Should we abandon corticosteroids during septic shock? No

Abstract

With the publication of the results of the recent CORTICUS trial, stress ('low') doses of corticosteroids for the treatment of vasopressor-dependent septic shock in adults can still be considered controversial. The purpose of this narrative review is to elaborate the pros and cons of this treatment in clinical practice and to formulate clinical and research directions. The recent CORTICUS study only shows a beneficial effect of stress doses of corticosteroids in the time interval to shock reversal and not on mortality, potentially explained by an increased risk for superinfection. The mortality in the placebo arm was relatively low and lower than in earlier randomized studies in which stress doses of corticosteroids had a favorable hemodynamic effect and conferred a survival benefit in septic shock. Treatment by stress doses of corticosteroids should not be abandoned during septic shock. Additional studies are needed, however, to better delineate the patient group with the highest likelihood to benefit from this therapy, as a function of severity of illness, response to adrenocorticotrophic hormone testing or both. For now, results of the CORTICUS study should not change current clinical practice of administering 200-300 mg of hydrocortisone daily (in divided doses) in case of fluid and vasopressor-insensitive septic shock and rapid tapering of this treatment on the basis of a hemodynamic response.