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Effect of hydrocortisone therapy on outcome and the incidence of infection in patients with septic shock

Introduction

In the CORTICUS study, despite the fact that the median time to shock reversal was shorter in the hydrocortisone (HC) group, improvement of outcome was not demonstrated. This is explained as an increased incidence of superinfection, including new episodes of sepsis or septic shock, but the explanation seems to be unclear so there are still debates about the study. We examined the outcome of HC therapy and the effect on later infectious complications, especially fungal infection.

Methods

A retrospective cohort study. Ninety-six adult patients >18 years old with septic shock treated at single university general ICU. Initially, fluid therapy, inotropic support, transfusion and management of infection were carried out according to the guideline of survival sepsis campaign, and we assessed the adrenal function by adrenocorticotropic hormone stimulation test (250 μg). In the earlier period (April 2004 to March 2007), 200 mg HC was administered to the nonresponders. Later (April 2007 onwards), HC was given only to patients that were poorly responsive to fluid resuscitation and vasopressor therapy. We assessed the 28-day and 90-day survival rate, hospital discharge rate, the incidence of new septic shock, the positive rate of endotoxin and β-D-glucan.

Results

Out of 96 patients, 38 patients were determined as responders and 58 as nonresponders. The Sequential Organ Failure Assessment score was higher in nonresponders (11 ± 3.3 vs. 13.6 ± 3.7, P = 0.0014). For the 58 nonresponders, HC was used for 40 patients (HC group). The 28-day survival rate was higher in HC (61% vs. non-HC 44%, P = 0.49), but the 90-day survival rate decreased to 33% in HC and 28% in non-HC (P = 0.47), and the discharge rate reversed as 25% in HC versus 28% in non-HC (P = 0.84). The incidence of new septic shock was 20% in HC, 11% in non-HC. The positive rate of endotoxin did not increase before and after treatment in both groups. The mean concentration of β-D-glucan did not increase in non-HC (59 ± 99 to 48 ± 44 pg/ml), but it significantly increased in HC (50 ± 70 to 69 ± 186 pg/ml) (P = 0.049).

Conclusion

The 28-day survival rate was higher in the HC group than the non-HC group as reported in the French study, but no beneficial effect was seen in longer outcome, consistent with the CORTICUS study. Moreover, HC therapy may have a risk to increase fungal infection.

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Hayami, H., Yamaguchi, O., Yamada, H. et al. Effect of hydrocortisone therapy on outcome and the incidence of infection in patients with septic shock. Crit Care 13, P325 (2009). https://doi.org/10.1186/cc7489

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Keywords

  • Hydrocortisone
  • Septic Shock
  • Fungal Infection
  • Sequential Organ Failure Assessment
  • Sequential Organ Failure Assessment Score