In response to the Letter to the Editor by Doson Chua in the April issue (2004:16), I disagree with her statement that the use of steroid therapy is currently advocated for use in all patients with severe sepsis. A large, well-done, randomized clinical trial11 demonstrated that empiric use of steroids in patients with severe sepsis or septic shock was associated with a significant reduction in mortality. However, this benefit was limited to patients who failed to increase their cortisol levels by 9 in response to corticotrophin stimulation test. Among this group, there was a 10% absolute reduction in mortality when treated appropriately. The evidence therefore indicates (1) a corticotrophin stimulation test on all patients with severe sepsis or septic shock and then (2) empirically treating patients with severe sepsis or septic shock (50 mg hydrocortisone every 6...

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