🦠 SEPSIS & SEPTIC SHOCK – INDIA

COMPREHENSIVE DUAL-LEVEL CARE PROTOCOL (UPDATED v2.0)

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PRIMARY CARE → SECONDARY CARE (SEPSIS-READY)

📋 For Doctors Only | Not for Public Use

Applies to: Sepsis | Septic Shock | Severe Infections with Organ Dysfunction

Key Update v2.0: Sepsis Six Bundle added; Antibiotics updated for Indian resistance patterns

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🏥 LEVEL OF CARE OVERVIEW

Procedure/Action	Primary Care	Secondary/Tertiary Care
Recognition (qSOFA, SIRS)	✅	✅
SEPSIS SIX Bundle	✅	✅
IV access & fluid bolus	✅	✅
First dose antibiotics	✅	✅
Blood glucose management	✅	✅
Lactate measurement	⚠️ (POC if available)	✅
Blood cultures	⚠️ (if available)	✅
Vasopressors	❌	✅
Central venous access	❌	✅
Mechanical ventilation	❌	✅
Renal replacement therapy	❌	✅
Source control procedures	❌	✅

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⏱️ CRITICAL TIME TARGETS

Milestone	Target Time
Recognize sepsis	Immediate
Complete SEPSIS SIX	≤ 1 HOUR
Start fluid resuscitation	≤ 15 min
Administer antibiotics	≤ 1 HOUR
Reassess after fluids	Every 250-500 mL
Re-measure lactate	Within 6 hours

⚠️ Each hour delay in antibiotics increases mortality by 7-8%

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📖 DEFINITIONS (SEPSIS-3, 2016)

Term	Definition
Sepsis	Life-threatening organ dysfunction caused by dysregulated host response to infection
	Operationally: Suspected infection + SOFA score increase ≥ 2
Septic Shock	Sepsis + Vasopressor required to maintain MAP ≥ 65 mmHg + Lactate > 2 mmol/L despite adequate fluid resuscitation
qSOFA	Quick bedside screening tool (NOT diagnostic, but prognostic)

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🟢 PART 1 — PRIMARY CARE

Goal: Recognise → Complete SEPSIS SIX within 1 hour → TRANSFER

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1️⃣ SEPSIS RECOGNITION

qSOFA (Quick SOFA) – Bedside Screening

Criterion	Finding	Points
Respiratory Rate	≥ 22/min	1
Altered Mentation	GCS < 15	1
Systolic BP	≤ 100 mmHg	1

qSOFA Score	Interpretation
0-1	Low risk (does NOT rule out sepsis)
≥ 2	High risk – urgent action needed

📌 Remember: qSOFA ≥ 2 or SIRS ≥ 2 with suspected infection = ACT NOW

SIRS Criteria (Still Useful for Screening in Primary Care)

Criterion	Abnormal Value
Temperature	> 38°C or < 36°C
Heart Rate	> 90 bpm
Respiratory Rate	> 20/min
WBC Count	> 12,000 or < 4,000/mm³ (if available)
SIRS ≥ 2 + Suspected Infection	Possible Sepsis → Act Immediately

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2️⃣ THE SEPSIS SIX BUNDLE (Primary Care)

🎯 Complete ALL SIX within 1 HOUR of recognizing sepsis

Memory Aid: "GIVE 3, TAKE 3"

🟢 GIVE THREE

#	Give	Details	Done?
1	OXYGEN	Target SpO₂ ≥ 94%; start with mask/cannula	☐
2	IV FLUIDS	Crystalloid (NS or RL) 500 mL bolus; repeat up to 30 mL/kg	☐
3	ANTIBIOTICS	Broad-spectrum IV within 1 hour (see table below)	☐

🔵 TAKE THREE

#	Take	Details	Done?
4	BLOOD CULTURES	If available; do NOT delay antibiotics	☐
5	LACTATE	POC lactate if available; otherwise note clinical perfusion	☐
6	URINE OUTPUT	Insert catheter if possible; measure hourly	☐

