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The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2024

JSICM/JAAM (J-SSCG 2024) · 2025 · Japan

Source and licence

Authors
Nobuaki Shime, Taka-aki Nakada, Tomoaki Yatabe et al.
Title
The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2024
Journal
Journal of Intensive Care, 2025
DOI
10.1186/s40560-025-00776-0
Licence
CC BY 4.0
Changes
Verbatim excerpts; formatting adapted

Full text retrieved 2026-10-27 from Europe PMC · PMC11907869

Licence statement of the original publication

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This page reproduces excerpts of the original publication; the original is authoritative. It has not been reviewed by a physician, does not state a recommendation of Medelix and does not replace medical advice. The guideline may have been updated since.

Open the original publication →Full text on Europe PMC

Recommendations

Verbatim, with grade of recommendation or strength of consensus where given.

CQ2-1: Is Gram stain testing useful for selecting empiric antimicrobials for sepsis?

  • Answer: We suggest using Gram stain testing for selecting empiric antimicrobials for sepsisGRADE 2C

CQ2-2: Is the administration of empiric antimicrobials for sepsis started within 1 h after diagnosing sepsis?

  • Answer: Although antimicrobials should be started as soon as possible after sepsis or septic shock is diagnosed, we suggest against the use of < 1 h target timeGRADE 2C

CQ2-7: Is continuous or extended infusion of antimicrobials used for sepsis?

  • Answers: We suggest using continuous or extended infusion of β-lactam antimicrobials for sepsisGRADE 2B
  • We suggest against using continuous or extended infusion of glycopeptide antimicrobials for sepsisGRADE 2C

CQ2-8: Is antimicrobial dosage adjusted using therapeutic drug monitoring (TDM) for sepsis?

  • Answer: We suggest antimicrobial administration using TDM for sepsisGRADE 2D

CQ 2–9: Is de-escalation based on culture and susceptibility results performed in antimicrobial therapy for sepsis?

  • Answer: We suggest applying de-escalation based on culture and susceptibility results performed in antimicrobial therapy for sepsisGRADE 2C

CQ2-10: In patients with sepsis receiving empiric antifungal drugs, are antifungal drugs discontinued using β-D glucan as an indicator?

  • Answer: We suggest the use of β-D glucan as an indicator for the discontinuation of antifungal drugs in patients with sepsis who have been administered empiric antifungal drugsGRADE 2C

CQ2-11: Is PCT used as an indicator for discontinuing antimicrobial therapy for sepsis?

  • Answer: We suggest the use of PCT as an indicator for discontinuing antimicrobial therapy for sepsisGRADE 2A

CQ2-12: Is short-term (≤ 7 days) antimicrobial therapy used for sepsis?

  • Answer: We suggest applying short-term (≤ 7 days) antimicrobial therapy for sepsisGRADE 2C

CQ3-3: What is the target mean arterial pressure (MAP) during initial resuscitation for sepsis?

  • Answer: We suggest 65 mmHg as the target MAP during initial resuscitation for sepsisGRADE 2C

CQ3-4: Which fluid is used for initial resuscitation of sepsis?

  • Answer: During initial resuscitation for sepsis, we suggest the administration of balanced crystalloid over normal salineGRADE 2C
  • We suggest the administration of isotonic albumin preparations (4–5%) when a patient with sepsis does not respond to standard treatment using crystalloids and requires a large volume of crystalloidsGRADE 2B
  • During initial resuscitation for sepsis, we recommend against the administration of synthetic colloidsGRADE 1B

CQ3-6: Is early administration of vasopressor performed during initial resuscitation for sepsis?

  • Answer: During initial resuscitation for sepsis with hypotension, we suggest early administration of vasopressor combined with resuscitative fluid therapyGRADE 2C

CQ3-7: Which vasopressor is used as the first-line and second-line drugs in patients with septic shock?

  • Answer: We suggest using noradrenaline as the first-line vasopressor for septic shock (GRADE 2D), and vasopressin as the second-line vasopressor for septic shockGRADE 2A

CQ3-8: Are steroids administered for septic shock?

  • Answer: We suggest administering low-dose hydrocortisone (200–300 mg/day) to patients with septic shock unresponsive to initial fluid resuscitation and vasopressors for the purpose of recovering from shockGRADE 2C

CQ3-9: What is the threshold of hemoglobin level for transfusion in initial resuscitation for septic shock?

