What is the role of corticosteroids (steroids) in the treatment of neonatal sepsis?

From the Guidelines

Corticosteroids are not routinely recommended for neonatal sepsis management, and their use should be reserved for specific situations like adrenal insufficiency or refractory shock, as suggested by the most recent guidelines 1. The primary management of neonatal sepsis remains early empiric antibiotics, fluid resuscitation, and supportive care.

• The use of hydrocortisone may be considered in cases of refractory shock, but only after standard treatments have failed, and with careful consideration of risks versus benefits in consultation with neonatal specialists.
• The theoretical benefit of steroids in sepsis relates to their anti-inflammatory properties and potential to improve hemodynamic stability by enhancing vascular responsiveness to catecholamines.
• However, evidence for routine steroid use in neonatal sepsis is limited, and concerns exist regarding adverse effects including hyperglycemia, hypertension, gastrointestinal perforation, and potential negative impacts on neurodevelopment and growth, as noted in previous guidelines 1.
• The most recent guidelines suggest against using intravenous hydrocortisone to treat children with septic shock if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability, with a weak recommendation and low quality of evidence 1.
• In cases where steroids are considered necessary, hydrocortisone may be administered at doses of 1-2 mg/kg/dose every 6-8 hours for 2-3 days with gradual tapering, as previously suggested 1.

From the Research

Steroids in Neonatal Sepsis

• The use of corticosteroids in neonatal sepsis has been studied in various research papers 2, 3, 4.
• A retrospective study of 62 premature neonates with septic shock found that hydrocortisone (HC) improved hemodynamic response, but had similar survival rates from the septic episode compared to those who only received inotropes 2.
• However, patients who received HC during their sepsis were less likely to survive at their 1-year postmenstrual age follow-up when accounted for gestational age at birth and duration of inotropes 2.
• Another study highlighted the need for definitions for the sepsis continuum and treatment algorithms specific for premature neonates to improve studies of septic shock and assess benefit from clinical interventions 3.
• A systematic review and meta-analysis of corticosteroids in sepsis and septic shock found that corticosteroids probably reduce short-term mortality and increase shock reversal, but may also increase the risk of hyperglycemia, hypernatremia, and neuromuscular weakness 4.
• The optimal dosing of corticosteroids was found to be approximately 260 mg/d of hydrocortisone or equivalent, which reduces mortality 4.

Pathophysiology and Treatment

• Neonatal septic shock is a devastating condition associated with high morbidity and mortality, and requires a high index of suspicion for diagnosis 3, 5.
• The pathophysiology of septic shock in neonates involves a complex interplay of immune system dysfunction and organ failure 3.
• Treatment of neonatal sepsis typically involves antimicrobial therapy and supportive care, with immunomodulatory agents potentially improving outcomes in the future 3, 5.
• The management of neonatal hypotension and shock requires an individualized approach, taking into account the dynamic physiologic transition from fetal to neonatal life and underlying conditions 6.