Sepsis Six Quick Reference Card

text

╔══════════════════════════════════════════════════════════════╗

║ SEPSIS SIX – DO IN 1 HOUR ║

╠══════════════════════════════════════════════════════════════╣

║ GIVE 3: TAKE 3: ║

║ ✓ Oxygen (SpO₂ ≥ 94%) ✓ Blood cultures (if possible) ║

║ ✓ IV Fluids (30 mL/kg) ✓ Lactate (if available) ║

║ ✓ IV Antibiotics (STAT) ✓ Urine output (catheterize) ║

╚══════════════════════════════════════════════════════════════╝

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3️⃣ IDENTIFY THE SOURCE

Common Sources of Sepsis in India

Rank	Source	Clinical Clues	Common Pathogens (India)
1	Respiratory	Cough, sputum, crackles, hypoxia	S. pneumoniae, Klebsiella, H. influenzae, TB
2	Urinary	Dysuria, flank pain, CVA tenderness	E. coli (high ESBL), Klebsiella, Enterococcus
3	Abdominal	Pain, tenderness, distension	E. coli, Klebsiella, Bacteroides, Enterococcus
4	Skin/Soft Tissue	Cellulitis, abscess, crepitus	Staphylococcus (MRSA 25-40%), Streptococcus
5	CNS	Headache, neck stiffness, altered sensorium	S. pneumoniae, N. meningitidis, TB
6	Tropical Infections	Travel, monsoon, endemic area	Dengue, Malaria, Scrub typhus, Leptospirosis, Enteric fever

Source Identification Checklist

Check	Source	Done?
Chest auscultation / percussion	Pneumonia	☐
Urine appearance / dipstick	UTI	☐
Abdominal examination	Intra-abdominal	☐
Skin examination (entire body)	Soft tissue infection	☐
IV sites, catheter sites	Device-related	☐
Neck stiffness, Kernig's sign	Meningitis	☐
Eschar (painless black scab)	Scrub typhus	☐
Jaundice + fever	Leptospirosis, Malaria, Hepatitis	☐
Splenomegaly	Malaria, Enteric fever, Kala-azar	☐
Recent travel / monsoon exposure	Tropical infections	☐

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4️⃣ FLUID RESUSCITATION AT PRIMARY CARE

Fluid Protocol

Step	Action	Details
1	Choose fluid	Ringer's Lactate (preferred) or Normal Saline
2	Initial bolus	500 mL over 15-30 minutes
3	Reassess	BP, HR, capillary refill, urine output
4	Repeat	Up to 30 mL/kg total in first 3 hours
5	Watch for overload	Crackles, rising JVP, worsening SpO₂

Fluid Bolus Quick Calculation

Patient Weight	30 mL/kg Volume
40 kg	1200 mL
50 kg	1500 mL
60 kg	1800 mL
70 kg	2100 mL
80 kg	2400 mL

When to Be Cautious with Fluids

Condition	Approach
Known heart failure	Smaller boluses (250 mL); watch for overload
Elderly (> 70 years)	Smaller boluses; frequent reassessment
Renal failure on dialysis	Very cautious; may need early transfer
Dengue shock	Judicious fluids (see dengue protocol)

⛔ Avoid: Dextrose-containing fluids (unless hypoglycemic), Colloids at primary level

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5️⃣ ANTIBIOTICS AT PRIMARY CARE – INDIA-SPECIFIC

🇮🇳 Key Indian Resistance Patterns to Know

Pathogen	Resistance Pattern in India	Implication
E. coli / Klebsiella	ESBL: 60-80% in hospitals; 40-60% in community	Ceftriaxone often fails; need Pip-Taz or Carbapenem
Klebsiella	Carbapenem resistance (CRE): 30-50% in some ICUs	May need Colistin/Polymyxin B
Staphylococcus aureus	MRSA: 25-50% in hospitals	Need Vancomycin/Teicoplanin for serious infections
Pseudomonas	MDR: 30-40% in ICUs	Need combination therapy
Acinetobacter	Extensively drug-resistant in many ICUs	Often needs Colistin
S. pneumoniae	Penicillin resistance: 2-5% (lower than West)	Ceftriaxone usually effective
Salmonella Typhi	Fluoroquinolone resistance: 80-90%	Ceftriaxone or Azithromycin

Primary Care Antibiotic Selection

Principle: At primary level, give a reasonable first dose that covers likely pathogens. Definitive therapy will be refined at higher centre.

