Steroid Use in Sepsis: Recommended Regimen
In patients with septic shock requiring vasopressors, use low-dose intravenous hydrocortisone 200 mg per day (administered as 50 mg every 6 hours or continuous infusion) for 5-7 days; do not use corticosteroids in sepsis without shock. 1, 2
Patient Selection
Initiate corticosteroids only in patients with septic shock that remains unresponsive to adequate fluid resuscitation and moderate-to-high dose vasopressor therapy (≥0.1 μg/kg/min norepinephrine or equivalent). 1, 2
- Patients with SOFA score ≥2 and requiring vasopressors derive the greatest mortality benefit 2
- Do not use corticosteroids in sepsis without shock, as there is no mortality benefit and potential for harm from secondary infections 1
- The exception is patients already on corticosteroids for other conditions (e.g., graft-versus-host disease), where steroids should be continued 1
Dosing Regimen
Use low-dose, long-course hydrocortisone rather than high-dose, short-course therapy: 1
- Hydrocortisone <400 mg/day (typically 200 mg/day) for ≥3 days at full dose 1
- Administration options: 50 mg IV every 6 hours OR continuous infusion 1, 3
- Continuous infusion is preferred over repetitive boluses to avoid hyperglycemia peaks 1
- Consider adding fludrocortisone 50 μg daily enterally, though evidence is mixed 1, 3
Duration and Tapering
Continue treatment for 5-7 days, then taper when vasopressors are no longer required: 1, 3
- Full-dose therapy should be maintained for at least 3 days 1
- Taper gradually over several days rather than abrupt cessation to avoid hemodynamic rebound 1
- No clear evidence exists for optimal tapering schedule, but clinical practice supports gradual reduction 1
Critical Pitfalls to Avoid
Never use high-dose corticosteroids (>400 mg/day hydrocortisone equivalent), as this increases mortality and secondary infections: 1
- Meta-analyses consistently show harm with high-dose steroids in sepsis 1
- Avoid etomidate for intubation in septic shock patients, as it suppresses the hypothalamic-pituitary-adrenal axis and may worsen outcomes 1
Expected Benefits and Monitoring
Corticosteroids may reduce 28-day mortality by approximately 2% and accelerate shock reversal, though the mortality benefit has low certainty: 1, 2
- More consistent benefit in shock reversal and reduced vasopressor duration 1, 4
- Monitor for hyperglycemia and hypernatremia as common side effects 1
- Maintain blood glucose <150 mg/dL during treatment 3
- No increased risk of superinfection with low-dose regimens 1, 4
Evidence Quality and Shared Decision-Making
The recommendation is conditional (weak) based on moderate-quality evidence, meaning both using and not using steroids are reasonable options 1, 2. Patients who prioritize avoiding death over quality of life concerns would likely choose corticosteroids, while those valuing functional status and quality of life may reasonably decline 1, 2. The greatest benefit occurs in patients with refractory shock and high SOFA scores 2.
Special Populations
Do not use corticosteroids in neutropenic patients with sepsis, as evidence suggests potential harm from secondary infections in this population 1. The CORTICUS trial showed higher secondary infection rates without mortality benefit 1.