When do you initiate corticosteroids (steroids) in sepsis?

When to Initiate Corticosteroids in Sepsis

Consider initiating low-dose corticosteroids (hydrocortisone 200 mg/day) in patients with septic shock who require vasopressors despite adequate fluid resuscitation, particularly those with high SOFA scores and evidence of multiorgan dysfunction. 1

Primary Indication: Septic Shock with Vasopressor Dependence

The key trigger for corticosteroid initiation is septic shock requiring vasopressors to maintain adequate perfusion pressure despite fluid resuscitation. 2, 1 This represents the population with the strongest evidence for potential mortality benefit, though the recommendation remains weak due to modest effect size (approximately 2% absolute mortality reduction). 2

Specific Clinical Criteria:

• Infection with SOFA score ≥2 (defining sepsis) 2
• Vasopressor requirement to maintain mean arterial pressure despite adequate fluid repletion 2, 1
• Elevated serum lactate despite fluid resuscitation 2

Patient Selection: Who Benefits Most

Patients at highest risk of death derive the greatest absolute mortality benefit from corticosteroids. 2 This includes:

• Escalating vasopressor requirements (not just stable low-dose pressors) 1, 3
• High SOFA scores indicating severe multiorgan dysfunction 2, 1
• Refractory shock despite standard resuscitation 2, 1
• Primary lung infections as the sepsis source 3

When NOT to Initiate Corticosteroids

Do not routinely use corticosteroids in sepsis without shock, as there is no evidence of benefit and potential for harm. 1 Patients with infection and organ dysfunction (SOFA ≥2) who maintain adequate blood pressure without vasopressors should not receive corticosteroids for sepsis treatment.

Practical Implementation

Dosing Strategy:

Use hydrocortisone 200-300 mg/day for 5-7 days (long course, low-dose strategy). 1, 4, 5 This regimen showed mortality benefit, whereas short-term high-dose therapy (up to 42g for 1-2 days) was ineffective or harmful. 4

Timing:

Initiate corticosteroids immediately after recognizing vasopressor-dependent septic shock. 5 Do not delay for corticotropin testing, as the benefit appears consistent regardless of adrenal insufficiency status. 2

Route of Administration:

Administer intravenously during the acute phase. 5 There is no clear advantage to continuous infusion over intermittent boluses for reducing hyperglycemia. 3

Evidence Quality and Clinical Nuance

The recommendation is weak because the mortality benefit is modest (2% absolute reduction), the confidence interval crosses the line of no difference, and trial results show inconsistency. 2 Both using and not using corticosteroids are reasonable management options. 2

The decision should incorporate patient values: 2, 1

• Patients prioritizing mortality reduction over quality of life concerns would likely choose corticosteroids
• Patients prioritizing functional independence and quality of life may reasonably decline, given the risk of neuromuscular weakness

Expected Benefits Beyond Mortality

Corticosteroids consistently accelerate shock reversal (increased proportion by day 7: RR 1.31) 6 and may reduce:

• ICU length of stay by approximately 2 days 2, 6
• Hospital length of stay 6
• SOFA score by day 7 (mean difference -1.53) 6
• Duration of mechanical ventilation 3

Important Adverse Effects to Monitor

Corticosteroids increase the risk of: 2, 6

• Hyperglycemia (RR 1.26) - monitor glucose closely and treat aggressively
• Hypernatremia (RR 1.64) - monitor electrolytes
• Potential neuromuscular weakness - though evidence is low quality and may be underestimated 2

Corticosteroids do NOT increase: 6

• Gastrointestinal bleeding (RR 1.24, not significant)
• Superinfection rates (RR 1.02)

Common Pitfalls to Avoid

• Do not use high-dose, short-course regimens (these are ineffective or harmful) 4
• Do not delay initiation waiting for corticotropin stimulation test results 5
• Do not routinely taper - there is no advantage to tapering for preventing rebound hypotension 3
• Do not withhold in patients without documented adrenal insufficiency - the benefit appears independent of baseline cortisol response 2