📋 EMPIRIC ANTIBIOTIC TABLE – PRIMARY CARE INDIA

Suspected Source	First-Line (Primary Care)	Dose	Alternative
Unknown source	Ceftriaxone + Metronidazole	2g IV + 500mg IV	Amoxicillin-Clavulanate 1.2g IV
Pneumonia (Community-Acquired)	Ceftriaxone + Azithromycin	2g IV + 500mg IV	Amoxicillin-Clavulanate 1.2g IV + Azithromycin
UTI / Pyelonephritis	Ceftriaxone	2g IV	Amikacin 15 mg/kg IV (single dose)
Abdominal / Biliary	Ceftriaxone + Metronidazole	2g IV + 500mg IV	Amoxicillin-Clavulanate 1.2g IV
Skin / Soft Tissue	Ceftriaxone + Clindamycin	2g IV + 600mg IV	Amoxicillin-Clavulanate 1.2g IV
Suspected Meningitis	Ceftriaxone	2g IV STAT	— (transfer urgently)
Suspected Enteric Fever	Ceftriaxone	2g IV	Azithromycin 1g IV/PO
Suspected Scrub Typhus	Doxycycline	100mg IV/PO	Azithromycin 500mg IV
Suspected Leptospirosis	Ceftriaxone	2g IV	Doxycycline 100mg IV

🚨 Critical Notes for Primary Care

Note
Do NOT wait for investigations to give first antibiotic dose
Ceftriaxone is the most practical first-line at primary level – covers many pathogens
Add Metronidazole if abdominal source suspected (anaerobic coverage)
Add Clindamycin for soft tissue infections (toxin suppression, anaerobic coverage)
Doxycycline is critical for scrub typhus – consider in fever with eschar, especially post-monsoon
Document exact time of antibiotic administration
Transfer patient – definitive antibiotic therapy will be at higher centre

What NOT to Use Empirically at Primary Care

⛔ Avoid Empirically	Reason
Oral antibiotics in sepsis	Unreliable absorption in shock
Fluoroquinolones alone for UTI	High resistance in India (80%+)
Cephalosporins alone for severe UTI in hospitalized patient	High ESBL rates
Aminoglycosides as monotherapy	Not sufficient as sole agent

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6️⃣ ADDITIONAL PRIMARY CARE MANAGEMENT

Blood Glucose

RBS	Action
< 70 mg/dL	25-50 mL of 25% Dextrose IV; recheck
70-180 mg/dL	No intervention
> 180 mg/dL	Avoid dextrose fluids; will need insulin at higher centre

Oxygen Therapy

SpO₂	Action
≥ 94%	No supplemental O₂ needed
90-94%	Nasal cannula 2-4 L/min
< 90%	Face mask 6-10 L/min; consider non-rebreather

What NOT to Do at Primary Care

⛔ Do NOT	Reason
Delay antibiotics for cultures	Each hour delay increases mortality
Start vasopressors	Requires ICU monitoring
Give steroids	Reserved for refractory shock at ICU
Delay transfer for investigations	Stabilise and transfer
Give excessive fluids without reassessing	Risk of pulmonary edema

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7️⃣ TRANSFER PROTOCOL

Transfer Indications

Indication	Urgency
All patients with suspected sepsis	URGENT
Septic shock (hypotensive despite fluids)	IMMEDIATE
Respiratory failure (SpO₂ < 90% on O₂)	IMMEDIATE
Altered mental status	IMMEDIATE
Lactate > 4 mmol/L	IMMEDIATE
Source requiring surgery/drainage	IMMEDIATE

Pre-Transfer Checklist

Item	Done?
SEPSIS SIX initiated/completed	☐
IV access × 2 secured	☐
Fluid volume given documented	☐
Antibiotic given – drug and time documented	☐
Blood glucose checked	☐
Vital signs documented	☐
Suspected source documented	☐
Allergies documented	☐
Receiving hospital pre-alerted	☐

