A bundle of evidence-based strategies that includes steroids for the treatment of CAP does not improve outcomes

Référence

Lloyd M, Karahalios A, Janus E, et al, for the Improving Evidence-Based Treatment Gaps and Outcomes in Community-Acquired Pneumonia (IMPROVE-GAP) Implementation Team at Western Health. Effectiveness of a bundled intervention including adjunctive corticosteroids on outcomes of hospitalized patients with community-acquired pneumonia. JAMA Intern Med 2019 Jul 8. doi: 10.1001/jamainternmed.2019.1438. [Epub ahead of print]

Sommaire

Prior evidence has shown improved outcomes for CAP using specific interventions, including early mobilization, nutrition screening, an early switch from intravenous to oral antibiotics, and adjunctive treatment with steroids. In this trial, investigators randomized patients hospitalized with CAP in 1 of 8 general medicine wards in Australia to receive either a bundle of interventions (n = 401) or usual care (n = 415). The intervention bundle included the following: (1) getting out of bed for more than 20 minutes on day of admission and progressive mobilization daily, (2) screening for malnutrition with targeted nutritional therapy, (3) switching from intravenous to oral antibiotics according to predefined criteria, and (4) receiving prednisolone acetate 50 mg daily, or its equivalent, for 7 days. These interventions were recommended, but complied with at the discretion of the treating team. Randomization was at the ward level using a stepped wedge process. After a 10-week control period, 2 of the 8 wards were transitioned to the intervention model every 10 weeks. Patients in the 2 groups were similar at baseline with a mean age of 76 years and similar co-morbidities. Half the patients had a pneumonia severity score of 0 or 1, corresponding to low risk. Analysis was by intention to treat. More patients in the intervention group received steroid prescriptions (76% vs 25%), early mobilization (72% vs 19%), and nutritional support (83% vs 55%); de-escalation to oral antibiotics was common for both groups (77% in the intervention group vs 69% in the control group). For the primary outcome of LOS, no significant difference was detected between the 2 groups. Notably, the median LOS in this study was only 3 days as compared with 6 or 7 days in prior studies of these interventions. Additionally, there were no differences detected in mortality, readmission rate, admission to the intensive care unit, or need for mechanical ventilation. Patients in the intervention group had higher rates of gastrointestinal bleeding (2.2% vs 0.7%).