Discuss the recent advances in the management of sepsis

Screening tools have been reordered: SSC 2026 strongly recommends NEWS, NEWS2, MEWS or SIRS in preference to qSOFA as a single in-hospital screening instrument, because qSOFA lacks sensitivity and detects patients too late.

Institutional systems, not just drugs, are now recommended: mandatory sepsis performance-improvement programmes (strong recommendation) and ‘code sepsis’ or sepsis-huddle protocols; screening is also suggested pre-hospital, in the ambulance.

Rapid molecular diagnostics — multiplex PCR panels, T2 magnetic resonance and metagenomic next-generation sequencing — allow pathogen and resistance-gene identification in hours; recommended for selected patients guided by local resistance patterns and stewardship input, not for everyone.

Host-response transcriptomic assays (e.g. SeptiCyte, IMX-BVN) that distinguish bacterial from viral and from non-infective inflammation are promising but evidence remains insufficient for a recommendation.

Artificial-intelligence early-warning systems using continuous EHR data are being deployed to predict deterioration hours before clinical recognition; validation in older, multimorbid populations is still limited.

Timing has been graded rather than universal: antibiotics within 1 hour for septic shock and probable sepsis, within 3 hours for ‘possible’ sepsis without shock after rapid investigation, and deferred if infection is unlikely — a deliberate correction of the over-treatment that blanket one-hour rules produced.

Prolonged/extended infusion of beta-lactams after a loading dose is now a strong recommendation, following BLING III and MERCY and their meta-analysis, which showed a mortality benefit through improved time-above-MIC.

Narrower empirical therapy: routine anaerobic cover and routine empirical antifungals are advised against; MDR cover only where specific risk factors exist (known colonisation, prior MDR infection, prolonged broad-spectrum exposure, prolonged stay in a high-prevalence unit).

Procalcitonin has moved from the front door to the exit: clinical evaluation alone is suggested to start antibiotics, but procalcitonin plus clinical evaluation is suggested to decide when to stop. Shorter courses are preferred where source control is adequate.

New agents against resistant gram-negatives — ceftazidime–avibactam, meropenem–vaborbactam, imipenem–relebactam, cefiderocol, ceftolozane–tazobactam and (emerging) aztreonam–avibactam and cefepime–taniborbactam — are of particular importance in India, where carbapenem-resistant Klebsiella and Acinetobacter dominate ICU sepsis.

Balanced crystalloids over 0.9% saline (BaSICS, PLUS and their meta-analyses), with starches and gelatins prohibited and albumin reserved for those already given large crystalloid volumes or with cirrhosis.

The liberal-versus-restrictive fluid debate has been closed to a draw: after the initial 30 mL/kg, CLASSIC and CLOVERS showed no mortality difference, so SSC 2026 permits either strategy, individualised to the patient (heart failure, renal reserve) and the health system.

Peripheral vasopressors are now suggested rather than delaying noradrenaline until central access is obtained — earlier MAP restoration and less fluid overload.

Capillary refill time is endorsed as an adjunct perfusion target (ANDROMEDA-SHOCK), and fluids should not simply be continued until lactate normalises.

Age-specific target: in patients ‡ 65 years, an initial MAP of 60–65 mmHg is suggested — the first explicitly geriatric haemodynamic recommendation in the guideline's history, reflecting the harm of vasopressor excess in stiff, atheromatous vasculature.

Therapies now recommended against after negative trials: IV vitamin C (VITAMINS, VICTAS, LOVIT — which showed possible harm), IV immunoglobulin, vitamin D (VIOLET), blood purification and polymyxin B haemoperfusion (EUPHRATES), levosimendan (LeoPARDS) and beta-blockers (STRESS-L).

Corticosteroids are suggested for septic shock; the practical residue of APROCCHSS/ADRENAL is hydrocortisone 200 mg/day in vasopressor-dependent shock. Evidence for methylene blue and angiotensin II in refractory vasoplegia remains insufficient for a recommendation.

Respiratory support has shifted to HFNC: HFNC over conventional oxygen, HFNC over NIV as initial therapy, and a trial of awake proning in the non-intubated — largely a legacy of COVID-19-era evidence.

Restrictive transfusion (strong), insulin initiation at ‡ 180 mg/dL (strong) rather than tight control, LMWH over unfractionated heparin (strong), and pharmacological prophylaxis alone rather than adding mechanical prophylaxis.

Sepsis survivorship is now formally part of sepsis management: goals-of-care discussion within 72 hours, pharmacist-led medication reconciliation at every transition, screening for social and economic needs, written and verbal patient/family education, post-ICU follow-up services, physical rehabilitation after > 48 hours of ventilation and mental-health support. For geriatrics this converts sepsis care into a comprehensive geriatric assessment problem, not merely an ICU one.

Health-system equity is explicit: single blood-culture sets are acceptable where resources are limited, and 38% of the guideline panel practised in low- and middle-income countries — making the 2026 document more directly applicable to Indian practice than any previous edition.