What to Communicate to Receiving Hospital

Information	Why Critical
Time of recognition	Tracking bundle compliance
Antibiotic given (drug, dose, time)	Avoid re-dosing; plan next doses
Fluid volume given	Guide ongoing resuscitation
Current BP and MAP	Vasopressor need
Suspected source	Guide investigations and surgery
Response to fluids	Fluid responsiveness

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🔵 PART 2 — SECONDARY/TERTIARY CARE (ICU-CAPABLE)

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8️⃣ EMERGENCY DEPARTMENT PROTOCOL

Immediate Actions

Action	Target Time
Primary survey (ABCDE)	0-5 min
Confirm SEPSIS SIX completed (or complete if not done)	≤ 1 hour
Measure lactate	≤ 15 min
Blood cultures (2 sets)	Before antibiotics (don't delay > 45 min)
Antibiotics (escalate if needed)	≤ 1 hour
Vasopressor if MAP < 65 despite fluids	ASAP

Hour-1 Bundle (Surviving Sepsis Campaign 2021)

Element	Target	Done?
Measure lactate	≤ 1 hr	☐
Blood cultures before antibiotics	≤ 45 min	☐
Broad-spectrum antibiotics	≤ 1 hr	☐
30 mL/kg crystalloid if hypotensive or lactate ≥ 4	Begin ≤ 1 hr	☐
Vasopressors if MAP < 65 during/after fluids	ASAP	☐

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9️⃣ SOFA SCORE

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🔟 INVESTIGATIONS

Essential Investigations

Investigation	Purpose	Timing
Blood cultures (×2 sets)	Identify pathogen	Before antibiotics
Lactate	Tissue perfusion	Immediately; repeat q2-4h
CBC	WBC, platelets	Immediately
RFT (Creatinine, BUN, electrolytes)	AKI, electrolyte disturbance	Immediately
LFT (Bilirubin, ALT, AST)	Hepatic dysfunction	Immediately
Coagulation (PT, INR, aPTT)	DIC	Immediately
ABG / VBG	Acidosis, oxygenation	Immediately
Procalcitonin	Bacterial infection marker	If available

India-Specific Investigations (Based on Clinical Suspicion)

Suspicion	Investigation
Malaria	Peripheral smear + Rapid antigen test (RDT)
Dengue	NS1 antigen (day 1-5), IgM (day 5+), platelet count
Scrub Typhus	IgM ELISA, Weil-Felix (less reliable)
Leptospirosis	IgM ELISA, MAT
Enteric Fever	Blood culture (gold standard), Widal (limited utility)
Tuberculosis	Sputum AFB, Gene Xpert, CBNAAT
HIV	Rapid antibody test (with consent)

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1️⃣1️⃣ ANTIBIOTIC THERAPY – SECONDARY CARE (INDIA-SPECIFIC)

🇮🇳 ICMR-Based Antibiotic Stewardship Principles

Principle	Details
Obtain cultures BEFORE antibiotics	But don't delay antibiotics > 45 min
Start empiric broad-spectrum	Narrow once cultures available
Know your local antibiogram	Hospital-specific resistance patterns
De-escalate at 48-72 hours	Based on culture results and clinical response
Duration: shorter is better	5-7 days for most infections if responding
Avoid carbapenems when possible	Reserve for confirmed ESBL/serious infections

