Association between hydrocortisone use and outcomes in sepsis patients with hospital-acquired bloodstream infections: An ancillary analysis of the EUROBACT-2 cohort.

Abstract

Corticosteroids are suggested for selected patients with septic shock, but their association with outcomes has not been specifically investigated in patients with hospital-acquired bloodstream infections (HA-BSI). We explored the association between hydrocortisone use and day-28 mortality in this population. Data from the prospective EUROBACT-2 study were used to assess the association between hydrocortisone use and day-28 mortality in ICU patients with HA-BSI and sepsis. Patients receiving hydrocortisone were compared with patients not receiving hydrocortisone. A 1:1 propensity score matching procedure was performed using nearest-neighbour matching without replacement and a caliper of 0.2 standard deviation of the logit propensity score, followed by multivariable logistic regression with cluster-robust standard errors by matched pair. Among 2,401 analyzed patients, 608 (25%) received hydrocortisone during the HA-BSI episode. The final propensity score included age, sex, Charlson comorbidity score, ICU admission diagnosis, SOFA score without cardiovascular component, septic shock, country of inclusion, lactate at HA-BSI diagnosis, and ICU-acquired versus non-ICU-acquired HA-BSI. Matching yielded 521 pairs (1,042 patients). In the multivariable model, hydrocortisone use was associated with increased day-28 mortality in the overall matched cohort (OR 1.448; 95% CI 1.096-1.914; p = 0.009). This association was observed in patients with sepsis without shock (OR 1.697; 95% CI 1.051-2.740; p = 0.031) and in the female subgroup (OR 1.718; 95% CI 1.055-2.796; p = 0.030), but not in patients with septic shock or in those receiving norepinephrine-equivalent dose ≥0.25 µg/kg/min. Hydrocortisone use was not associated with improved day-28 survival in ICU patients with HA-BSI. In the matched analysis, hydrocortisone use was associated with higher day-28 mortality in the overall cohort, whereas no significant association was observed in patients with septic shock or high-dose norepinephrine. These findings are observational and hypothesis-generating and should not be interpreted causally.