Search for a command to run...
The Surviving Sepsis Campaign (SSC): International Guidelines for Management of Sepsis and Septic Shock 2026 provide guidance on the identification and management of sepsis in adult patients with sepsis. They were developed according to Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) methodology. This executive summary reviews the history, methodology, content, and major changes since the 2021 guidelines. HISTORY AND SPONSORSHIP OF THE GUIDELINES The SSC has published guidelines for the management of sepsis and septic shock in 2004, 2008, 2012, 2016, and 2021. The 2026 SSC guidelines are an update from 2021 and focus on evidence published through June 2025. The guidelines are funded by the Society of Critical Care Medicine and the European Society of Intensive Care Medicine, with methodological support by the Guidelines in Intensive Care Development and Evaluation (GUIDE) group, and endorsement by 24 sponsoring professional societies. There was no industry funding. Panel membership, patient involvement, and conflict of interest management are detailed in the guidelines and the Supplemental Digital Content in the guidelines (1). METHODOLOGY Figure 1 in the guidelines (1) summarizes the process for determining the type of statement. We classified graded recommendations as strong (“we recommend”) or conditional (“we suggest”). A strong recommendation indicates that most, if not all, well-informed patients/caregivers in the relevant clinical situation would choose the recommended action or intervention. A conditional recommendation acknowledges that the balance between desirable and undesirable effects may vary depending on patient values, clinical circumstances, or resource availability. We used standardized language to summarize the findings of evidence syntheses based on effect size (i.e., point estimate) and certainty of the evidence, as recommended by GRADE methodology (2). We required a minimum 75% response rate and 80% agreement among eligible panelists for all statements and formal remarks. We retained several statements from the 2021 SSC guidelines that remain clinically relevant, accurate, and essential to comprehensive sepsis care. These “carry-over” statements did not undergo updated evidence synthesis but were voted on to ensure continued relevance and accuracy. We also considered the universal applicability of each recommendation and comment in the narratives about applicability to different settings, including low resource settings. Because the diagnosis of sepsis may be uncertain in clinical practice, we developed standardized language for definite, probable, possible, and unlikely sepsis, which are used throughout the SSC guidelines and described in Table 3 in the guidelines (1) . SUMMARY OF 2026 SSC GUIDELINES CONTENT The 2026 guidelines include 129 statements covering screening and early management (16 statements), infection (25), hemodynamic management (23), respiratory support (14), adjunctive therapies for sepsis (8), additional supportive management (13), goals of care (8), transitions of care (16), and long-term outcomes (6). Most statements (81, 63%) are conditional recommendations, 17 are strong recommendations, 19 are good practice statements, and 11 are statements of insufficient evidence to issue a recommendation. The 2026 SSC guidelines additionally include 13 “in our practice” statements describing the panel’s practice as determined via independent survey of the panel. These statements are not an endorsement of a specific intervention or treatment approach. Rather, they document how panelists currently approach situations characterized by uncertainty, absence of data, or context-specific clinical variability. Figures 2 and 3 in the guidelines (1) highlight key recommendations related to antibiotic timing and hemodynamic management, respectively. Table 1 in the guidelines (1) lists all 129 statements and describes how they relate to the 2021 SSC guideline statements. Below we highlight selected statements in the 2026 SSC guidelines that are new, changed, and consistent with the 2021 guidelines. WHAT IS NEW SINCE 2021 The 2026 SSC guidelines contain 46 statements addressing new questions not covered in the 2021 guidelines. Table 1 highlights seven new recommendations. TABLE 1. - Abridged Rationale for Selected New statements Selected New Statements Abridged Rationale 3. In acutely ill adults en route to hospital by ambulance or flight, we “suggest” using a standard sepsis screening tool over not using a screening tool.