Headline change
The guideline strongly recommends using NEWS, NEWS2, MEWS, or SIRS over qSOFA as a single tool for sepsis screening in hospital, a direct reversal from prior guidance.
Bedside action
Implement a performance improvement program for sepsis, including screening with NEWS/NEWS2/MEWS/SIRS, and ensure immediate antimicrobial therapy for septic shock within one hour.
The 2026 Surviving Sepsis Campaign (SSC) guidelines, a joint effort by SCCM and ESICM, arrive at a critical juncture, offering updated, evidence-based recommendations for the management of sepsis and septic shock. This comprehensive revision aims to further refine clinical practice, particularly in early recognition, fluid resuscitation, and antimicrobial stewardship, reflecting new research and a continued push for improved patient outcomes.
Versus the Previous Version
The 2026 Surviving Sepsis Campaign guidelines build upon the 2021 version, incorporating new evidence to refine existing recommendations and introduce several key changes, particularly in screening, fluid management, and antimicrobial therapy.
Sepsis Screening Tool
Previous version
The 2021 guideline recommended against using qSOFA compared with SIRS, NEWS, or MEWS as a single screening tool for sepsis or septic shock.
This version
The 2026 guideline recommends using NEWS, NEW2, MEWS, or SIRS over qSOFA as a single tool to screen for sepsis in acutely ill patients in hospital.
Clinical impact Clinicians should shift away from qSOFA as a primary single screening tool in favor of other Early Warning Scores for in-hospital sepsis identification.
Initial Fluid Resuscitation Volume
Previous version
The 2021 guideline suggested that at least 30 mL/kg of IV crystalloid fluid should be given within the first 3 hours of resuscitation (Weak, low quality of evidence).
This version
The 2026 guideline suggests administering at least 30 mL/kg of IV crystalloid in the first 3 hours for adults with sepsis-induced hypoperfusion or septic shock (conditional recommendation, low certainty evidence).
Clinical impact The recommendation for 30 mL/kg crystalloid within 3 hours remains, but the strength of evidence is now explicitly conditional with low certainty, emphasizing individualized patient assessment.
Balanced Crystalloids vs. Saline
Previous version
The 2021 guideline suggested using either balanced crystalloids or saline for fluid resuscitation of patients with sepsis or septic shock (Weak, low quality of evidence).
This version
The 2026 guideline suggests using balanced crystalloids over 0.9% saline for adults with sepsis or septic shock undergoing initial resuscitation (conditional recommendation, moderate certainty evidence).
Clinical impact Clinicians should prioritize balanced crystalloids over 0.9% saline for initial resuscitation, reflecting strengthened evidence for their benefit.
IV Corticosteroids in Septic Shock
Previous version
The 2021 guideline suggested using IV corticosteroids for adults with septic shock and an ongoing requirement for vasopressor therapy (Weak, moderate-quality evidence).
This version
The 2026 guideline suggests using IV corticosteroids for adults with septic shock (conditional recommendation, low certainty evidence).
Clinical impact The recommendation for IV corticosteroids in septic shock remains, but the evidence certainty is now low, and the indication is broadened slightly from 'ongoing requirement for vasopressor therapy'.
Prolonged Beta-Lactam Infusion
Previous version
The 2021 guideline suggested using prolonged infusion of beta-lactams for maintenance (after an initial bolus) over conventional bolus infusion (Weak, moderate-quality evidence).
This version
The 2026 guideline recommends using prolonged infusion of beta-lactams for maintenance (after an initial loading dose) over bolus administration (strong recommendation, moderate certainty evidence).
Clinical impact This is now a strong recommendation, indicating a clearer preference for prolonged beta-lactam infusions due to strengthened evidence, potentially improving outcomes.
MAP Target for Elderly
Previous version
The 2021 guideline recommended an initial target MAP of 65 mm Hg over higher MAP targets for adults with septic shock on vasopressors.
