In a recent issue, Dr Britt et al1 reported an increased morbidity in critically ill patients receiving steroids. The immunosuppressive properties of corticosteroids as well as other hazardous adverse effects such as hyperglycemia and myopathy are well-described and definite causes of morbidity in the critically ill. However, although the morbidity burden associated with corticosteroids cannot be underestimated, we believe the study's results should be viewed with caution because it presents significant shortcomings. A major drawback is imposed by dissimilar indications and, consequently, dosages, type, and duration of steroid treatment for a heterogeneous population. In the past decade, several studies revealed that severe infections and the immune response to microorganisms are implicated in hypothalamic-pituitary-adrenal axis alterations, resulting in a status of relative adrenocortical insufficiency.2,3 Recent studies provide strong evidence that patients with severe sepsis4 or severe community-acquired pneumonia5 have high rates of relative adrenal failure and can have significant improvement in organ function and mortality when treated with a short course (7-10 days) of low-dose hydrocortisone.4,6
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