Critical Care

Surviving Sepsis Campaign 2026 International Guidelines for Management of Sepsis and Septic Shock in Adults

Society of Critical Care Medicine (SCCM) and European Society of Intensive Care Medicine (ESICM)Published March 23, 2026

Refines the 1-hour bundle into a phenotype-aware approach, de-emphasizes fixed 30 mL/kg fluid resuscitation, and strengthens antibiotic stewardship within sepsis care.

What changed in this edition

Initial fluid resuscitation individualized; 30 mL/kg no longer a hard requirement for all patients.
Balanced crystalloids preferred over 0.9% saline.
Early norepinephrine initiation (including peripheral through appropriate IV) endorsed for persistent hypotension.
Procalcitonin integrated to support antibiotic de-escalation and shortened durations.
Shorter antibiotic courses (5–7 days) supported for most uncomplicated infections.
Formal integration of long-term sepsis survivorship pathways.
Emphasis on diagnostic stewardship to reduce overdiagnosis of sepsis in non-infected critical illness.

Clinical takeaways

First hour

Lactate, blood cultures before antibiotics when feasible, broad-spectrum antibiotics within 1 hour for septic shock and within 3 hours for sepsis without shock, fluid resuscitation tailored to hemodynamics, early vasopressors.

Fluids

Give balanced crystalloids in dynamic boluses (e.g., 500 mL) guided by response (passive leg raise, stroke volume variation, lactate clearance). Avoid reflexive 30 mL/kg in heart failure, ESRD, or obesity.

Vasopressors

Norepinephrine first-line; add vasopressin 0.03 U/min at norepinephrine ≥0.25 µg/kg/min; epinephrine or angiotensin II next. Peripheral norepinephrine is safe through a good proximal IV with close monitoring.

Antibiotic stewardship

Reassess at 48–72 hours with clinical response, cultures, and procalcitonin. Stop antibiotics by day 5–7 when infection is controlled; extend only for proven deep-seated or multidrug-resistant infections.

Corticosteroids

Hydrocortisone 200 mg/day for septic shock requiring ongoing vasopressors; reassess at 48 hours. Do not use in sepsis without shock.

Survivorship

Screen for post-sepsis syndrome at discharge and at 2–4 weeks: cognitive changes, functional decline, depression, readmission risk. Structured follow-up reduces mortality and readmission.

Supporting trials

CLASSICPubMed 35709019
Restrictive IV fluid strategy did not reduce 90-day mortality vs standard fluids in septic shock, but supports de-emphasis of reflexive large-volume resuscitation.
CLOVERSPubMed 36688507
Earlier vasopressor strategy non-inferior to liberal fluid strategy for 90-day mortality.
SMART / BaSICS / PLUSPubMed 29485925
Balanced crystalloids reduced composite kidney outcome vs saline across multiple trials.
ADRENALPubMed 29347874
Hydrocortisone did not reduce mortality but reduced shock duration and ICU stay.
PROCALCITONIN-guided (SAPS)PubMed 26947523
Procalcitonin-guided antibiotic stopping reduced exposure and mortality in ICU sepsis.

Clinical Reasoning

Sepsis Management: From Early Recognition to Evidence-Based Resuscitation

The Surviving Sepsis Campaign 2024 guidelines refined the approach to sepsis resuscitation, antibiotic timing, and vasopressor selection. This review covers the current evidence for hour-1 bundle compliance, fluid strategy, and organ support.

Methodology

Neonatal Sepsis: Early vs Late Onset and Empiric Antibiotic Selection

Neonatal sepsis remains a leading cause of morbidity and mortality in the NICU, with early-onset sepsis occurring within 72 hours and late-onset sepsis after 72 hours of life. This review covers risk stratification tools, empiric antibiotic regimens, and evidence for antibiotic duration.

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