(conditional recommendation, very low certainty evidence) Sepsis is a time-sensitive medical emergency, and approximately half of patients hospitalized for sepsis arrive via ambulance. Prehospital screening has been associated with improved processes of care. The panel determined that the balance of effects probably favors prehospital, ambulance-based sepsis screening for identifying patients with sepsis and improving the timeliness of sepsis care. 13. For adults with septic shock, we “recommend” an initial MAP target of 65 mm Hg over higher MAP targets.(strong recommendation, moderate certainty evidence) Remark: In practice, it is not feasible to maintain MAP at exactly 65 mm Hg, so a reasonable range (e.g., within 5 mm Hg) should be used. Vasopressors should be titrated to maintain MAP within this range. 14. For adults with septic shock 65 yr old or older, we “suggest” an initial MAP range of 60–65 mm Hg over higher ranges.(conditional recommendation, low certainty evidence) Consistent with the 2021 guidelines, the 2026 guidelines recommend an initial MAP target of 65 mm Hg. However, the 2026 guidelines include a new remark acknowledging that MAP cannot be maintained at exactly 65 mm Hg, but instead requires a target range, for example, within 5 mm Hg. In a meta-analysis done for the guidelines limited to patients 65 yr old or older, a lower blood pressure target was associated with reduced mortality at longest follow-up. The panel thus determined that the balance of desirable and undesirable effects probably favors permissive hypotension over use of vasopressors to maintain a MAP > 65 mm in adults 65 yr old or older. 21. For adults with definite or probable sepsis and hypotension (i.e., septic shock) and who have an anticipated time to in-hospital medical evaluation of over 60 min, we “suggest” administering antimicrobial therapy in ambulance or flight.(conditional recommendation, very low certainty evidence). Remark: Prehospital antibiotic delivery should be implemented only after having a structured process in place to screen for sepsis in ambulance or flight, as discussed in recommendation 3. Sepsis is a time-sensitive medical emergency, and approximately half of patients hospitalized for sepsis arrive via ambulance. A meta-analysis of observational studies was uncertain but suggested a possible reduction in mortality with prehospital antibiotics. Meta-analysis of randomized controlled trials also suggested that prehospital antibiotics may reduce 28-d mortality. The panel determined that the balance of effects probably favors prehospital antibiotic administration in patients with sepsis and hypotension and who have an anticipated time to in-hospital medical evaluation of over 60 min. This recommendation aligns with the recommendation to administer antibiotics within 1 hr in patients with septic shock. 28. For adults with sepsis or septic shock without risk factors for anaerobic infection, we “suggest” using an empiric antibiotic regimen without anaerobic coverage.(conditional recommendation, very low certainty evidence) Remark: Agents with anaerobic activity that are needed to cover possible MDR pathogens (e.g., piperacillin-tazobactam, carbapenems) are reasonable to use to provide adequate MDR coverage if alternative agents without anaerobic coverage are inadequate. The prevalence of sepsis and septic shock due to anaerobic bacteria is low, compared with aerobic bacteria and fungi. Many patients with sepsis or septic shock, particularly of lung or urinary origin, are unlikely to benefit from empiric anaerobic coverage. Observational studies suggest an increased risk of adverse outcomes, including increased mortality, in patients treated with empiric anti-anaerobic antibiotics when no risk factors for anaerobic infection are present. The panel thus issued paired statements suggesting to withhold vs. include anti-anaerobic coverage based on clinical context. 29. For adults with sepsis or septic shock with specific risk factors for anaerobic infection, we “suggest” using an empiric antibiotic regimen that includes anaerobic coverage.(conditional recommendation, very low certainty evidence) Remark: Risk factors for anaerobic infection include intra-abdominal or deep seated gynecological/obstetric source of infection, necrotizing soft-tissue infection, head and neck infection, and CNS abscesses or empyema. 41. In mechanically ventilated adults with sepsis or septic shock in units with a low prevalence of antimicrobial resistance, we “suggest” using selective decontamination of the digestive tract (SDD).