Corticosteroids in childhood sepsis: given to 1 in 10, mostly outside refractory shock

Design

Multicentre prospective observational cohort

Population

5,119 children admitted with suspected community-acquired sepsis in 11 EDs

Primary outcome

Corticosteroid use within 24 hours, agent and associated factors

Effect

9.6% overall; 31.3% in Phoenix sepsis; dexamethasone 69.5%, hydrocortisone 25.4%

A prospective observational study across 11 emergency departments in Australia and New Zealand included 5,119 children admitted with suspected community-acquired sepsis, median age 1.6 years, between 2021 and 2023. In-hospital mortality was 1.0% overall and 12.7% in the 252 who met the Phoenix sepsis criteria.

Corticosteroids were given within 24 hours to 9.6% of all children and 31.3% of those meeting Phoenix criteria. Dexamethasone was used in 70% of cases and hydrocortisone in 25%, with large differences between hospitals. Use was associated with older age, comorbidities, raised lactate, large fluid volumes and vasopressors, but most courses were given outside fluid- or catecholamine-refractory shock.

This describes practice rather than testing it. Steroid use in paediatric sepsis has little trial evidence, and the variation shows clinicians filling that gap differently. It is a reason to check why a steroid is being given, not evidence for or against giving it.

• Reserve hydrocortisone in paediatric septic shock mainly for fluid- and catecholamine-refractory shock, as current guidance does.
• Record a clear indication whenever a corticosteroid is given to a child with sepsis.
• Consider adrenal insufficiency in children on long-term steroids presenting with sepsis.
• Note that dexamethasone given for another reason, such as croup or asthma, still counts as steroid exposure.

Why it matters

Steroids are given in sepsis far more widely than the evidence supports, and the choice of agent varies by hospital.

Don't overread it

Observational and descriptive; it says nothing about whether steroids helped or harmed.

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