In this retrospective cohort study, the authors tried to evaluate the cortisol levels and use of corticosteroids on clinical outcomes in patients with sepsis. I have a few concerns regarding the methodology of the study. 1. Timing of cortisol is one of the critical parameters which can affect the levels. As mentioned by the authors, different studies have shown the timing of cortisol in relation to early vs late sepsis, in regard to timings over 24 hours (morning vs evening) and finally, whether hydrocortisone was administered before or after cortisol levels. These factors can have a significant impact on the levels measured. This should be included in the limitation of this study. 2. Higher cortisol levels may reflect the degree of stress, but the timing of collection of cortisol in relation to the phase of sepsis is critical. As a late collection of cortisol during CARS may not reflect stress response. 3. There was no standard protocol followed for the administration of corticosteroids in this study. This is interesting, and the choice of corticosteroids will be biased by the perception of physicians with guidelines that have changed evidence on corticosteroids from recommendation to suggestion in the last two versions. In this case, it is unclear whether higher mortality in the corticosteroid group is based on the high acuity of illness in that group or because of physician bias to use corticosteroids as a last resort. 4. Authors have use real world and real evidence. This sounds incorrect. As it is open label study with no fixed protocol on timing of cortisol or administration of corticosteroids, it does not reflect evidence. Instead it is exclusively a real world study with administration and management of corticosteroids based on physician choice.

Minor corrections 1. introduction, Para 2 3800 patients with septic shock requiring mechanical ventilation. 2. Methods Extra space - any standard protocol. Other outcomes.

Thank you for the revision. There are no further comments.