  • Answer: We suggest a hemoglobin level of 7 g/dL as a threshold for transfusion in initial resuscitation for septic shockGRADE 2C

CQ3-10: Are β1-adrenoceptor antagonists used for septic patients with persistent tachycardia after initial resuscitation?

  • Answer: We suggest administering β1-adrenoceptor antagonists for patients with sepsis to manage persistent tachycardia after initial resuscitationGRADE 2C

CQ3-11: Is sodium bicarbonate intravenously administered for septic patients with severe metabolic acidosis (pH ≤ 7.2)?

  • Answer: We suggest the intravenous administration of sodium bicarbonate for septic patients with severe metabolic acidosis (pH ≤ 7.2)GRADE 2C

CQ3-13: Is restrictive fluid management provided in septic patients with stable hemodynamics?

  • Answer: We suggest providing restrictive fluid management in septic patients with stable hemodynamics with monitoring for ischemic organ dysfunction due to hypoperfusionGRADE 2C

CQ4-1: Is polymyxin B-immobilized fiber column (PMX-DHP) used for patients with septic shock?

  • Answer: We suggest against using PMX-DHP for patients with septic shockGRADE 2D

CQ4-2: Is early renal replacement therapy (RRT) performed for septic acute kidney injury (AKI)?

  • Answer: We suggest against performing early RRT for patients with septic AKIGRADE 2C

CQ4-3: Is continuous RRT provided for septic AKI?

  • Answer: Either continuous or intermittent RRT can be selected as an RRT modality for septic AKIGRADE 2D

CQ4-4: Is treatment dose increased in RRT for septic AKI?

  • Answer: We recommend against increasing the RRT dose beyond the international standard dose (20–25 mL/kg/h) for patients with septic AKIGRADE 1A

CQ5-3: Is antithrombin administered for sepsis-induced DIC?

  • Answer: We suggest the administration of antithrombin for sepsis-induced DICGRADE 2B

CQ5-4: Is recombinant thrombomodulin administered for sepsis-induced DIC?

  • Answer: We suggest the administration of recombinant thrombomodulin for sepsis-induced DICGRADE 2B

CQ6-1: Is intravenous immunoglobulin (IVIG) administered for sepsis?

  • Answer: We suggest against the administration of IVIG for sepsisGRADE 2C

CQ6-2: Is high-dose vitamin C therapy used for sepsis?

  • Answer: We suggest against the use of high-dose vitamin C therapy for sepsisGRADE 2B

CQ6-3: What is the target blood glucose level for sepsis?

  • Answer: We suggest 144–180 mg/dL as a target blood glucose level for sepsisGRADE 2C

CQ6-4: Is antipyretic therapy provided to febrile patients with sepsis?

  • Answer: We suggest against antipyretic therapy for febrile patients with sepsisGRADE 2C

CQ6-5: Is stress ulcer prophylaxis performed for patients with sepsis to prevent gastrointestinal hemorrhage?

  • Answer: We suggest performing stress ulcer prophylaxis for patients with sepsis to prevent gastrointestinal bleedingGRADE 2D

CQ7-1: Is early rehabilitation implemented to prevent post-intensive care syndrome (PICS)?

  • Answer: We suggest conducting early rehabilitation to prevent PICSGRADE 2D

CQ 7–2: Is neuromuscular electrical stimulation used to prevent ICU-acquired weakness (ICU-AW)?

  • Answer: We suggest using neuromuscular electrical stimulation to prevent ICU-AWGRADE 2C

CQ7-3: Is follow-up after ICU discharge be implemented to improve physical, cognitive, and mental functions?

  • Answer: We suggest conducting follow-up after ICU discharge to improve physical, cognitive, and mental functionsGRADE 2D

CQ7-4: Is rehabilitation after hospital discharge implemented to improve physical, cognitive, and mental functions?

  • Answer: We suggest performing rehabilitation after hospital discharge to improve physical, cognitive, and mental functionsGRADE 2C

CQ 8–1: Is written information provided to the families of critically ill patients?