(conditional recommendation, moderate certainty evidence) Selective decontamination of the digestive tract (SDD) is a preventive infection control strategy consisting of the administration of nonabsorbable, topical antimicrobial agents to the oropharynx and upper gastrointestinal tract (oropharyngeal decontamination), with the administration of a short-term course of broad-spectrum IV antimicrobials in mechanically ventilated patients. SDD is specifically designed to eliminate pathogenic aerobic bacteria while preserving anaerobic gut bacteria essential to digestion and immune function. Meta-analysis of showed a probable reduction in short-term mortality and—counter to concerns—a possible reduction antimicrobial resistance. 89. For adults with septic shock after the acute resuscitation phase, we “suggest” using active fluid removal.(conditional recommendation; very low certainty evidence). Remark: Acute resuscitation refers to escalating doses of vasopressors, ongoing high doses of vasopressors, or needing ongoing volume expansion. Active fluid removal refers to diuretics and, if diuretics are insufficient, ultrafiltration or extracorporeal fluid removal. Factors to be considered when deciding to initiate active fluid removal include: cardiorespiratory function; vasopressor dose; clinical course; peripheral edema; weight; and fluid balance. Fluid overload in patients with sepsis and septic shock can lead to tissue edema, impaired oxygen delivery, and organ dysfunction and is associated, in observational studies, with increased mortality. The management of fluid balance appears to be important, therefore, particularly in the “evacuation” or “de-escalation” phase of resuscitation. We considered a recent meta-analysis that assessed de-resuscitation strategies. Across all critically ill patients, the pooled analysis demonstrated an uncertain effect of active fluid removal on mortality, with the use of diuretics only having a potentially more favorable effect than the use of diuretics with or without renal replacement therapy. Our suggestion for active fluid removal was influenced by input from patient representatives to the Surviving Sepsis Campaign guidelines, who placed a high value on avoiding edema. WHAT HAS CHANGED SINCE 2021 The 2026 SSC guidelines contain 38 statements addressing questions that were revisited from the 2021 guidelines. However, only three of these statements differ from prior guidance, as described in Table 2. TABLE 2. - Abridged Rationale for Statements that Differ From 2021 Surviving Sepsis Campaign Guidelines Statements that Differ From 2021 Abridged Rationale 27. For adults with sepsis or septic shock, we “suggest against” using empirical antifungal therapy.(conditional recommendation, low certainty evidence) Remark: Empiric antifungal therapy should be considered on a case-by-case basis in selected patients with sepsis or septic shock and risk factors for fungal infection, including immunosuppression, prolonged use of antibiotics, prolonged hospitalization, and intra-abdominal source of infection. The 2021 SSC guidelines contained a pair of conditional recommendations that suggested using empiric antifungal therapy in patients at high risk or fungal infection and suggested against using empiric antifungal therapy in patients at low risk of antifungal infection. There are no new data from 2021. The 2026 guidelines streamline the guidance to a single conditional recommendation against using empirical antifungal therapy, recognizing that the majority of patients do not warrant empiric antifungal therapy. However, we have included a remark for case-by-case consideration of empiric antifungal therapy in select circumstances. 42. For adults with septic shock, we “suggest” using either invasive or noninvasive blood pressure monitoring.(conditional recommendation; very low certainty evidence) Remark: Invasive blood pressure monitoring is advised in patients with shock who: require intermediate-to-high dose vasopressors, escalating doses of vasopressor, or multiple vasopressors; are receiving frequent arterial blood sampling; or have noninvasive blood pressure measurements which are inconsistent on repeated assessments. The 2021 SSC guidelines included a conditional recommendation for invasive blood pressure monitoring. However, considering the very low certainty of evidence, the lack of clear associations with clinical benefit, and concerns regarding equity, patient comfort, and measurement discordance, the panel issued a conditional recommendation supporting the use of either noninvasive or invasive blood pressure monitoring. The multicenter EVERDAC RCT testing a noninvasive strategy to blood pressure monitoring in circulatory failure (i.e., avoidance of arterial line unless pre-specified safety criteria were met) was published after the 2026 SSC guideline recommendations were finalized. EVERDAC found that, among 1010 patients randomized, 28-day all-cause mortality was noninferior in the noninvasive-strategy group (34.3% mortality vs. 36.9% in the invasive strategy, p = 0.006 for noninferiority). 