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To the Editor: I am concerned that Dr Annane and colleagues¹ studied a highly selected subgroup of the entire population of septic patients. Of the more than half million patients estimated to have severe sepsis in the United States annually,² only a small fraction would have vasopressor- and ventilator-dependent septic shock with documented relative adrenal insufficiency within 1 to 8 hours of the onset of septic shock. Remarkably, only 24% of the patients in this study were bacteremic, yet they experienced an exceedingly high mortality rate of 55% to 61%. The majority of patients had a community-acquired infection with a nonfatal underlying disease state. Such patients should receive optimal supportive care and should have reversible disease physiology. It remains unclear whether corticosteroids benefit a more heterogeneous population with serious underlying diseases or nosocomial infections.

Steven M. Opal, MD
Department of Medicine
Brown Medical School
Providence, RI

1. Annane D, Sebille V, Charpentier C, et al. Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. JAMA. 2002;288:862-871. FREE FULL TEXT 2. Angus DC, Winde-Ziirble WT, Lidicker J, Clermont G, Caricillo J, Pinsky MR. Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care. Crit Care Med. 2001;29:1303-1310. FULL TEXT | ISI | PUBMED

Letters Section Editor: Stephen J. Lurie, MD, PhD, Senior Editor.

JAMA. 2003;289:41-42.

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