We received responses from 43 of the 48 hospitals (89.6 %). The type and frequency of local guidelines were distributed as follows (Figure 1): 26 hospitals (six regional hospitals, 13 large emergency hospitals, 7 emergency hospitals) had their own local guidelines. Ten hospitals (two large emergency hospitals, eight emergency hospitals) had local guidelines from larger hospitals. In addition, eight of these reported to use the guidelines for antibiotics use in the specialist health service issued by the Directorate of Health.
Four hospitals (three large emergency hospitals, one emergency hospital) had their own guidelines, but reported that at the time of the survey they preferred to use national/international guidelines, since their own were either outdated or undergoing revision. Three hospitals (one large emergency hospital, two emergency hospitals) had no local guidelines and used national and international guidelines directly.
The local guidelines were largely consistent with the national ones, but were less detailed. There were also some minor differences between them. For initiation of antibiotics treatment, the guidelines used by three hospitals tended to favour the use of more broad-spectrum drugs. Admittedly, two of these were unspecific, but still recommended 'broad-spectrum antibiotics within one hour after the diagnosis has been made in the intensive care department, ward or accident and emergency department'. The third set of guidelines recommended piperacillin/tazobactam or meropenem as the first choice. The remaining guidelines were consistent with the national ones, which recommend high-dose penicillin in combination with gentamicin.
All the guidelines pointed to concern for the assumed focus of infection or the suspected microbe, but were not as elaborate as the national guidelines. Only a single hospital stated that aminoglycosides were contraindicated in all patients with sepsis and septic shock.
All hospitals had crystalloids as their first choice for fluid therapy, while only 20 referred to colloids as an alternative. The national guidelines list albumin as an option. Three large emergency hospitals referred to hydroxyethyl starch as an alternative, which is clearly advised against in the national guidelines.
There were also some differences concerning the indication for starting fluid therapy, infusion rate and total fluid volume. According to the national guidelines, all sepsis patients should be provided with 30 ml/kg fluid within the first 60–120 minutes, depending on the clinical response. If there is a response (normalisation of blood pressure, reduced heart rate and increased urine production), fluid therapy should continue to the extent necessary to maintain stable circulation.
In intensive care departments, it is recommended to monitor the subsequent fluid therapy with objective measures of cardiac minute volume, pulmonary artery wedge pressure or intrathoracic blood volume. Most local guidelines recommended an initial fluid bolus of 20–35 mg/kg over the first 30–60 minutes. In case of persistent hypotension, initiation of vasoactive drugs was recommended, in combination with continued fluid therapy, with the aim of achieving a central venous pressure equal to 8–12 mmHg. Seven local guidelines noted that fluid volumes up to 10–12 litres are often required during the first 24 hours. Only five guidelines underscored that this treatment should continue only for as long as it produces a clinical response.
For the use of noradrenaline as a vasoactive drug, eleven hospitals had alternatives that are not mentioned in the national guidelines: adrenaline (11 hospitals), levosimendan (four hospitals) and phenylephrine (two hospitals). The national guidelines recommend noradrenaline as the first choice and dopamine and dobutamine as alternatives if an inotropic effect is also needed.
Vasopressin is recommended in patients with refractory shock. Altogether 23 hospitals lacked alternatives that are described in the national guidelines, eight of which did not refer to vasopressin. The greatest range in the use of vasoactive drugs was associated with the use of dopamine. One hospital gave dopamine as its first choice, while 20 hospitals had noradrenaline as their first choice and dopamine as an alternative. Four of these underscored that dopamine should only be used for selected patients. Ten guidelines made no reference to dopamine, while three explicitly stated that this drug should be avoided.
The national guidelines mention glucocorticoids as an alternative if hypotension persists despite treatment with fluids and vasopressors. Of the local guidelines, 28 were consistent with this, while there was no such reference in the remaining ones.