This version
The 2026 guideline suggests an initial MAP range of 60–65 mm Hg over higher ranges for adults with septic shock 65 years old or older (conditional recommendation, low certainty evidence).
Clinical impact For older adults (≥65 years) with septic shock, a lower MAP target (60-65 mmHg) is now conditionally suggested, allowing for more individualized care.
Practice Notes
Key practical considerations and caveats for managing sepsis and septic shock:
Caution
Do not delay blood cultures for antimicrobial therapy in septic shock.
While blood cultures should ideally be collected before antibiotics, delaying antibiotics in septic shock to obtain cultures can significantly worsen outcomes. Prioritize immediate antimicrobial administration.
Implementation
Implement 'code sepsis' or 'sepsis huddle' protocols.
These multidisciplinary team protocols can expedite diagnosis and treatment, potentially improving patient outcomes by ensuring rapid, coordinated care.
Monitoring
Use dynamic measures to guide fluid resuscitation beyond initial bolus.
Static measures like CVP are poor indicators of fluid responsiveness. Employ dynamic assessments (e.g., passive leg raise, SVV/PPV) to avoid under- or over-resuscitation.
Shared decision point
Engage patients and families in goals of care discussions early.
Proactive discussions about prognosis, treatment preferences, and quality of life ensure care aligns with patient values, especially in severe illness like sepsis.
Stop doing this
Avoid qSOFA as a single screening tool for sepsis in hospital.
qSOFA has poor sensitivity for sepsis diagnosis. Utilize more sensitive tools like NEWS, NEWS2, MEWS, or SIRS for better early identification.
Special population
Consider lower MAP targets for older adults with septic shock.
For patients aged 65 or older, a MAP target of 60-65 mm Hg may be appropriate, balancing perfusion with potential harms of higher vasopressor doses.
Key Recommendations
The 2026 Surviving Sepsis Campaign guidelines provide a comprehensive framework for managing sepsis and septic shock, from early recognition to long-term recovery. These key recommendations highlight critical interventions and shifts in practice to optimize patient care and outcomes.
Key recommendations15 highlighted
01
In hospitals and health systems, implement performance improvement programs for sepsis, including screening, standard operating procedures, and quality improvement strategies.
Line / Strengthstrong recommendation
Level of Evidencemoderate certainty evidence for screening; very low certainty evidence for standard operating procedures; moderate certainty evidence for quality improvement strategies
EvidenceEvidence supports that sepsis performance improvement programs, including screening and QI strategies, are associated with improved care delivery and reduced mortality. While screening has moderate certainty evidence, standard operating procedures have very low certainty, and QI strategies have moderate certainty, with meta-analyses showing reduced mortality and improved processes of care.
Establish or refine hospital-wide sepsis protocols and quality initiatives to ensure consistent, evidence-based care.
Programs should be adapted to local setting capabilities and resource availability.
p. 13 · Performance Improvement Programs
02
In acutely ill patients in hospital, use NEWS, NEWS2, MEWS, or SIRS as a single tool to screen for sepsis, rather than qSOFA.
Line / Strengthstrong recommendation
Level of Evidencemoderate certainty evidence
EvidenceFour systematic reviews and meta-analyses consistently report that Early Warning Scores (NEWS, NEWS2, MEWS, SIRS) are more sensitive for sepsis diagnosis than qSOFA. qSOFA's poor sensitivity makes it unsuitable as a single screening tool.
Shift from qSOFA to more sensitive screening tools for in-hospital sepsis identification.
Bedside clinicians must understand the limitations of each tool.
p. 15 · Screening for Sepsis in Hospital
03
In adults with possible, probable, or definite sepsis or septic shock, collect blood cultures as soon as possible, ideally before antimicrobial therapy.
Line / Strengthstrong recommendation
Level of Evidencelow certainty evidence
EvidenceLimited direct evidence exists, but given high mortality and importance of appropriate antimicrobial coverage, prompt collection is crucial. Studies show blood culture positivity decreases significantly after antimicrobial administration.
