Vitamin C, Hydrocortisone, and Thiamine for the Treatment of Severe Sepsis and Septic Shock: A Retrospective Analysis of Real-World Application.

Jane Litwak,Nam Cho,Kayvan Moussavi,Thomas Bushell,H Nguyen

doi:10.3390/jcm8040478

Abstract

A recent study suggested mortality benefits using vitamin C, hydrocortisone, and thiamine combination therapy (triple therapy) in addition to standard care in patients with severe sepsis and septic shock. In order to further evaluate the effects of triple therapy in real-world clinical practice, we conducted a retrospective observational cohort study at an academic tertiary care hospital. A total of 94 patients (47 in triple therapy group and 47 in standard care group) were included in the analysis. Baseline characteristics in both groups were well-matched. No significant difference in the primary outcome, hospital mortality, was seen between triple therapy and standard care groups (40.4% vs. 40.4%; p = 1.000). In addition, there were no significant differences in secondary outcomes, including intensive care unit (ICU) mortality, requirement for renal replacement therapy for acute kidney injury, ICU length of stay, hospital length of stay, and time to vasopressor independence. When compared to standard care, triple therapy did not improve hospital or ICU mortality in patients with septic shock. A randomized controlled trial evaluating the effects of triple therapy is necessary prior to implementing vitamin C, hydrocortisone, and thiamine combination therapy as a standard of care in patients with septic shock.

Highlights

Sepsis is a serious disease state affecting 15–19 million people globally every year [1]
The authors concluded that the early use of IV vitamin C, corticosteroids, and thiamine is effective in preventing progressive organ dysfunction, including acute kidney injury (AKI), and in reducing mortality in patients with severe sepsis and septic shock [6]
Twenty-seven patients (57.4%) did not complete triple therapy (TT) treatment for a full four days or until intensive care unit (ICU) discharge due to following reasons: therapy discontinuation by primary team (n = 9 (33.3%)), patient death (n = 9 (33.3%)), missed doses due to medication delivery issues, line access issues, operations (n = 5 (18.5%)), insufficient number of doses ordered (n = 3 (11.1%)), and thiamine shortage (n = 1 (3.7%))

Summary

Introduction

Sepsis is a serious disease state affecting 15–19 million people globally every year [1]. A recent retrospective before-and-after study exploring the use of triple therapy (TT) with 1.5 g intravenous (IV) vitamin C every six hours (for four days or until intensive care unit (ICU) discharge), 50 mg IV hydrocortisone every six hours (for seven days or until ICU discharge), and 200 mg IV thiamine every 12 h (for four days or until ICU discharge) in severe sepsis and septic shock patients demonstrated mortality benefits [6]. The authors concluded that the early use of IV vitamin C, corticosteroids, and thiamine is effective in preventing progressive organ dysfunction, including acute kidney injury (AKI), and in reducing mortality in patients with severe sepsis and septic shock [6]. A recent review article by Moskowitz et al further discusses the physiological rationale and existing data supporting the use of TT in sepsis [7]

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Discussion

Conclusion