  • Answer: We suggest providing information related to intensive care to the families of critically ill patients in written or other formsGRADE 2C

CQ 8–4: Is an ICU diary kept for critically ill patients?

  • Answer: We suggest keeping an ICU diary for critically ill patientsGRADE 2C

CQ 8–5: Is follow-up after ICU discharge provided to families of critically ill patients to improve their mental health?

  • Answer: In facilities with well-established systems, we suggest providing follow-ups, such as face-to-face, phone, and online interviews after ICU discharge, to families of critically ill patients to improve their mental healthGRADE 2C

CQ 9–5: Are steroids administered to pediatric patients with septic shock who are unresponsive to initial fluid therapy and vasopressors?

  • Answer: We suggest against routine administration of steroids for pediatric patients with septic shock who are unresponsive to initial fluid therapy and vasopressorsGRADE 2D

CQ 9–6: What is the optimal hemoglobin level for blood transfusion in pediatric patients with sepsis who have stable hemodynamics?

  • Answer: We suggest transfusing at a hemoglobin level of 7.0 g/dL in hemodynamically stable pediatric patients with sepsisGRADE 2C

CQ 9–7: Is strict blood glucose control performed for pediatric sepsis?

  • Answer: We suggest against strict blood glucose control for pediatric sepsisGRADE 2C

Rationale

  • The Surviving Sepsis Campaign Guidelines 2021 (SSCG 2021) recommended administering antimicrobials immediately, ideally within 1 h of recognition [72]. However, adhering to the time frame of antimicrobial-administration target of within 1 h may lead to an increase in unnecessary and excessive administration of broad-spectrum and multiple antimicrobials [73]. The J-SSCG 2020 [8, 9] suggested that antibacterial drugs are administered as soon as possible upon identification of sepsis or septic shock, but against using the target time of < 1 h (GRADE 2C: certainty of evidence = “low”). Although immediate administration of antimicrobials is recommended, mandating a 1 h timeframe is controversial.

CQ3-11: Is sodium bicarbonate intravenously administered for septic patients with severe metabolic acidosis (pH ≤ 7.2)?

  • Answer: We suggest the intravenous administration of sodium bicarbonate for septic patients with severe metabolic acidosis (pH ≤ 7.2) (GRADE2C).

Rationale

  • Antithrombin has anticoagulant effects, mainly by inhibiting thrombin and activated factor X. Additionally, it has an anti-inflammatory effect that may help control sepsis-induced DIC [367]. Previous meta-analyses have conflicting results regarding its contribution to improving the prognosis of sepsis-induced DIC, and no clear evidence has been established [368, 369]. The J-SSCG2020 suggested the administration of antithrombin (GRADE 2C) [8, 9].

Abstract

The 2024 revised edition of the Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock (J-SSCG 2024) is published by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine. This is the fourth revision since the first edition was published in 2012. The purpose of the guidelines is to assist healthcare providers in making appropriate decisions in the treatment of sepsis and septic shock, leading to improved patient outcomes. We aimed to create guidelines that are easy to understand and use for physicians who recognize sepsis and provide initial management, specialized physicians who take over the treatment, and multidisciplinary healthcare providers, including nurses, physical therapists, clinical engineers, and pharmacists. The J-SSCG 2024 covers the following nine areas: diagnosis of sepsis and source control, antimicrobial therapy, initial resuscitation, blood purification, disseminated intravascular coagulation, adjunctive therapy, post-intensive care syndrome, patient and family care, and pediatrics. In these areas, we extracted 78 important clinical issues. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) method was adopted for making recommendations, and the modified Delphi method was used to determine recommendations by voting from all committee members. As a result, 42 GRADE-based recommendations, 7 good practice statements, and 22 information-to-background questions were created as responses to clinical questions. We also described 12 future research questions.

Supplementary Information: The online version contains supplementary material available at 10.1186/s40560-025-00776-0.

Contents of the original publication

The section headings of the original.

