control |
|---|---|---|
| Obstructive pyelonephritis | Hydronephrosis on POCUS, stone | Nephrostomy or DJ stent, urgently |
| Acute cholangitis | Fever, jaundice, dilated CBD | ERCP drainage (PTBD if ERCP unavailable) |
| Empyema | Loculated effusion, pH < 7.2 | Chest drain ± fibrinolytics or VATS |
| Liver abscess | Hypoechoic lesion | Aspiration or catheter drainage if large, left lobe or not improving |
| Necrotising soft-tissue infection | Pain out of proportion, crepitus, bullae | Urgent surgical debridement |
| Perforated viscus | Free air, peritonitis | Laparotomy or laparoscopy |
| Line infection | Erythema or pus at site, no other source | Remove catheter; culture tip |
References
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Source control pathway
Step 1 of ~5
Examine + POCUS + CT when safe
Based on Prescott HC, Antonelli M, Alhazzani W, et al; Sawyer RG, Claridge JA, Nathens AB, et al. Educational use; follow local protocol.
Evidence
- SSC 2026: adults with sepsis should be rapidly evaluated for a source needing emergent control (good practice). It suggests early over late source control, ideally within 6 h of diagnosis (conditional, very low certainty). In 11 observational studies, early control was linked to lower short-term mortality (RR 0.70, 95% CI 0.51-0.95). Prolonged attempts to stabilise a severely ill patient without source control are unlikely to succeed.
- SSC 2021 added a best-practice statement to remove intravascular devices that may be the source once other access is established.
- STOP-IT (2015): after adequate source control for complicated intra-abdominal infection, a fixed ~4 days of antibiotics gave outcomes similar to treating until 2 days after physiological resolution (median ~8 days).
Controversies
- Exact timing: SSC 2026 picked 6 h because most observational studies defined 'early' that way; no RCT defines a cut-off. Percutaneous vs surgical control is a research priority.
- Damage-control laparotomy with an open abdomen vs primary closure in septic peritonitis.
🇮🇳 India notes
- Interventional radiology may not be available around the clock in smaller centres: plan early transfer or bedside ultrasound-guided drainage.
- Amoebic and pyogenic liver abscesses are common in India. Aspirate or drain if large (often > 5-10 cm), left lobe, impending rupture or not responding after 48-72 h.
References
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