What is the current advice for corticosteroid use in urosepsis (urinary tract infection with sepsis)?

From the Guidelines

The current advice for corticosteroid use in urosepsis is to administer hydrocortisone at a dose of less than 400 mg/day for at least 3 days in patients with septic shock who are not responding to adequate fluid resuscitation and vasopressor therapy. This recommendation is based on the latest guidelines from the Society of Critical Care Medicine (SCCM) and European Society of Intensive Care Medicine (ESICM) [ 1 ]. The use of corticosteroids in septic shock is supported by evidence from a Cochrane systematic review, which showed that corticosteroids significantly reduced the risk of death at 28 days compared with placebo [ 1 ]. Specifically, hydrocortisone should be given as a continuous intravenous infusion, and treatment should be tapered and discontinued once vasopressors are no longer needed [ 1 ]. It's essential to note that steroids are not recommended for all cases of urosepsis, only for those progressing to septic shock with refractory hypotension [ 1 ]. Before starting steroids, ensure that appropriate antibiotics have been administered and that adequate fluid resuscitation has been performed. The rationale for steroid use in septic shock is based on the concept of relative adrenal insufficiency, where exogenous steroids can help stabilize blood pressure, reduce inflammation, and potentially improve survival [ 1 ]. However, steroids should be used judiciously due to potential side effects, including hyperglycemia, increased risk of secondary infections, and impaired wound healing [ 1 ]. Close monitoring of blood glucose levels and overall clinical status is essential during steroid therapy. Some key points to consider when using corticosteroids in urosepsis include:

• Using the lowest effective dose and shortest duration of treatment necessary to achieve the desired clinical effect
• Monitoring patients closely for signs of adrenal insufficiency and adjusting the corticosteroid dose accordingly
• Being aware of the potential for corticosteroids to increase the risk of secondary infections and taking steps to minimize this risk
• Considering the use of corticosteroids in patients with septic shock who are not responding to adequate fluid resuscitation and vasopressor therapy, as supported by the evidence [ 1 ].

From the Research

Current Advice for Corticosteroid Use in Urosepsis

The use of corticosteroids in urosepsis, a condition characterized by a urinary tract infection accompanied by sepsis, is a topic of ongoing debate.

• The Surviving Sepsis Campaign advises consideration of corticosteroids in patients with vasopressor and fluid-resistant septic shock 2.
• Physiologic-dose corticosteroids may decrease the need for vasopressors, although the mortality benefit is controversial 2, 3.
• Hydrocortisone is recommended at a dose of 100 mg intravenously every 8 hours or 50 mg intravenously every 6 hours for patients with vasopressor-resistant septic shock and no contraindications to corticosteroids 2.
• The optimal timing of corticosteroid initiation in septic shock patients is debatable, with some studies suggesting early initiation (within 3 hours) may reduce the time needed to discontinue vasopressors 4.
• Low-dose hydrocortisone therapy should be considered in vasopressor-dependent septic shock, with a recommended dose of 200-300 mg per day 3, 5.

Corticosteroid Regimens

Different corticosteroid regimens have been studied, including:

• Hydrocortisone at a dose of 200-300 mg per day for 5-7 days or longer in septic shock 3.
• Hydrocortisone at a dose of 100 mg intravenously every 8 hours or 50 mg intravenously every 6 hours for patients with vasopressor-resistant septic shock 2.
• Fludrocortisone is not recommended at this time, although its role is uncertain 2, 3.

Patient Selection and Treatment Duration

The selection of patients for corticosteroid therapy and the duration of treatment are crucial considerations.

• Patients with relative adrenal insufficiency (RAI) may benefit from low-dose hydrocortisone, although the diagnosis of RAI is highly dependent on cut-off values and definition of RAI 3.
• Treatment should be continued at full doses for 7 days when adrenal insufficiency is confirmed, otherwise, hydrocortisone should be stopped 5.
• The efficacy and safety of corticosteroid therapy in severe sepsis need to be assessed in a large-scale study 5.