📋 EMPIRIC ANTIBIOTIC TABLE – SECONDARY/TERTIARY CARE INDIA

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RESPIRATORY INFECTIONS

Condition	Likely Pathogens (India)	Empiric Regimen	Duration
CAP – Ward	S. pneumoniae, H. influenzae, Klebsiella, Atypicals	Ceftriaxone 2g IV q24h + Azithromycin 500mg IV q24h	5-7 days
CAP – ICU (no Pseudomonas risk)	Same + Legionella	Ceftriaxone 2g IV q24h + Azithromycin 500mg IV q24h OR Levofloxacin 750mg IV	7 days
CAP – ICU (Pseudomonas risk)	Add Pseudomonas	Piperacillin-Tazobactam 4.5g IV q6h + Levofloxacin 750mg IV q24h	7 days
HAP (non-severe, early onset)	S. aureus, Enterobacteriaceae	Piperacillin-Tazobactam 4.5g IV q6h	7 days
HAP/VAP (severe or late onset)	Pseudomonas, Acinetobacter, MRSA, ESBL producers	Meropenem 1g IV q8h + Vancomycin 15-20mg/kg q8-12h ± Colistin	7-8 days
VAP with MDR risk	MDR GNB, Acinetobacter	Meropenem 1g q8h + Colistin 9 MU load then 4.5 MU q12h + Vancomycin	7-8 days
Aspiration Pneumonia	Anaerobes, oral flora	Piperacillin-Tazobactam 4.5g IV q6h OR Ceftriaxone + Metronidazole	7 days

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URINARY TRACT INFECTIONS

Condition	Likely Pathogens (India)	Empiric Regimen	Duration
Uncomplicated UTI (outpatient)	E. coli (40-60% ESBL in community)	Nitrofurantoin 100mg BD OR Fosfomycin 3g single dose	5 days / single
Complicated UTI / Pyelonephritis (community onset)	E. coli, Klebsiella (60%+ ESBL)	Piperacillin-Tazobactam 4.5g IV q6h OR Ertapenem 1g IV q24h	7-10 days
Healthcare-associated UTI / Catheter-associated	ESBL producers, Pseudomonas, Enterococcus	Meropenem 1g IV q8h (if critically ill) OR Pip-Taz 4.5g q6h	7 days
Urosepsis (critically ill)	ESBL, Pseudomonas, possible CRE	Meropenem 1g IV q8h ± Amikacin 15mg/kg q24h	7-10 days

📌 Fluoroquinolones (Ciprofloxacin) have 80%+ resistance in India – avoid as empiric therapy for UTI

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INTRA-ABDOMINAL INFECTIONS

Condition	Likely Pathogens	Empiric Regimen	Duration
Community-acquired (mild-moderate)	E. coli, Klebsiella, Bacteroides, Enterococcus	Ceftriaxone 2g IV q24h + Metronidazole 500mg IV q8h	4-7 days (source controlled)
Community-acquired (severe / septic)	Same + higher ESBL risk	Piperacillin-Tazobactam 4.5g IV q6h	4-7 days
Healthcare-associated / Post-operative	ESBL, Pseudomonas, Enterococcus, Candida	Meropenem 1g IV q8h + Vancomycin (if Enterococcus concern) ± Fluconazole	4-7 days
Biliary Sepsis	E. coli, Klebsiella, Enterococcus	Piperacillin-Tazobactam 4.5g IV q6h	4-7 days + source control
Tertiary Peritonitis / MDR risk	CRE, MDR Pseudomonas, Candida	Meropenem + Colistin + Fluconazole/Echinocandin	Based on cultures

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SKIN & SOFT TISSUE INFECTIONS

Condition	Likely Pathogens	Empiric Regimen	Duration
Cellulitis (non-purulent)	Streptococcus, MSSA	Ceftriaxone 2g IV q24h	5-7 days
Cellulitis (purulent / abscess)	MRSA (25-40% in India)	Ceftriaxone 2g + Clindamycin 600mg IV q8h OR Vancomycin	5-7 days + drainage
Diabetic foot – Mild	Streptococcus, Staphylococcus	Amoxicillin-Clavulanate 1.2g IV q8h	7-14 days
Diabetic foot – Moderate/Severe	MRSA, Pseudomonas, Anaerobes, ESBL	Piperacillin-Tazobactam 4.5g q6h + Vancomycin OR Meropenem + Vancomycin	14-21 days
Necrotizing Fasciitis	Mixed aerobic/anaerobic, GAS, Clostridium	Meropenem 1g q8h + Vancomycin + Clindamycin 900mg q8h	Until debridement complete + 7-14 days
Fournier's Gangrene	Mixed flora	Meropenem + Vancomycin + Clindamycin	Urgent surgery + antibiotics

📌 Clindamycin is added in necrotizing infections for toxin suppression (inhibits protein synthesis)

