Evolution of the surviving sepsis campaign guidelines: A systematic narrative review with focus on resuscitation, antimicrobials, and implementation

This systematic narrative review analyses the evolution of the Surviving Sepsis Campaign guidelines from inception in 2002 to the 2021 update. Following preferred reporting items for systematic reviews and meta-analyses (PRISMA) methodology, we conducted a comprehensive search of PubMed/MEDLINE, Embase, Cochrane Library, and Web of Science databases to identify official guideline documents and key studies influencing guideline development. Twenty-one pivotal references were selected for detailed analysis. This review was conducted according to PRISMA methodology but was not prospectively registered in PROSPERO, which may limit systematic reproducibility; however, we have provided complete search strategies and methodology for transparency. The review documents substantial changes in three key domains: (1) Fluid resuscitation strategies, shifting from protocol-driven approaches to individualized therapy with preference for balanced crystalloids; (2) antimicrobial timing and stewardship, evolving from universal rapid administration to risk-stratified approaches with increased emphasis on de-escalation; and (3) implementation strategies, progressing from rigid bundles to context-adapted protocols. Recent guidelines increasingly acknowledge the heterogeneity of sepsis, emphasizing personalized management based on patient characteristics and response patterns. Critical knowledge gaps identified include optimal fluid resuscitation parameters, validation of biomarker-guided therapy, and implementation strategies for resource-limited settings. This review provides clinicians with a comprehensive understanding of guideline evolution, highlights the evidence supporting major recommendations, and identifies priorities for future research to continue improving sepsis outcomes worldwide.