  • Background
  • Basic principles and overview of the guidelines
  • Name
  • Objective
  • Target patients
  • Reflection of patients’ values
  • Revision schedule
  • Methods for creating the guidelines and interpretation of recommendations
  • Important clinical issues
  • Searching, collecting, and integrating evidence through systematic reviews
  • Quick reference list of CQs & answers
  • CQ1 Diagnosis and source control.
  • CQ2 Antimicrobial therapy
  • CQ3 Initial resuscitation
  • CQ4 Blood purification
  • CQ5 Disseminated intravascular coagulation
  • CQ6 Adjuvant therapy
  • CQ7 Post-intensive care syndrome
  • CQ8 Patient and family care
  • CQ9 Pediatrics
  • Quick reference list of FRQs
  • CQ1 Diagnosis and source control
  • CQ1-1: Definition of sepsis
  • CQ1-2: Diagnosis and severity classification of sepsis
  • CQ1-3: What methods are there for early detection of sepsis in general wards and ER?
  • CQ1-4: When and how are blood culture samples collected for patients suspected with sepsis?
  • CQ1-5: When and how are culture specimens other than blood culture samples collected for patients suspected with sepsis?
  • CQ1-6: What are the roles of CRP, PCT, P-SEP, and IL-6 as biomarkers for sepsis diagnosis?
  • CQ1-7: Are imaging tests performed to identify the source of infection in patients suspected of having sepsis?
  • CQ1-8: When is the source of infection controlled in patients with sepsis?
  • CQ1-9: Which facility is appropriate for managing patients with sepsis who are unresponsive to initial fluid resuscitation?
  • FRQ1-1: Do AI-based detection systems for sepsis in the ER and ICU improve prognosis compared to conventional detection systems?
  • FRQ1-2: Is a tele-ICU system useful for managing patients with sepsis?
  • CQ2 Antimicrobial therapy
  • CQ2-1: Is Gram stain testing useful for selecting empiric antimicrobials for sepsis?
  • CQ2-2: Is the administration of empiric antimicrobials for sepsis started within 1 h after diagnosing sepsis?
  • CQ2-3: How are empiric antimicrobials selected for sepsis?
  • CQ2-4: Under what circumstances is carbapenem included in empiric antimicrobials for sepsis?
  • CQ2-5: Under what circumstances are empiric antimicrobials against MRSA or atypical pathogens (such as Candida, viruses, Legionella, Rickettsia, and Clostridioides difficile) selected for sepsis?
  • CQ2-6: What is used as a reference for adjusting the doses of renally-excreted antimicrobials for sepsis?
  • CQ2-7: Is continuous or extended infusion of antimicrobials used for sepsis?
  • CQ2-8: Is antimicrobial dosage adjusted using TDM for sepsis?
  • CQ 2–9: Is de-escalation based on culture and susceptibility results performed in antimicrobial therapy for sepsis?
  • CQ2-10: In patients with sepsis receiving empiric antifungal drugs, are antifungal drugs discontinued using β-D glucan as an indicator?
  • CQ2-11: Is PCT used as an indicator for discontinuing antimicrobial therapy for sepsis?
  • CQ2-12: Is short-term (≤ 7 days) antimicrobial therapy used for sepsis?
  • CQ3 Initial resuscitation
  • CQ3-1: What parameters are used to assess tissue hypoperfusion in initial resuscitation for sepsis?
  • CQ3-2: Are cardiac function and preload evaluated using echocardiography in initial resuscitation for sepsis?
  • CQ3-3: What is the target mean arterial pressure (MAP) during initial resuscitation for sepsis?
  • CQ3-4: Which fluid is used for initial resuscitation of sepsis?
  • CQ3-5: How is initial fluid therapy given for patients with sepsis?
  • CQ3-6: Is early administration of vasopressor performed during initial resuscitation for sepsis?
  • CQ3-7: Which vasopressor is used as the first-line and second-line drugs in patients with septic shock?
  • CQ3-8: Are steroids administered for septic shock?
  • CQ3-9: What is the threshold of hemoglobin level for transfusion in initial resuscitation for septic shock?
  • CQ3-10: Are β1-adrenoceptor antagonists used for septic patients with persistent tachycardia after initial resuscitation?
  • CQ3-11: Is sodium bicarbonate intravenously administered for septic patients with severe metabolic acidosis (pH ≤ 7.2)?