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CNS INFECTIONS

Condition	Likely Pathogens	Empiric Regimen	Duration
Community Bacterial Meningitis (adult)	S. pneumoniae, N. meningitidis	Ceftriaxone 2g IV q12h + Vancomycin 15-20mg/kg q8-12h + Dexamethasone	10-14 days
Community Meningitis (> 50 yrs / immunocompromised)	Add Listeria	Add Ampicillin 2g IV q4h to above	10-21 days
Healthcare-associated Meningitis	Staphylococcus, GNB, Pseudomonas	Meropenem 2g IV q8h + Vancomycin	14-21 days
Brain Abscess	Streptococcus, Staphylococcus, Anaerobes, GNB	Ceftriaxone 2g q12h + Metronidazole + Vancomycin	4-8 weeks
TB Meningitis	M. tuberculosis	ATT (HRZE) + Dexamethasone	9-12 months

📌 Give Dexamethasone 0.15 mg/kg IV q6h × 4 days BEFORE or WITH first antibiotic dose in bacterial meningitis

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TROPICAL INFECTIONS (INDIA-SPECIFIC)

Condition	Likely Pathogen	Empiric Regimen	Notes
Scrub Typhus	Orientia tsutsugamushi	Doxycycline 100mg IV/PO q12h	Continue until afebrile × 3 days; total 7-14 days
		OR Azithromycin 500mg q24h (if pregnant/child)
Leptospirosis	Leptospira spp.	Ceftriaxone 2g IV q24h OR Penicillin G 1.5 MU IV q6h	7 days
		Doxycycline 100mg BD for mild cases
Enteric Fever	S. Typhi (FQ-resistant 80%+)	Ceftriaxone 2g IV q24h OR Azithromycin 1g then 500mg q24h	10-14 days
Severe Malaria	P. falciparum	IV Artesunate 2.4 mg/kg at 0, 12, 24h then q24h	Switch to oral ACT when able
Dengue with Warning Signs	Dengue virus	Supportive care; judicious IV fluids	No antibiotics unless bacterial co-infection
Melioidosis	B. pseudomallei	Meropenem 1g q8h OR Ceftazidime 2g q8h	2+ weeks IV, then oral TMP-SMX × 3-6 months

📌 In fever with eschar (painless black scab, especially in axilla/groin), empirically treat for Scrub Typhus with Doxycycline

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BLOODSTREAM INFECTIONS

Condition	Likely Pathogens	Empiric Regimen	Duration
Community-onset bacteremia (unknown source)	E. coli, S. aureus, Streptococcus	Piperacillin-Tazobactam 4.5g q6h OR Ceftriaxone 2g + Metronidazole	Based on source
Healthcare-associated bacteremia	MRSA, ESBL, Pseudomonas	Meropenem 1g q8h + Vancomycin	Based on source
Catheter-related BSI	CoNS, S. aureus (MRSA), GNB, Candida	Vancomycin 15-20mg/kg q8-12h ± Piperacillin-Tazobactam	Remove catheter; 7-14 days
S. aureus bacteremia	MSSA or MRSA	Cloxacillin 2g q4h (MSSA) OR Vancomycin (MRSA)	Minimum 14 days (longer if complicated)
Candidemia	Candida spp.	Echinocandin (Caspofungin/Micafungin/Anidulafungin)	14 days after first negative culture

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NEUTROPENIC SEPSIS

Condition	Regimen	Notes
Low-risk neutropenic fever	Amoxicillin-Clavulanate + Ciprofloxacin (oral)	Only if MASCC ≥ 21, outpatient capable
High-risk neutropenic fever	Meropenem 1g IV q8h OR Piperacillin-Tazobactam 4.5g IV q6h OR Cefepime 2g IV q8h	Monotherapy usually sufficient
Add Vancomycin if:	Catheter infection, skin/soft tissue, hypotension, MRSA colonization
Add Antifungal if:	Persistent fever > 4-7 days despite antibiotics	Caspofungin or Liposomal Amphotericin B

