What is the recommended steroid regimen for immunocompromised patients with septic shock?

Steroid Regimen for Immunocompromised Patients with Septic Shock

For immunocompromised patients with septic shock, intravenous hydrocortisone at doses <400 mg/day for ≥3 days is recommended when shock is not responsive to fluid resuscitation and moderate to high-dose vasopressor therapy. 1, 2

Dosing Recommendations

• Use low-dose IV hydrocortisone at <400 mg/day (typically 200 mg/day) for at least 3 days at full dose for septic shock not responsive to fluid resuscitation and moderate to high-dose vasopressors (>0.1 μg/kg/min of norepinephrine or equivalent) 1
• Long course and low dose is preferred over high dose and short course regimens 1
• Hydrocortisone can be administered either as divided doses or as a continuous infusion 2
• Continuous infusion is preferred over repetitive bolus injections to avoid significant increases in blood glucose levels 1

Duration and Discontinuation

• Continue treatment for at least 3 days at full dose or longer in patients with septic shock 1, 2
• Taper steroids when vasopressors are no longer required rather than stopping abruptly 1, 2
• Tapering over several days is recommended to avoid hemodynamic and immunologic rebound effects 1
• Abrupt discontinuation can lead to deterioration from a reconstituted inflammatory response 2

Special Considerations for Immunocompromised Patients

• Despite the general recommendation for steroids in septic shock, a cohort study specifically in immunocompromised patients found that corticosteroids were not associated with improved 30-day mortality 3
• In the subgroup of immunocompromised patients with metastatic cancer, corticosteroids were associated with increased 30-day mortality risk 3
• Immunocompromised patients may be at higher risk for adverse effects including secondary infections 3
• Infection surveillance is particularly important in immunocompromised patients receiving corticosteroids 2

Monitoring and Adverse Effects

• Monitor for hyperglycemia and hypernatremia, which are common side effects of corticosteroid therapy 1
• Watch for secondary infections, as immunocompromised patients are already at increased risk 2, 3
• Be aware that corticosteroids may prolong ICU and hospital duration in immunocompromised patients 3
• Regular blood pressure determinations and serum electrolyte monitoring are recommended 2

Common Pitfalls to Avoid

• Do not use the ACTH stimulation test to identify patients with septic shock who should receive hydrocortisone 1, 2
• Do not administer corticosteroids for sepsis in the absence of shock 1
• Do not use high-dose corticosteroids as these have not shown benefit and may be detrimental 4, 5
• Be cautious with corticosteroid use in immunocompromised patients with metastatic cancer due to potential increased mortality 3

Clinical Decision Algorithm

1. Confirm septic shock diagnosis in immunocompromised patient 1
2. Ensure adequate fluid resuscitation has been performed 1
3. If patient remains on moderate to high-dose vasopressors (>0.1 μg/kg/min norepinephrine or equivalent) despite fluid resuscitation 1
4. Initiate IV hydrocortisone at 200 mg/day as continuous infusion or in divided doses 1, 2
5. Continue for at least 3 days at full dose 1
6. Monitor for hyperglycemia, hypernatremia, and secondary infections 1, 2
7. When vasopressors are no longer required, taper steroids gradually over several days 1, 2
8. Exercise particular caution in immunocompromised patients with metastatic cancer 3