Prioritize rapid blood culture collection, but never at the expense of delaying antibiotics in critically ill patients.
Blood cultures should not delay the initiation of antimicrobial therapy, especially in hypotensive patients.
p. 16 · Blood Cultures
04
In adults with sepsis-induced hypoperfusion or septic shock, administer at least 30 mL/kg of IV crystalloid within the first 3 hours.
Line / Strengthconditional recommendation
Level of Evidencelow certainty evidence
EvidenceThis recommendation is based on observational studies and bundles of care. Retrospective analyses link failure to receive 30 mL/kg within 3 hours to increased mortality and ICU length of stay. Prospective interventional studies comparing different volumes are lacking.
Initiate 30 mL/kg IV crystalloid fluid bolus promptly, but tailor to patient response and comorbidities.
Consider individual patient characteristics and ongoing reassessment to avoid under- or over-resuscitation.
p. 18 · Initial Fluid Resuscitation
05
In adults with sepsis-induced hypotension, initiate IV crystalloid fluid bolus resuscitation, followed by vasopressor support if hypotension persists.
Line / Strengthconditional recommendation
Level of Evidencevery low certainty evidence
EvidenceMixed evidence from systematic reviews and small RCTs. Some suggest early vasopressors reduce fluid needs and mortality, while others show no difference. Observational studies link persistent hypotension to worse outcomes.
Start with fluids, but be prepared to add vasopressors promptly if hypotension does not resolve, especially in unstable patients.
In unstable septic shock, immediate concurrent administration of vasopressors with fluids may be warranted.
p. 19 · Timing of Vasopressor Initiation Relative to Fluid Resuscitation
06
In adults with septic shock, target an initial mean arterial pressure (MAP) of 65 mm Hg over higher MAP targets.
Line / Strengthstrong recommendation
Level of Evidencemoderate certainty evidence
EvidenceA meta-analysis of two RCTs showed no difference in short-term mortality with higher MAP targets. Targeting 65 mmHg avoids higher vasopressor doses and associated risks like atrial fibrillation.
Maintain an initial MAP target of 65 mmHg, avoiding unnecessarily high targets that may increase vasopressor burden.
In practice, aim for a reasonable range (e.g., within 5 mm Hg) around 65 mm Hg.
p. 21 · Mean Arterial Pressure (MAP) Targets
07
In adults with possible, probable, or definite septic shock, administer antimicrobial therapy immediately, ideally within 1 hour of recognition.
Line / Strengthstrong recommendation
Level of Evidencevery low certainty evidence
EvidenceSystematic reviews and meta-analyses of observational studies show early antimicrobial therapy is associated with reduced short-term mortality, particularly in septic shock. RCTs did not show this, but primarily included patients without septic shock.
Treat septic shock as a medical emergency; initiate antibiotics within one hour of recognition.
This imperative must be balanced against the harms of unnecessary antimicrobial use in patients without infection.
p. 22 · Timing of Antibiotic Initiation in Hospital
08
In adults with sepsis or septic shock, administer beta-lactam antibiotics via prolonged infusion for maintenance (after an initial loading dose) instead of bolus administration.
Line / Strengthstrong recommendation
Level of Evidencemoderate certainty evidence
EvidenceA systematic review and meta-analysis of 18 RCTs, including the large BLING III trial, showed prolonged infusions reduce short-term mortality and increase days alive out of ICU and hospital.
Adopt prolonged infusion for beta-lactam antibiotics to optimize pharmacodynamics and improve patient outcomes.
Requires suitable IV access and resources for infusion pumps, which may be challenging in some settings.
p. 30 · Prolonged Infusion of β-Lactam Antibiotics
09
In adults with sepsis or septic shock undergoing initial resuscitation, use balanced crystalloids instead of 0.9% saline.