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SPECIAL SITUATIONS

Situation	Adjustment
CrCl < 30 mL/min	Reduce carbapenem dose; avoid aminoglycosides or dose-adjust
Hemodialysis	Give antibiotics post-HD; adjust dosing
ESBL confirmed on culture	De-escalate to Ertapenem (if susceptible) or continue Meropenem
CRE (Carbapenem-resistant)	Add Colistin 9 MU load → 4.5 MU q12h OR Polymyxin B 1.5-2.5 mg/kg/day divided ± Tigecycline (100mg load → 50mg q12h) ± Aminoglycoside
MDR Acinetobacter	Colistin + Meropenem (high dose 2g q8h) OR Colistin + Tigecycline
VRE (Vancomycin-resistant Enterococcus)	Linezolid 600mg IV/PO q12h OR Daptomycin (not for pneumonia)

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🔄 DE-ESCALATION PROTOCOL

Timing	Action
24-48 hours	Review culture results
48-72 hours	Narrow antibiotic spectrum based on culture and sensitivity
Day 5-7	Assess for stopping antibiotics (procalcitonin may guide)

De-escalation Example	From	To
ESBL E. coli UTI sensitive to Pip-Taz	Meropenem	Piperacillin-Tazobactam
MSSA bacteremia	Vancomycin	Cloxacillin 2g IV q4h
Pneumococcal pneumonia	Broad-spectrum	Ceftriaxone alone (or Penicillin if sensitive)

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1️⃣2️⃣ ANTIFUNGAL THERAPY

When to Consider Empiric Antifungal

Risk Factor
Prolonged ICU stay > 7 days
Total parenteral nutrition
Broad-spectrum antibiotics > 7 days
Central venous catheter
Recent abdominal surgery
Candida colonization at multiple sites
Hemodialysis
Immunosuppression

Antifungal Selection

Scenario	Drug	Dose
Suspected invasive candidiasis (stable)	Fluconazole	800mg load → 400mg IV q24h
Critically ill / Prior azole / Unknown Candida	Echinocandin preferred
	Caspofungin	70mg load → 50mg IV q24h
	Micafungin	100mg IV q24h
	Anidulafungin	200mg load → 100mg IV q24h
CNS candidiasis	Liposomal Amphotericin B	5 mg/kg/day
Mucormycosis	Liposomal Amphotericin B	5-10 mg/kg/day

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1️⃣3️⃣ VASOPRESSOR THERAPY

When to Start

Indication
MAP < 65 mmHg despite 30 mL/kg crystalloid
MAP < 65 mmHg during fluid resuscitation with poor perfusion
Lactate > 4 mmol/L with hypotension

Vasopressor Selection

Drug	Dose Range	Role
Norepinephrine	0.1-1+ μg/kg/min	FIRST-LINE
Vasopressin	0.03-0.04 U/min (fixed)	Second-line (add to NE)
Epinephrine	0.05-1 μg/kg/min	Third-line or cardiac dysfunction
Dopamine	—	⛔ AVOID (more arrhythmias)

Vasopressor Escalation Ladder

Step	Action	Target
1	Start Norepinephrine 0.1 μg/kg/min	MAP ≥ 65
2	Titrate NE up to 0.5 μg/kg/min	MAP ≥ 65
3	Add Vasopressin 0.03 U/min	MAP ≥ 65
4	Further increase NE	MAP ≥ 65
5	Add Epinephrine OR Hydrocortisone	MAP ≥ 65

Norepinephrine Preparation

Preparation	Concentration
4 mg in 50 mL NS/D5W	80 μg/mL
8 mg in 50 mL NS/D5W	160 μg/mL

Weight (kg)	0.1 μg/kg/min (mL/hr) [80 μg/mL]	0.3 μg/kg/min	0.5 μg/kg/min
60	4.5	13.5	22.5
70	5.25	15.75	26.25
80	6	18	30

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1️⃣4️⃣ CORTICOSTEROIDS IN SEPTIC SHOCK

When to Use

Indication
Septic shock refractory to fluids AND vasopressors
Norepinephrine ≥ 0.25 μg/kg/min for ≥ 4 hours

Steroid Protocol

Drug	Dose	Duration
Hydrocortisone	50 mg IV q6h OR 200 mg/day continuous infusion	7 days or until shock resolved

