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Intensive Care Medicine

, Volume 37, Issue 3, pp 420–429 | Cite as

Low-dose steroids for septic shock and severe sepsis: the use of Bayesian statistics to resolve clinical trial controversies

  • Andre C. KalilEmail author
  • Junfeng Sun
Systematic Review

Abstract

Purpose

Low-dose steroids have shown contradictory results in trials and three recent meta-analyses. We aimed to assess the efficacy and safety of low-dose steroids for severe sepsis and septic shock by Bayesian methodology.

Methods

Randomized trials from three published meta-analyses were reviewed and entered in both classic and Bayesian databases to estimate relative risk reduction (RRR) for 28-day mortality, and relative risk increase (RRI) for shock reversal and side effects.

Results

In septic shock trials only (Marik meta-analysis; N = 965), the probability that low-dose steroids decrease mortality by more than 15% (i.e., RRR > 15%) was 0.41 (0.24 for RRR > 20% and 0.14 for RRR > 25%). For severe sepsis and septic shock trials combined, the results were as follows: (1) for the Annane meta-analysis (N = 1,228), the probabilities were 0.57 (RRR > 15%), 0.32 (RRR > 20%), and 0.13 (RRR > 25%); (2) for the Minneci meta-analysis (N = 1,171), the probability was 0.57 to achieve mortality RRR > 15%, 0.32 (RRR > 20%), and 0.14 (RRR > 25%). The removal of the Sprung trial from each analysis did not change the overall results. The probability of achieving shock reversal ranged from 65 to 92%. The probability of developing steroid-induced side effects was as follows: for gastrointestinal bleeding (N = 924), there was a 0.73 probability of steroids causing an RRI > 1%, 0.70 for RRI > 2%, and 0.67 for RRI > 5%; for superinfections (N = 964), probabilities were 0.81 (RRI > 1%), 0.76 (RRI > 2%), and 0.70 (RRI > 5%); and for hyperglycemia (N = 540), 0.99 (RRI > 1%), 0.97 (RRI > 2%), and 0.94 (RRI > 5%).

Conclusions

Based on clinically meaningful thresholds (RRR > 15–25%) for mortality reduction in severe sepsis or septic shock, the Bayesian approach to all three meta-analyses consistently showed that low-dose steroids were not associated with survival benefits. The probabilities of developing steroid-induced side effects (superinfections, bleeding, and hyperglycemia) were high for all analyses.

Keywords

Steroids Sepsis Shock 

Notes

Acknowledgments

The authors thank Ms. Elaine Litton and Ms. Ashley Calhoon for providing outstanding administrative support.

Conflict of interest

Andre Kalil has received research grants from Eisai and Astra Zeneca. Junfeng Sun has no conflicts to report.

Supplementary material

134_2010_2121_MOESM1_ESM.doc (38 kb)
Supplementary material 1 (DOC 38)

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Copyright information

© Copyright jointly held by Springer and ESICM 2011

Authors and Affiliations

  1. 1.Department of MedicineUniversity of Nebraska Medical CenterOmahaUSA
  2. 2.Critical Care Medicine DepartmentNational Institutes of HealthBethesdaUSA

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