Executive Summary: Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2026

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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

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