Table 2.

Corticosteroid recommendations in various versions of the guidelines.

Guideline	Corticosteroid recommendations	Grade of evidence	Reference
2004	Intravenous corticosteroids (hydrocortisone 200–300 mg/day, for 7 days in 3 or 4 divided doses or by continuous infusion) are recommended in patients with septic shock who, despite adequate fluid replacement, require vasopressor therapy to maintain adequate blood pressure	Grade C	[52]
	Doses of corticosteroids higher than > 300 mg hydrocortisone daily should not be used in severe sepsis or septic shock for the purpose of treating septic shock	Grade A
2008	We suggest intravenous hydrocortisone be given only to adult septic shock patients after blood pressure is identified to be poorly responsive to fluid resuscitation and vasopressor therapy	Grade 2 C	[53]
	We suggest the ACTH stimulation test not be used to identify the subset of adults with septic shock who should receive hydrocortisone	Grade 2B
	We suggest that patients with septic shock should not receive dexamethasone if hydrocortisone is available	Grade 2B
	We suggest the daily addition of oral fludrocortisone (50 μg) if hydrocortisone is not available and the steroid that is substituted has no significant mineralocorticoid activity. Fludrocortisone is considered optional if hydrocortisone is used	Grade 2 C
	We recommend doses of corticosteroids comparable to > 300 mg hydrocortisone daily not be used in severe sepsis or septic shock for the purpose of treating septic shock	Grade 1 A
2012	We suggest not using intravenous hydrocortisone as a treatment of adult septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability (see goals for Initial Resuscitation). If this is not achievable, we suggest intravenous hydrocortisone alone at a dose of 200 mg per day	Grade 2 C	[54]
	We suggest not using the ACTH stimulation test to identify the subset of adults with septic shock who should receive hydrocortisone	Grade 2B
2016	We suggest against using IV hydrocortisone to treat septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability. If this is not achievable, we suggest IV hydrocortisone at a dose of 200 mg per day	weak recommendation, low quality of evidence	[55]
2021	For adults with septic shock and an ongoing requirement for vasopressor therapy we suggest using IV corticosteroids	Weak recommendation; moderate quality of evidence	[56]