  • CQ3-12: What is the indication for mechanical circulatory support for septic shock?
  • CQ3-13: Is restrictive fluid management provided in septic patients with stable hemodynamics?
  • FRQ3-1: Is hypertonic albumin solutions (20–25%) used as an initial fluid for septic shock?
  • FRQ3-2: Is adrenaline added when patients with septic shock have difficulty in maintaining hemodynamics with concomitant use of noradrenaline and vasopressin?
  • FRQ3-3: Are inotropes used for septic shock patients with decreased cardiac function and tissue hypoperfusion?
  • FRQ3-4: Is the serum albumin level maintained at 3.0 g/dL using hypertonic albumin solutions (20–25%) after initial resuscitation for septic shock?
  • FRQ3-5: What is the threshold of hemoglobin levels for transfusion in patients with sepsis who have stable hemodynamics?
  • CQ4 Blood purification
  • CQ4-1: Is PMX-DHP used for patients with septic shock?
  • CQ4-2: Is early RRT performed for septic AKI?
  • CQ4-3: Is continuous RRT provided for septic AKI?
  • CQ4-4: Is treatment dose increased in RRT for septic AKI?
  • CQ5 Disseminated intravascular coagulation
  • CQ5-1: What is the diagnostic method for sepsis-induced DIC?
  • CQ5-2: What are the differential diagnoses for patients with suspected sepsis-induced DIC?
  • CQ5-3: Is antithrombin administered for sepsis-induced DIC?
  • CQ5-4: Is recombinant thrombomodulin administered for sepsis-induced DIC?
  • FRQ5-1: Are antithrombin and thrombomodulin concomitantly administered for sepsis-induced DIC?
  • FRQ5-2: Is heparin or heparin analogs administered for sepsis-induced DIC?
  • CQ6 Adjuvant therapy
  • CQ6-1: Is IVIG administered for sepsis?
  • CQ6-2: Is high-dose vitamin C therapy used for sepsis?
  • CQ6-3: What is the target blood glucose level for sepsis?
  • CQ6-4: Is antipyretic therapy provided to febrile patients with sepsis?
  • CQ6-5: Is stress ulcer prophylaxis performed for patients with sepsis to prevent gastrointestinal hemorrhage?
  • CQ6-6: How is the body temperature managed in septic patients with hypothermia?
  • CQ6-7: How is tracheal intubation performed for patients with sepsis?
  • FRQ6-1: Is IVIG administered for patients with STSS?
  • CQ7 Post-intensive care syndrome
  • CQ7-1: Is early rehabilitation implemented to prevent PICS?
  • CQ 7–2: Is neuromuscular electrical stimulation used to prevent ICU-AW?
  • CQ7-3: Is follow-up after ICU discharge be implemented to improve physical, cognitive, and mental functions?
  • CQ7-4: Is rehabilitation after hospital discharge implemented to improve physical, cognitive, and mental functions?
  • FRQ7-1: Is the ABCDEFGH bundle implemented to prevent PICS?
  • CQ8 Patient and family care
  • CQ 8–1: Is written information provided to the families of critically ill patients?
  • CQ 8–2: What is the relaxation of visitation restrictions for families of critically ill patients?
  • CQ 8–3: What are the methods for supporting decision-making that respect the value systems and ways of thinking in a patient?
  • CQ 8–4: Is an ICU diary kept for critically ill patients?
  • CQ 8–5: Is follow-up after ICU discharge provided to families of critically ill patients to improve their mental health?
  • CQ9 Pediatrics
  • Emergence of new diagnostic criteria for pediatric sepsis and septic shock: the Phoenix Sepsis Score
  • CQ 9–1: How are empiric antimicrobials selected for pediatric septic shock?
  • CQ 9–2: How is initial fluid therapy administered for pediatric sepsis?
  • CQ 9–3: How are vasopressors selected for pediatric patients with septic shock?
  • CQ 9–4: What is the route of administering vasopressors for pediatric sepsis?
  • CQ 9–5: Are steroids administered to pediatric patients with septic shock who are unresponsive to initial fluid therapy and vasopressors?
  • CQ 9–6: What is the optimal hemoglobin level for blood transfusion in pediatric patients with sepsis who have stable hemodynamics?
  • CQ 9–7: Is strict blood glucose control performed for pediatric sepsis?
  • CQ 9–8: What are treatment and support policies centered on critically ill pediatric patients?
  • FRQ9-1: Is IVIG administered for pediatric sepsis?

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