Surviving Sepsis Campaign updates guidelines; still no support from IDSA

Henry Masur

An updated version of the 2016 Surviving Sepsis Campaign, or SSC, now includes an “Hour-1 Bundle” focusing on five crucial treatment steps that should be employed within the first hour of identifying sepsis, the campaign announced.

“Like multiple trauma, heart attack, or stroke, sepsis is a medical emergency,” Mitchell M. Levy, MD, chief of the division of pulmonary, critical care and sleep medicine at Brown University School of Medicine and lead author of the latest SSC update, said in a press release. “Our revised Hour-1 Bundle reflects the clinical reality at the bedside of seriously ill patients with sepsis or septic shock — with the explicit intention of beginning resuscitation and management immediately.”

The SSC, which is a global collaboration to improve sepsis treatment and decrease mortality, was developed by the Society of Critical Care Medicine in conjunction with various other organizations. The guidelines are updated frequently to address new evidence. The Hour-1 Bundle elucidates five steps that should be taken by health care professionals upon recognizing sepsis:

Measure blood lactate level: a high blood lactate level suggests insufficient oxygen supply from the blood, which may identify a patient at higher risk of a worsening condition.
Perform blood cultures to determine the cause of the infection. These samples should ideally be taken before antibiotics are administered.
Use broad-spectrum antibiotics that are effective against the causative organism.
Initiate IV fluids. Restoration of fluids is crucial in stabilizing the patient’s condition.
Use vasopressors to increase blood pressure. This step is important in resuscitating patients with septic shock.

Despite being part of the working group that formulated the guidelines in 2016, the Infectious Diseases Society of America decided to withhold its endorsement of the campaign and released a position paper explaining the reasoning behind its decision. IDSA’s main concern was that the guidelines did not sufficiently acknowledge the difficulties in diagnosing sepsis. The authors of the IDSA position paper noted that up to 40% of patients admitted to ICUs for sepsis are misdiagnosed. The 2016 SSC guidelines strongly encouraged initiation of IV antimicrobials within the first hour of recognizing sepsis, but IDSA urged a more cautious approach until additional information could be gathered.

Overall, IDSA commends the SSC for its efforts to optimize the treatment of sepsis.

“The Surviving Sepsis Campaign is a terrific initiative to try to reduce the impact of sepsis in the United States,” Henry Masur, MD, chief of the critical care medicine department at the NIH Clinical Center and professor of medicine at George Washington University, told Infectious Disease News. “This was initiated by the Society of Critical Care with multiple domestic and global partners. It has been very effective in raising awareness of sepsis and improving the way hospitals deal with it.”

When the guideline was revised, Masur, who was one of the authors of the position paper, said the IDSA was again invited to participate. He said that although the organization appreciated its inclusion in the discussion, they could not reach a consensus.

“There were differences of opinion as to exactly how to use antibiotics, in terms of what kinds of assessments should be done before antibiotics were started, and in terms of what antibiotics should be started,” he said. “Ultimately, there was a difference of opinion as to whether or not 1 hour vs. 3 hours were realistic. There were disagreements about whether to start one or more antibiotics, and whether to continue multiple antibiotics when you know what the pathogen was. This was really a scientific issue in which the IDSA felt the data pointed in one direction, and the Society of Critical Care Medicine decided that it pointed in a different direction.”

Although an agreement has not yet been reached, Masur said he is confident that the groups will eventually come to one.

“In this process, it takes time for everybody to see the issue in the same way,” he said. “So, I don’t think it’s terribly surprising that it’s going to take several iterations before everybody can agree on what the data show. Unfortunately, it just didn’t happen on the first or second try.” – by Jennifer Byrne

Disclosure: Masur reports no relevant financial disclosures.