Sepsis is a medical emergency in which the body's response to an infection causes organ dysfunction and can rapidly become life-threatening. When a bacterial infection is suspected, antibiotics are a critical part of treatment, and delaying appropriate therapy in patients with sepsis or septic shock can have serious consequences. But treating sepsis aggressively does not mean that every patient should remain on broad-spectrum antibiotics indefinitely.

This is where antibiotic stewardship becomes an important part of sepsis management. It means choosing the most appropriate antibiotic, at the right dose, for the right patient and infection, and reassessing that decision as new clinical and laboratory information becomes available.

"Antibiotic stewardship plays a crucial role in the management of sepsis because these medicines can be lifesaving when a bacterial infection is responsible, but inappropriate use can also create serious problems," said Dr Niraj Kumar, Senior Consultant, Internal Medicine, ShardaCare - Healthcity.

The challenge for doctors is therefore a delicate balance: act quickly enough to treat a potentially life-threatening bacterial infection while avoiding unnecessary antibiotic exposure when evidence later suggests that antibiotics are not required.

Why are antibiotics important in sepsis?

Sepsis can be caused by bacterial, viral, fungal or other infections. Antibiotics specifically target bacterial infections and therefore are not automatically appropriate for every person who develops a sepsis-like illness.

The latest Surviving Sepsis Campaign (SSC) 2026 guidelines state that sepsis and septic shock are medical emergencies requiring immediate treatment and resuscitation. For adults with possible, probable or definite sepsis or septic shock, the guidelines recommend obtaining blood cultures as soon as possible, ideally before antimicrobial therapy.

For patients with septic shock or a high likelihood of sepsis, the 2021 SSC guidelines recommended administering antimicrobials immediately, ideally within one hour of recognition. For patients with possible sepsis without shock, the approach is more nuanced: clinicians should rapidly assess whether infection is likely and provide antibiotics promptly when the likelihood of sepsis remains high.

"Antibiotic stewardship does not mean delaying or withholding antibiotics from patients who need them," Dr Kumar said. "Instead, it means using antibiotics responsibly while ensuring that patients with suspected bacterial sepsis receive timely and effective treatment."

Why doctors may initially use broad-spectrum antibiotics

When a patient arrives with severe infection or sepsis, the exact organism causing the infection may not yet be known. The source could be the lungs, urinary tract, abdomen, bloodstream, skin or another site.

Doctors may therefore initially choose empirical broad-spectrum antibiotics that cover the bacteria most likely to be responsible, taking into account the suspected source, the patient's previous infections, recent antibiotic exposure, immune status and local patterns of antimicrobial resistance.

However, broad-spectrum treatment is intended as an initial strategy, not necessarily a final one.

Blood cultures and other appropriate samples can help identify the pathogen and determine which medicines it is susceptible to. The SSC 2026 guidelines recommend de-escalating antimicrobial therapy when microbiological results and susceptibility information become available. De-escalation can mean switching to a narrower-spectrum antibiotic or stopping unnecessary treatment altogether.

What happens when antibiotics are overused?

Antibiotics are powerful medicines, but their use can have consequences beyond the individual infection.

Antimicrobial resistance (AMR) occurs when microorganisms develop the ability to survive medicines designed to kill or inhibit them. This can make infections harder to treat and increase the risk of complications and death.

The World Health Organization estimates that bacterial antimicrobial resistance was directly responsible for 1.27 million deaths globally in 2019, while resistant bacterial infections were associated with approximately 4.95 million deaths.

In sepsis, this is particularly concerning because resistant infections can leave doctors with fewer effective treatment options. WHO notes that antimicrobial resistance is an important factor in treatment failure and the progression of infection to sepsis and septic shock.

Unnecessary antibiotic exposure can also cause direct harm. According to the US Centers for Disease Control and Prevention, antibiotic use can cause adverse effects ranging from diarrhoea and allergic reactions to serious complications such as Clostridioides difficile infection. Antibiotic exposure also creates selective pressure that contributes to resistance.

Why the right duration matters

Another common stewardship question is: How long should antibiotics be continued?

There is no single duration that applies to every case of sepsis. Treatment depends on the infection source, the organism involved, whether adequate source control has been achieved, the patient's clinical response and other individual factors.

The SSC 2021 guidelines recommend daily assessment for antimicrobial de-escalation rather than simply following fixed durations without reassessment. They also suggest shorter antibiotic courses rather than longer ones when adequate source control has been achieved.

The 2026 guidelines similarly emphasise continuous reassessment and recommend discontinuing empirical antimicrobials when an alternative, non-infectious explanation for the patient's illness becomes evident or strongly suspected.

This means that antibiotics should not continue simply because they were started on the first day of hospitalisation.

Cultures can help guide antibiotic decisions

Ideally, appropriate blood cultures should be collected before antibiotics are administered, provided doing so does not cause a clinically significant delay in treatment.

The purpose is not to wait for culture results before treating a critically ill patient. Cultures typically take time, while sepsis treatment cannot always wait.

Instead, cultures provide information that can later help doctors determine whether the initial antibiotic regimen is still appropriate.

"If the source of infection or the responsible organism is not yet known, doctors may initially use broad-spectrum antibiotics. Blood cultures and other relevant samples should ideally be collected before antibiotics are administered, provided this does not cause a clinically significant delay," Dr Kumar explained.

What patients and families should know about antibiotic stewardship

Antibiotic stewardship is not only a hospital-level responsibility. Patients and families also have an important role.

Antibiotics should not be self-medicated for fever, cough, sore throat, diarrhoea or other symptoms without medical advice. Antibiotics do not work against viruses, which cause illnesses such as most common colds and influenza.

Leftover antibiotics should not be saved for a future illness, shared with another person or taken at a different dose or duration than prescribed.

In hospitalised patients with sepsis, families may also wonder why a doctor changes, narrows or stops an antibiotic after initially starting intensive treatment. Such changes can be a sign of appropriate stewardship rather than inadequate treatment, particularly when laboratory results and the patient's clinical condition provide new information.

The goal: Fast treatment, followed by smart treatment

The central principle of antibiotic stewardship in sepsis is not "less antibiotics at all costs." It is "the right antibiotics for the right patient, for the right amount of time."

"Treatment should be guided by the infection source, clinical response, microbiological findings and the patient's overall condition rather than continuing antibiotics automatically," Dr Kumar said.

For a patient with septic shock and a serious bacterial infection, rapid antibiotic treatment can be lifesaving. But once the clinical picture becomes clearer, continuing unnecessarily broad or prolonged treatment may expose the patient to avoidable harm and contribute to the wider problem of antimicrobial resistance.

That balance is at the heart of modern sepsis care.

Antibiotic stewardship is an essential part of treating sepsis safely and effectively. The first priority remains recognising sepsis and providing timely treatment when bacterial infection is likely. At the same time, clinicians need to obtain appropriate cultures, reassess the diagnosis, select antibiotics according to the suspected or confirmed source and resistance patterns, and narrow or discontinue treatment when evidence supports doing so.

For patients and families, responsible antibiotic use means avoiding self-medication and understanding that antibiotics are not a universal treatment for fever or infection.

"Act rapidly when antibiotics are indicated, obtain appropriate cultures, reassess treatment as new information becomes available and avoid unnecessary or prolonged antibiotic exposure," Dr Kumar said. "Responsible antibiotic use today helps preserve the effectiveness of these critical medicines for patients with severe infections in the future."



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