⛔ Do NOT give steroids for sepsis without shock

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1️⃣5️⃣ SOURCE CONTROL

As important as antibiotics – identify and control the source

Source Control Urgency

Source	Intervention	Timing
Necrotizing fasciitis	Surgical debridement	Immediate (within hours)
Perforated viscus	Surgical repair	Emergent (within 6 hrs)
Ascending cholangitis	ERCP / Cholecystostomy	Urgent (within 6-12 hrs)
Obstructed pyelonephritis	Nephrostomy / Ureteric stent	Urgent
Abscess (any site)	Drainage (percutaneous or surgical)	Within 12 hrs
Infected device/catheter	Remove device	Immediate
Empyema	Chest tube drainage	Urgent

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1️⃣6️⃣ ORGAN SUPPORT

Respiratory Support

SpO₂	Intervention
94-98%	Target; no O₂ if achieved
90-94%	Nasal cannula or mask
< 90% on mask	HFNC or NIV
Failure of NIV or GCS < 8	Intubation

Ventilator Settings (ARDS)

Parameter	Target
Tidal Volume	6 mL/kg PBW
Plateau Pressure	< 30 cm H₂O
PEEP	Per ARDSNet table
FiO₂	Titrate to SpO₂ 92-96%

Renal Support

Indication for RRT
Refractory hyperkalemia (K > 6.5 mEq/L)
Refractory acidosis (pH < 7.1)
Refractory fluid overload
Uremic complications
Severe AKI with oliguria

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1️⃣7️⃣ ADDITIONAL ICU CARE

Glucose Control

Target: 140-180mg/dl

DVT Prophylaxis

Agent	Dose
Enoxaparin	40 mg SC OD
UFH	5000 U SC BD/TID
IPC	If anticoagulation contraindicated

Stress Ulcer Prophylaxis

Indication	Agent
Mechanically ventilated > 48 hrs	Pantoprazole 40 mg IV OD
Coagulopathy	Pantoprazole 40 mg IV OD

Nutrition

Timing	Route
Within 24-48 hrs	Enteral nutrition (preferred)
Target	20-25 kcal/kg/day; Protein 1.2-2 g/kg/day

Sedation

Target RASS: -1 to 0(light sedation)

Drug	Dose
Fentanyl	25-100 μg/hr
Propofol	5-50 μg/kg/min
Dexmedetomidine	0.2-1.4 μg/kg/hr

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1️⃣8️⃣ MONITORING PARAMETERS

Signs of Improvement

Parameter	Sign
MAP	≥ 65 without increasing vasopressors
Lactate	Decreasing > 10% every 2-4 hrs
Urine output	Improving
Mental status	Improving
Vasopressor requirement	Decreasing

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1️⃣9️⃣ DISCHARGE CRITERIA FROM ICU

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📌 QUICK REFERENCE CARDS

🔴 PRIMARY CARE – SEPSIS SIX CARD

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🔵 HOUR-1 BUNDLE (SECONDARY CARE)

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💊 PRIMARY CARE ANTIBIOTIC QUICK CARD

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💉 VASOPRESSOR QUICK REFERENCE

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⚠️ CRITICAL WARNINGS

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🇮🇳 INDIA-SPECIFIC REMINDERS

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📚 ABBREVIATIONS

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📖 REFERENCES

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Document Version: 2.0

Key Updates in v2.0:

• ✅ Sepsis Six Bundle added for Primary Care
• ✅ Antibiotics updated for Indian resistance patterns (high ESBL, CRE, MRSA)
• ✅ Tropical infections (Scrub Typhus, Leptospirosis, Malaria, Enteric Fever) included
• ✅ ICMR-based antibiotic stewardship principles incorporated
• ✅ Fluoroquinolone de-emphasized due to high resistance in India
• ✅ Carbapenem-sparing strategies where appropriate

Disclaimer: This protocol provides general guidance based on available evidence and Indian resistance patterns. Local antibiograms should always guide antibiotic selection. Clinical judgment must be exercised. Consult Infectious Disease specialists for complex cases.