Management of abdominal sepsis: Principles, pitfalls, and perspectives

Sepsis of abdominal origin remains one of the most complex and time-sensitive conditions in acute care surgery. Despite significant advances in diagnostics and therapeutics, outcomes continue to depend critically on early recognition and rapid intervention, as delays may result in progression to multi-organ dysfunction and death. The Surviving Sepsis Campaign has revolutionized the global management of sepsis by providing evidence-based recommendations that have standardized early recognition, resuscitation, antimicrobial therapy, and hemodynamic support, thereby contributing to improved patient outcomes worldwide. Nevertheless, although its recommendations represent the cornerstone of modern sepsis care, they do not fully address the unique surgical challenges posed by intra-abdominal infections, particularly the central role of source control and procedure-specific decision-making. This highlights the need for a more tailored and integrated approach. Effective management relies on multiple interconnected and interdependent pillars, including hemodynamic stabilization, timely and appropriate antimicrobial therapy, early and effective source control, and continuous infection prevention and control (IPC). Rapid restoration of tissue perfusion through individualized fluid resuscitation and early vasopressor support is essential, while the prompt initiation of empiric antibiotic therapy remains a key determinant of survival, particularly in septic shock. In this context, emergency surgeons play a central role, not only in achieving definitive source control but also in early diagnosis and strategic decision-making. Close collaboration with intensivists is essential to optimize resuscitation, provide organ support, and ensure continuous reassessment of the patient’s physiological status. This integrated approach is crucial to avoid delays and fragmentation of care. Importantly, IPC should be integrated into patient management from admission and maintained throughout the clinical course to reduce the risk of secondary healthcare-associated infections and additional and potentially unnecessary antimicrobial exposure. Ultimately, abdominal sepsis requires a coordinated, multidisciplinary strategy in which surgical and critical care expertise converge. In this setting, time, teamwork, and clinical judgment remain the most decisive factors influencing patient outcomes. This narrative review aims to provide an integrated overview of the management of abdominal sepsis, focusing on early recognition, prompt hemodynamic stabilization, appropriate antimicrobial therapy, timely source control, and IPC. Particular emphasis is placed on close collaboration between emergency surgeons and intensivists to ensure coordinated, dynamic, and increasingly personalized patient care.