International multidisciplinary consensus statement on sepsis code guidelines: A Delphi approach

Sepsis remains a major global health challenge. International guidelines exist, but their implementation is inconsistent, and supporting evidence largely comes from high-income settings. The objective of this study was to generate international, multidisciplinary expert consensus on controversial aspects of sepsis management within the framework of sepsis code programs.

A multinational modified Delphi study was conducted with 164 experts from 22 countries, 12 specialties, and 105 scientific societies. Seven domains were evaluated: early diagnosis, biomarkers, diagnostic microbiology, hemodynamic monitoring, source control, antimicrobial therapy, and hemodynamic management. Consensus was defined as ≥70% agreement across three iterative rounds using Likert scales (Rounds 1-2) and binary format (Round 3).

Consensus was achieved for 40 statements. Strong endorsement (82%-95%) was reached for structured hospital sepsis programs, NEWS-2 as the preferred early recognition tool, biomarker use (notably procalcitonin) to complement clinical assessment, urgent source control within 6 h independent of hemodynamic status, rapid molecular diagnostics integrated with antimicrobial stewardship, and norepinephrine as first-line vasopressor therapy. Experts also supported pharmacokinetic- and pharmacodynamic-guided antibiotic dosing, prolonged infusion of time-dependent agents, and dynamic rather than fixed fluid strategies. No consensus was reached on routine reliance on Sepsis-2, Sepsis-3, or qSOFA; high mean arterial pressure targets; or universal combination antimicrobial therapy.

These results provide multidisciplinary guidance for sepsis management, with emphasis on rapid recognition, targeted antimicrobial therapy, timely source control, and hemodynamic management guided by patient physiology. The recommendations are applicable to high- and middle-income healthcare systems.