Surviving Sepsis Campaign 2026

At a Glance

1 hr

ABx target: septic shock & probable sepsis

3 hr

ABx target: possible sepsis without shock

65 mmHg

Default MAP target; 60–65 for age ≥65

30 mL/kg

Initial IV crystalloid within 3 hours

6 hr

Source control target from diagnosis

NEWS2

Replaces qSOFA as inpatient screening tool

Key Changes 2021 → 2026

Area	2021	2026	Change
Screening Tool	qSOFA recommended	Use `NEWS / NEWS2 / MEWS / SIRS` — qSOFA not recommended alone	Major Change
Beta-lactam Infusion	Suggest prolonged infusion	Recommend prolonged (extended/continuous) infusion after loading dose	Upgraded → Strong
ABx De-escalation	Suggest when culture available	Recommend when culture + susceptibility available	Upgraded → Strong
ABx Timing Framework	1-hour bundle (single tier)	1 hr (shock/probable) · 3 hr (possible without shock)	New Framework
MAP Target (Elderly)	Not specifically addressed	Suggest 60–65 mmHg for patients ≥65 years	New
HFNC / Awake Proning	Not addressed	Suggest HFNC over conventional O₂; suggest awake proning (non-intubated)	New
Blood Purification	Against polymyxin B hemoperfusion	Against all blood purification therapies (hemoperfusion, HVHF, plasma exchange)	Expanded Against
Prehospital ABx	Not addressed	Suggest prehospital ABx if time to evaluation >60 min (septic shock)	New
Corticosteroids	Suggest IV corticosteroids broadly	Suggest hydrocortisone 200 mg/day — clarified to refractory vasopressor-dependent shock	Downgraded
Fluid Post-Resus	Insufficient evidence	Suggest liberal or restrictive strategy — individualized to patient	New Statement
Post-Sepsis Rehab	Not addressed	New domain: physical, cognitive, mental health rehabilitation after discharge	New Domain
Norepinephrine Priority	Recommend over dopamine, etc.	Suggest over vasopressin or angiotensin II specifically (downgraded vs. vaso)	Conditional

Antibiotic Timing Framework

≤ 1 hr

Septic Shock

Immediate antimicrobials ideally within 1 hour. No delay for diagnostic workup.

≤ 1 hr

Probable / Definite Sepsis

Immediate therapy even without shock. Don't wait for culture confirmation.

≤ 3 hr

Possible Sepsis (no shock)

Rapid assessment for infectious vs. non-infectious cause. Defer if low likelihood.

Vasopressor Escalation Ladder

① Norepinephrine — First Line

Recommended first-line. Preferred over dopamine (high certainty), epinephrine, selepressin, terlipressin.

② Add Vasopressin — When Escalating

Suggest vasopressin when norepinephrine dose is escalating. Moderate certainty.

③ Add Epinephrine — Refractory MAP

Add epinephrine if MAP inadequate despite norepinephrine + vasopressin. Very low certainty.

➕ Inotropes — Cardiac Dysfunction

Dobutamine or epinephrine if cardiac dysfunction + persistent hypoperfusion despite adequate fluid & MAP. Avoid levosimendan & beta-blockers.

Clinical Domains — Key Recommendations

Diagnosis & Screening

RECUse NEWS/NEWS2/MEWS/SIRS over qSOFA for inpatient screening
RECBlood cultures before ABx, but don't delay treatment
SUGMeasure lactate in possible/probable/definite sepsis
SUGPrehospital screening tool for acutely ill patients in transit
RECHospitals implement performance improvement program for sepsis

Initial Resuscitation

SUG≥30 mL/kg IV crystalloid in first 3 hrs (hypoperfusion/shock)
SUGBalanced crystalloids (LR/PlasmaLyte) over 0.9% saline
AGAINSTStarches (HES) — high certainty. Gelatin — moderate.
SUGDynamic measures (PLR, SVV, echo) to guide fluids
SUGSerial lactate to guide resuscitation in elevated lactate
SUGLiberal or restrictive post-resus strategy — individualized

ABx

Antibiotic Therapy

RECImmediately (≤1 hr) for shock and probable/definite sepsis
SUGWithin 3 hrs for possible sepsis without shock
RECProlonged (extended/continuous) beta-lactam infusion — upgraded to Strong
RECDe-escalate when culture + susceptibility available — upgraded to Strong
SUGProcalcitonin + clinical assessment to guide discontinuation
AGAINSTEmpiric antifungal in most patients; MDR coverage in low-risk

Source Control

SUGRapid anatomical evaluation for all sepsis patients
SUGEarly source control ideally within 6 hours of diagnosis
SUGDon't delay source control for hemodynamic optimization when life-threatening (necrotizing fasciitis, septic joint)

Adj

Adjunctive Therapies

SUGHydrocortisone 200 mg/day for vasopressor-dependent septic shock
AGAINSTBlood purification (hemoperfusion, HVHF, plasma exchange)
RECLow tidal volume 6 mL/kg IBW for ARDS (high certainty)
SUGHFNC over conventional O₂ or NIPPV for hypoxemic failure
SUGAwake proning in non-intubated hypoxemic patients
SUGSDD in mechanically ventilated patients in low-AMR units

F/U

Post-Sepsis Care (New Domain)

SUGICU admission within 6 hours for patients needing ICU-level care
SUGStructured follow-up for physical functional recovery
SUGStructured follow-up for cognitive recovery
SUGStructured follow-up for mental health (PTSD, anxiety, depression)
SUGEarly goals-of-care discussion; palliative consultation for poor prognosis

10 Take-Home Points

Sepsis is a medical emergency. Time to treatment is the single most modifiable factor. Don't wait.

qSOFA is OUT for inpatient screening. Use NEWS, NEWS2, MEWS, or SIRS instead.

Tiered ABx timing: ≤1 hr for shock/probable sepsis · ≤3 hr for possible sepsis without shock after rapid evaluation.

Prolonged beta-lactam infusion is now a Strong recommendation — use extended or continuous infusion for maintenance dosing.

De-escalation is now a Strong recommendation — mandatory once culture and susceptibility results are available.

Balanced crystalloids preferred (LR/PlasmaLyte). Starches are contraindicated. Dynamic measures guide ongoing resuscitation.

MAP 65 mmHg default. In patients ≥65 years, 60–65 mmHg is acceptable — higher targets offer no benefit.

Blood purification is out broadly — the recommendation expands from polymyxin B to ALL blood purification therapies.

HFNC + awake proning for non-intubated patients with hypoxemic respiratory failure — new recommendations.

Post-sepsis rehabilitation is now a formal domain. 30–40% of survivors face lasting physical, cognitive, and psychological impairment.