45. For adults with sepsis or septic shock, we “suggest” using crystalloids alone over crystalloids with supplemental albumin for fluid resuscitation.(conditional recommendation; moderate certainty evidence). Remark: Use of supplemental albumin may be appropriate for patients who already received large crystalloid volumes or have cirrhosis. Supplemental albumin should be avoided in patients with traumatic brain injury. The 2021 SSC guidelines included a conditional recommendation for using albumin in patients who had received large volumes of crystalloid. An updated meta-analysis found probably no effect of albumin on prioritized patient-centered outcomes. Given the lack of proven benefit and increased costs, the 2026 guidance has been updated to suggest crystalloids alone over supplemental albumin. We have included a remark to denote specific clinical contexts where albumin may be appropriate on a case-by-case basis. SSC = Surviving Sepsis Campaign. There are eight statements for which the guidance is consistent with 2021, but the certainty of evidence and/or strength of recommendation has changed. These are presented in Table 3. TABLE 3. - Statements With a Change in Strength of Recommendation or Certainty of Evidence Statements Change in Certainty or Strength 33. For adults with sepsis or septic shock, we “recommend” using prolonged infusion of beta-lactams for maintenance (after an initial loading dose) over bolus administration.(strong recommendation, moderate certainty evidence) Upgraded from a conditional to strong recommendation. 36. For adults with sepsis or septic shock, we “recommend” de-escalation of antimicrobial therapy over no de-escalation when a confirmed microbiological diagnosis and susceptibility profile is available.(strong recommendation, very low certainty evidence) Remark: De-escalation involves discontinuing unnecessary antimicrobial therapy or narrowing the spectrum of antimicrobial agents where appropriate. Upgraded from a conditional to strong recommendation. 44. For adults with sepsis or septic shock undergoing initial resuscitation, we “suggest” using balanced crystalloids over 0.9% saline.(conditional recommendation, moderate certainty evidence). Remark: For patients with sepsis and traumatic brain injury, we suggest using 0.9% saline. Upgraded from low to moderate certainty evidence. 49. For adults with sepsis or septic shock, we “suggest” using dynamic measures to guide initial fluid resuscitation over physical examination or static measures alone.(conditional recommendation, low certainty evidence) Remark: Dynamic measures include response to a passive leg raise or a fluid bolus using stroke volume, stroke volume variation, pulse pressure, or pulse pressure variation. Upgraded from very low to low certainty evidence. 55. For adults with septic shock, we “suggest” using norepinephrine as the first-line agent over vasopressin or angiotensin II.(conditional recommendation)Vasopressin. Low certainty evidence.Angiotensin II. Very low certainty evidence. Downgraded from strong to conditional recommendation. (Note: Use of norepinephrine as the first-line agent over dopamine, epinephrine, or selepressin remains a strong recommendation.) 57. For adults with septic shock and inadequate MAP levels despite norepinephrine and vasopressin, we “suggest” adding epinephrine.(conditional recommendation, very low certainty evidence). Remark: In settings where vasopressin is not available, epinephrine can be added to norepinephrine alone. Downgraded from low to very low certainty evidence. 61. For adults with septic shock with persistent hypoperfusion and cardiac dysfunction despite adequate fluid resuscitation and arterial blood pressure, we “suggest” adding dobutamine to norepinephrine or using epinephrine alone.(conditional recommendation, very low certainty evidence). Remark: Data were insufficient to make a recommendation for dobutamine vs. milrinone. Downgraded from low to very low certainty evidence. 79. For adults with septic shock, we “suggest” using IV corticosteroids.