For patients with severe community-acquired pneumonia, does hydrocortisone improve outcomes?
This study found a clear mortality benefit for intravenous hydrocortisone in patients with severe CAP, without any worrisome adverse effects such as an increase in infections. Another July 2023 POEM presents a systematic review that found a reduction in the need for ICU admission or mechanical ventilation, but no impact on mortality. However, the bulk of the studies in that analysis were in hospitalized patients without severe pneumonia. 1b
Randomized controlled trial (double-blinded)
Inpatient (ICU only)
Previous randomized trials of systemic corticosteroids as a supplemental treatment for community-acquired pneumonia (CAP) have found reductions in length of stay, but in most cases have failed to find an improvement in mortality. They have also been criticized for flaws in study design, including the failure to mask or conceal allocation. In this trial, researchers analyzed data from 795 adults at 31 French hospitals who were in the intensive care unit (ICU) for severe CAP. This was defined as the need for mechanical ventilation or high-flow oxygenation, or a Pneumonia Severity Index (PSI) score greater than 130, which is the highest category for severity. Patients with sepsis were excluded. In addition to standard therapy for CAP, patients were randomized to intravenous hydrocortisone 200 mg for 4 days or 7 days, depending on the judgment of the medical team, followed by a taper for a total of 8 days or 14 days. The median time from ICU admission to hydrocortisone infusion was 15 hours. At baseline, the groups were balanced, with a median age of 67 years, 69% were men, and approximately 28% had comorbid chronic lung disease (83% were PSI class IV or V [on a scale of I to V, where V is the most severe]). Overall, approximately 12% in each group received vasopressors. Analysis was by intention to treat. All-cause mortality was significantly lower in the hydrocortisone group at 28 days (6.1% vs 11.9%; 95% CI for difference -9.6 to -1.7; number needed to treat [NNT] = 17) and at 90 days (9.3% vs 14.7%; 95% CI for difference -9.9 to -0.8; NNT = 18). Among patients who did not require mechanical ventilation at enrollment, fewer patients in the treatment group later required it (18.0% vs 29.5%; hazard ratio 0.59; 95% CI 0.40 - 0.86; NNT = 9). There was no significant difference in hospital-acquired infections between groups. Patients who use insulin required 15 additional units per day on average in the hydrocortisone group.
Mark H. Ebell, MD, MS
University of Georgia