Last reviewed: April 2018
Last updated: January  2018

Corticosteroids do not reduce mortality in patients with septic shock

For many years corticosteroids have been recommended as an adjunctive treatment in patients with septic shock who are refractory to fluids and vasopressor agents. Now a large randomised controlled trial, published in January 2018, has cast doubt on the benefits of this approach. In the trial of 3,658 patients with septic shock, there was no significant difference in 28-day or 90-day mortality between those who received a continuous infusion of hydrocortisone (200 mg per day for 7 days) compared with those who received placebo (90-day mortality of 27.9% in the hydrocortisone group vs 28.8% for placebo). Those who received hydrocortisone did experience faster resolution of shock (median 3 vs 4 days) and were less likely to need a blood transfusion (37.0% vs 41.7%) but there were no significant differences in length of ICU stay or need for renal replacement therapy.

See Management: approach See Management: treatment algorithm

Original source of update

Benefits of procalcitonin guided antibiotic therapy in sepsis

Where available, measurement of serum procalcitonin should be considered in all patients with sepsis to guide antibiotic therapy. Among patients with acute respiratory infections (including those resulting in sepsis), procalcitonin guided therapy was associated with a 2 day reduction in the antibiotic course, a 27% reduction in antibiotic related side-effects, and a 10% reduction in 30 day mortality rate.

See Diagnosis: investigations

Original source of update



History and exam

Key diagnostic factors

  • presence of risk factors
  • high (>38°C) or low (<36°C) temperature
  • tachycardia
  • tachypnoea
  • acutely altered mental status
  • poor capillary refill, mottling of the skin, or ashen appearance
  • signs associated with specific source of infection
  • low oxygen saturation
  • arterial hypotension
  • decreased urine output
  • cyanosis

Other diagnostic factors

  • purpura fulminans
  • jaundice
  • ileus

Risk factors

  • underlying malignancy
  • age >65 years
  • immunocompromise
  • haemodialysis
  • alcoholism
  • diabetes mellitus
  • recent surgery or other invasive procedures
  • breached skin integrity
  • indwelling lines or catheters
  • intravenous drug misuse
  • pregnancy
  • urban residence
  • lung disease
  • male sex
  • non-white ancestry
  • winter season

Diagnostic investigations

1st investigations to order

  • FBC with differential
  • blood urea and serum electrolytes
  • serum creatinine
  • LFT
  • coagulation studies (INR, aPTT)
  • serum glucose
  • lactate levels
  • CRP
  • blood culture
  • other cultures (e.g., of sputum, stool, urine, wounds, catheters, prosthetic implants, epidural sites, pleural or peritoneal fluid)
  • arterial blood gas (ABG) or venous blood gas (VBG)
  • chest x-ray
  • ECG
Full details

Investigations to consider

  • lumbar puncture
  • echocardiogram (transthoracic or transoesophageal)
  • ultrasound scan
  • CT chest or abdomen
  • serum procalcitonin
Full details

Emerging tests

  • PhenoTest™ BC Kit
Full details

Treatment algorithm


Authors VIEW ALL

Chief Executive

United Kingdom Sepsis Trust

Chief Executive

Global Sepsis Alliance

Programme Director

Survive Sepsis

Consultant in Critical Care and Anaesthesia

Heart of England NHS Foundation Trust




RD has received payment for consultancy on sepsis from Kimal Plc, manufacturers of vascular access devices, from the Northumbria Partnership, a patient safety collaborative, and, where annual leave or other income was compromised in fulfilling his charity duties, from the UK Sepsis Trust. RD has received sponsorship to attend and speak at one meeting from Abbott Diagnostics. He is CEO of the UK Sepsis Trust and Global Sepsis Alliance, and advises HM Government, the World Health Organisation and NHS England on sepsis. Each of these positions demands that he express opinion on strategies around the recognition and management of sepsis.

Consultant in Emergency Medicine

Clinical Academic

University of Plymouth

Lead Doctor

Devon Air Ambulance Trust

Derriford Hospital




TN is a clinical advisor to the UK Sepsis Trust.

Specialty Registrar in Emergency Medicine

Derriford Hospital




EC declares that he has no competing interests.

Dr Ron Daniels, Dr Tim Nutbeam, and Dr Edward Berry would like to gratefully acknowledge Dr Lewys Richmond and Dr Paul Kempen, the previous contributors to this monograph. LR and PK declare that they have no competing interests.

Peer reviewers VIEW ALL

Professor of Medicine

Infectious Disease Division

Rhode Island Hospital

Alpert Medical School of Brown University




SMO declares that he has no competing interests.

Associate Professor

NYU School of Medicine

Medical Director of Critical Care

Bellevue Hospital Center

New York



LE serves as the guidelines co-chair and on the steering committee of the Surviving Sepsis Campaign.

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