(conditional recommendation, low certainty evidence) Downgraded from moderate to low certainty evidence. WHAT IS THE SAME FROM 2021 The 2026 SSC guidelines contain 44 statements that were carried over directly from the 2021 SSC guidelines without un updated evidence synthesis (based on panel assessment that sufficient new evidence to justify a change in recommendation was unlikely). Statements carried over without an updated evidence synthesis are clearly denoted. The 2026 SSC guidelines additionally contain 39 statements that were revisited from 2021 SSC guidelines, of which 7 are unchanged and 29 are consistent with the 2021 recommendations but have revised wording and/or a new remark to refine or clarify guidance. Table 4 highlights recommendations that are consistent with the 2021 SSC guidelines. TABLE 4. - Abridged Rationale for Selected Statements that are Consistent With 2021 Surviving Sepsis Campaign Guidelines Selected Statements That are Consistent With 2021 Abridged Rationale 9. Sepsis and septic shock are medical emergencies; treatment and resuscitation should begin immediately.(good practice statement) This good practice statement was carried over directly from 2021. Sepsis is a leading cause of global mortality, contributing to an estimated 13.7 million deaths annually. In-hospital mortality is higher for patients with sepsis than patients with ST-elevation myocardial infarction. Prompt recognition and treatment reduce mortality. 10. For adults with sepsis-induced hypoperfusion or septic shock, we “suggest” administering at least 30 mL/kg of IV crystalloid in the first 3 hr. (conditional recommendation, low certainty evidence). Remark: Consideration should be given to individual patient characteristics and when initial fluid Remark: should ongoing and patients to of or Remark: fluid volume should be based on or by or in patients with This recommendation is unchanged from 2021. were added to clarify the of ongoing consideration of and for patients with high fluid resuscitation is for the of sepsis-induced tissue hypoperfusion in sepsis and septic shock. evidence in support of 30 mL/kg from observational studies and includes studies 30 mL/kg as of a of care are no new data suggesting a change is needed from prior SSC guidelines. Fluid overload with volumes 30 However, in patients at higher risk of from volume dynamic assessment to guide fluid resuscitation can prior to 30 mL/kg recommendation regarding dynamic measures to guide resuscitation, discussed For adults with possible, probable, or definite septic shock, we “recommend” administering antimicrobial therapy within 1 hr of recommendation, very low certainty evidence) These recommendations are unchanged from 2021 from wording changes for administration of appropriate antimicrobials is the initial intervention to reduce mortality in patients with sepsis or septic shock, with fluid resuscitation. Given the high risk of with septic shock and the more consistent and of antimicrobial timing and short-term mortality in patients with septic shock, the panel issued a strong recommendation to administer antimicrobials in adults with possible, probable, and definite septic shock and in adults with probable or definite sepsis. For adults with possible sepsis without shock, where the diagnosis of infection is the panel issued a conditional recommendation for a 3 assessment of and of This assessment may include additional history, clinical and testing to antimicrobials should be should be as as infection appears to be the of the and after no more than 3 hr if a for infection For adults with probable or definite sepsis without shock, we “recommend” administering antimicrobial therapy within 1 hr of recognition recommendation, very low certainty evidence) For adults with possible sepsis without shock, we “suggest” a course of and if for infection the administration of antimicrobial therapy within 3 hr from the time when sepsis was first recommendation, very low certainty of evidence) 49. For adults with sepsis or septic shock, we “suggest” using dynamic measures to guide fluid resuscitation over physical examination or static measures alone.(conditional recommendation, low certainty evidence) Remark: Dynamic measures include response to a passive leg raise or a fluid bolus using stroke volume, stroke volume variation, pulse pressure, or pulse pressure variation. This recommendation is unchanged from 2021. with sepsis or septic shock require additional IV fluid an initial 30 mL/kg fluid resuscitation. However, additional resuscitation fluid be balanced against the risk of fluid and associated with fluid or fluid administration the initial resuscitation phase should be by assessment of volume organ and fluid In a meta-analysis done for these SSC guidelines, fluid management by dynamic measures mortality and may in a in SSC = Surviving Sepsis Campaign. This executive summary describes the of the 2026 SSC guidelines and highlights selected new, and unchanged statements that are relevant to The guidelines document all 129 statements and narratives for all statements by a new or updated evidence