BMJ  2004;329:480 (28 August), doi:10.1136/bmj.38181.482222.55 (published 2 August 2004)

Paper

Corticosteroids for severe sepsis and septic shock: a systematic review and meta-analysis

¹ Critical Care Department, Université de Versailles Saint-Quentin en Yvelines, Assistance Publique-Hôpitaux de Paris, Hôpital Raymond Poincaré, Garches 92380, France, ² Clinical Investigation Centre, INSERM 0203, Université de Rennes 1, Centre Hospitalier Universitaire, Hôpital de Pontchaillou, Rennes 35033, France, ³ Critical Care Department, Université de Nancy 1, Centre Hospitalier Universitaire, Hôpital Central, Nancy 54000, France, ⁴ Institut für Anaesthesiology, Klinikum der Universität München, Munich, 81366, Germany, ⁵ Intensive Care Unit, Charité-Campus Virchow Clinic, Berlin, 13353, Germany, ⁶ Division of Pulmonary and Critical Care Medicine, Maimonides Medical Centre, Brooklyn, New York, NY 11219, USA

Objective To assess the effects of corticosteroids on mortality in patients with severe sepsis and septic shock.

Data sources Randomised and quasi-randomised trials of corticosteroids versus placebo (or supportive treatment alone) retrieved from the Cochrane infectious diseases group's trials register, the Cochrane central register of controlled trials, Medline, Embase, and LILACS.

Review method Two pairs of reviewers agreed on eligibility of trials. One reviewer entered data on to the computer and four reviewers checked them. We obtained some missing data from authors of trials and assessed methodological quality of trials.

Results 16/23 trials (n = 2063) were selected. Corticosteroids did not change 28 day mortality (15 trials, n = 2022; relative risk 0.92, 95% confidence interval 0.75 to 1.14) or hospital mortality (13 trials, n = 1418; 0.89, 0.71 to 1.11). There was significant heterogeneity. Subgroup analysis on long courses ( 5 days) with low dose ( 300 mg hydrocortisone or equivalent) corticosteroids showed no more heterogeneity. The relative risk for mortality was 0.80 at 28 days (five trials, n = 465; 0.67 to 0.95) and 0.83 at hospital discharge (five trials, n = 465, 0.71 to 0.97). Use of corticosteroids reduced mortality in intensive care units (four trials, n = 425, 0.83, 0.70 to 0.97), increased shock reversal at 7 days (four trials, n = 425; 1.60, 1.27 to 2.03) and 28 days (four trials, n = 425, 1.26, 1.04 to 1.52) without inducing side effects.

Conclusions For all trials, regardless of duration of treatment and dose, use of corticosteroids did not significantly affect mortality. With long courses of low doses of corticosteroids, however, mortality at 28 days and hospital morality was reduced.

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Rapid Responses:

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Is it appropriate to withhold beneficial therapy in critical illness?

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bmj.com, 23 Aug 2004 [Full text]

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Corticosteroids for sepsis and septic shock - Credible evidence………..or not?

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Re: Corticosteroids for sepsis and septic shock - Credible evidence………..or not?

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