A meta-analysis showed that treatment shortened duration of shock but did not affect mortality or length of stay.

Should patients with sepsis receive glucocorticoids? Debate continues because two recent, large randomised trials have yielded conflicting results (NEJM JW Gen Med Apr 15 2018 and N Engl J Med 2018; 378: 809-818; NEJM JW Gen Med Mar 1 2018 and N Engl J Med 2018; 378: 797-808). Most studies have shown more rapid reversal of shock with glucocorticoid administration, but questions remain about whether treatment lowers short-term mortality in specific populations.

Investigators conducted a patient-level meta-analysis of 17 trials that involved more than 7800 patients with sepsis or septic shock who were treated with as much as 400 mg of hydrocortisone daily for at least 72 hours. Patients treated with hydrocortisone or placebo had similar 90-day mortality. Patients treated with hydrocortisone plus fludrocortisone had a significant, but small, lowering of 90-day mortality; however, this finding was based on the results of only two studies. Patients who received hydrocortisone averaged 1.24 more days alive and off vasopressors; no difference was noted in days free of mechanical ventilation or organ failure. Hospital and intensive care unit days were similar among groups. Subgroup analyses, including pattern of administration of hydrocortisone, site of infection, pathogen or type of admission (i.e. medical vs surgical) revealed no differences among treatments.

Comment: Unfortunately, this meta-analysis did not help identify patients with sepsis and specific characteristics who might be better candidates for hydrocortisone. Using hydrocortisone to shorten duration of shock (but without clear mortality benefit) might be reasonable, but I would still reserve that for patients who require multiple vasopressors.

Patricia Kritek, MD, EdM, Professor of Medicine, Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, USA.

Pirracchio R, et al. Patient-level meta-analysis of low-dose hydrocortisone in adults with septic shock. NEJM Evid 2023 Jun; 2: EVIDoa2300034.

This summary is taken from the following Journal Watch titles: General Medicine, Infectious Diseases, Emergency Medicine, Hospital Medicine.