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To the Editor: The systematic review by Dr Annane and colleagues¹ summarized the results of 22 clinical trials investigating corticosteroid therapy in sepsis. The review suggested that prolonged low-dose corticosteroid therapy (5 days, 300 mg/d of hydrocortisone or equivalent) decreases mortality and recommended treating adult patients with vasopressor-dependent septic shock. However, we believe that these recommendations are weakened by possible publication bias and by the relationship between severity of illness and the treatment effect of corticosteroids.

The review stated that "the funnel plot did not suggest evidence for publication bias."¹ However, in a recent systematic review of corticosteroids in sepsis,² we demonstrated publication bias within the group of trials investigating prolonged low-dose corticosteroids using an Egger regression test³ and a funnel plot. Therefore, we recommend performing similar analyses to examine the 12 trials investigating prolonged low-dose corticosteroids included in this review. Findings consistent with publication bias would imply that . . . [Full Text of this Article]

Peter C. Minneci, MD
minneci@email.chop.edu
Department of Surgery

Katherine J. Deans, MD
Department of Surgery
The Children's Hospital of Philadelphia
Philadelphia, Pennsylvania

Charles Natanson, MD
Critical Care Medicine Department
National Institutes of Health
Bethesda, Maryland

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