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Systemic corticosteroids reduce need for ICU or mechanical ventilation in patients with community-acquired pneumonia
Clinical Question
Are systemic corticosteroids beneficial for patients hospitalized with community-acquired pneumonia?
Bottom line
This meta-analysis of hospitalized patients with CAP found evidence that systemic corticosteroids reduce the need for ICU admission and mechanical ventilation, and a suggestion that mortality may be reduced in patients with greater disease severity. This is consistent with the findings of the just-reported French randomized controlled trial of patients in the ICU with severe CAP who were treated for 8 to 14 days with intravenous hydrocortisone 200 mg daily. Two of the largest studies set in general medical wards found no benefit to systemic steroids, so for now their use should be limited to patients with severe CAP. 1a
Reference
Study design: Meta-analysis (randomized controlled trials)
Funding: Self-funded or unfunded
Setting: Inpatient (any location)
Synopsis
According to current UK guidelines and current Infectious Diseases Society of America guidelines, systemic corticosteroids are not recommended for any patients with community-acquired pneumonia (CAP). However, another July 2023 POEM presented the results of the largest study to date, finding a significant mortality reduction with 8 to 14 days of intravenous hydrocortisone for patients with severe CAP. This study is a methodologically sound meta-analysis of randomized trials comparing a systemic corticosteroid with a placebo or usual care and reporting all-cause mortality. The authors identified 16 randomized trials with a total of 3842 hospitalized patients. A variety of corticosteroids were used: most commonly, intravenous hydrocortisone (6 studies). Steroids were given for 7 or more days in 10 trials and for 5 or fewer days in 6 trials. No mortality benefit was seen (9.5% vs 10.8%; 95% CI 0.67 - 1.07; I2 = 14%). The authors performed meta-regression to evaluate the impact of study design and population factors on mortality. They found an association between greater baseline severity of illness and lower mortality, but not with dose or duration of treatment. However, with only 16 trials for meta-regression, the power to detect associations is limited. In 6 studies with 2619 patients that reported the need for intensive care unit (ICU) admission, the outcome was lower in the corticosteroid groups (3.1% vs 4.7%; P = .04; I2 = 0%; number needed to treat [NNT] = 62). In 8 smaller studies with 1457 patients, the need for mechanical ventilation was also reduced (4.2% vs 7.1%; P = .001; NNT = 34). The authors found no difference in the likelihood of treatment failure, gastrointestinal bleeding, or secondary infections, but found an increase in hospital readmission (5 studies; 2853 patients; 21.5% vs 17.7%; P = -.008; number needed to treat to harm = 26) and hyperglycemia.
Reviewer
Mark H. Ebell, MD, MS
Professor
University of Georgia
Athens, GA
Comments
Impact assessment
Excellent