Hydrocortisone plus fludrocortisone for adults with septic shock


Background: Septic shock is a serious and common health problem, associated with a more than 50% mortality rate. It is characterized by a dysregulated patient response to infection, resulting in life-threatening circulatory, cellular, and metabolic abnormalities. The benefit of corticosteroid use in septic shock is still controversial.

Study design: Double-blinded, randomized, placebo-controlled trial.

Setting: The study was conducted in 34 centers in France.

Synopsis: All 1,241 septic shock patients received usual care. Of these patients, 614 patients received hydrocortisone and fludrocortisone (HF), while 627 patients received placebo. HF patients had a lower rate of 90-day mortality (43.0% vs. 49.1%; P = .03), mortality at ICU discharge (35.4% vs. 41.0%; P = .04), mortality at hospital discharge (39.0% vs. 45.3%; P = .02), and mortality at day 180 (46.6% vs. 52.5%; P = .04). There was no significant difference between mortality at day 28 (33.7% in the HF group versus 38.9% in the placebo group; P = .06), ventilator-free days (11 vs. 10 days; P = .07), and rate of serious adverse events (53.1% vs. 58.0%; P = .08). The number of vasopressor-free days to day 28 was significantly higher in the HF group (17 vs. 15 days; P less than .001), as were the number of organ failure–free days (14 vs. 12 days; P = .003). There was more hyperglycemia in the HF group (89.1% vs. 83.1%; P = .002).

Bottom line: Patients with septic shock who received hydrocortisone plus fludrocortisone have a lower rate of 90-day all-cause mortality, compared with placebo.

Citation: Annane D et al. Hydrocortisone plus fludrocortisone for adults with septic shock. N Engl J Med. 2018 Mar 1. 378(9):809-18.

Dr. Salih is a hospitalist and instructor in the division of hospital medicine at the University of Kentucky, Lexington.

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