Line / Strengthconditional recommendation
Level of Evidencemoderate certainty evidence
EvidenceMeta-analyses of RCTs suggest balanced crystalloids probably reduce mortality and new renal replacement therapy compared to 0.9% saline, which is associated with hyperchloremic acidosis and AKI.
Prefer balanced crystalloids (e.g., Ringer's lactate) for initial fluid resuscitation unless contraindicated.
For patients with sepsis and traumatic brain injury, 0.9% saline is suggested.
p. 36 · Fluid Type
10
In adults with sepsis or septic shock, do not use starches for resuscitation.
Line / Strengthstrong recommendation
Level of Evidencehigh-certainty evidence
EvidenceConsistent high-certainty evidence demonstrates harm associated with the use of starches for fluid resuscitation in sepsis and septic shock.
Eliminate the use of starches for fluid resuscitation in all patients with sepsis or septic shock.
p. 36 · Fluid Type
11
In adults with sepsis or septic shock, use dynamic measures (e.g., response to passive leg raise or fluid bolus using SV, SVV, PP, PPV) to guide fluid resuscitation, rather than physical examination or static measures alone.
Line / Strengthconditional recommendation
Level of Evidencelow certainty evidence
EvidenceMeta-analyses suggest fluid management guided by dynamic measures likely reduces mortality and need for RRT. Static measures (heart rate, CVP) are poor predictors of fluid responsiveness.
Incorporate dynamic fluid responsiveness assessments to guide ongoing fluid administration, moving beyond static indicators.
Requires technical expertise for some dynamic measures; pulse pressure changes can be useful in resource-limited settings.
p. 38 · Fluid Resuscitation Guided by Dynamic Measures
12
In adults with septic shock, use norepinephrine as the first-line vasopressor agent over dopamine, epinephrine, or selepressin.
Line / Strengthstrong recommendation
Level of EvidenceDopamine. High-certainty evidence; Epinephrine. Low certainty evidence; Selepressin. Low certainty evidence
EvidenceNorepinephrine is superior to dopamine due to high-certainty evidence. Comparisons with epinephrine and selepressin have lower certainty but still favor norepinephrine as first-line.
Norepinephrine remains the first-choice vasopressor for septic shock.
In settings where norepinephrine is unavailable, epinephrine is an acceptable alternative.
p. 41 · IV Vasopressors
13
In adults with septic shock on escalating doses of norepinephrine, add vasopressin.
Line / Strengthconditional recommendation
Level of Evidencemoderate certainty evidence
EvidenceMeta-analysis of 9 RCTs found a probable reduction in mortality with adding vasopressin compared to increasing norepinephrine alone, with less atrial fibrillation.
Consider adding vasopressin when norepinephrine doses are escalating to achieve MAP targets.
Vasopressin may cause more digital ischemia.
p. 41 · IV Vasopressors
14
In adults with sepsis and ARDS, use a low tidal volume ventilation strategy (6 mL/kg) over a high tidal volume strategy (> 10 mL/kg).
Line / Strengthstrong recommendation
Level of Evidencehigh certainty of evidence
EvidenceHigh-certainty evidence from numerous trials demonstrates that low tidal volume ventilation significantly improves outcomes in ARDS by reducing ventilator-induced lung injury.
Strictly adhere to low tidal volume ventilation (6 mL/kg ideal body weight) for all patients with sepsis-induced ARDS.
p. 49 · Invasive Mechanical Ventilation
15
In adults with septic shock, use IV corticosteroids.
Line / Strengthconditional recommendation
Level of Evidencelow certainty evidence
EvidenceA meta-analysis of 45 RCTs suggests corticosteroids may result in a small reduction in 28-day and long-term mortality, and increase shock reversal, despite risks of hyperglycemia and hypernatremia.
Consider IV corticosteroids for patients with septic shock, balancing potential benefits against adverse effects.
This recommendation applies to septic shock, not sepsis without shock.
p. 51 · IV Corticosteroids