Steroids for Pneumonia
SUMMARY
Multiple SRMAs show a convincing effect of systemic corticosteroids on the need for mechanical ventilation. However, there is no clear effect on mortality. Pneumonia is a heterogenous clinical syndrome with varying levels of inflammation, fibrosis, infectious, hydrostatic, immune processes and it is likely that some subgroups would benefit more than others (see COVID/ARDS trials of steroids where mortality benefit is quite convincing).
Severe CAP
Siemieniuk et al. 2015
- in adult patients hospitalized for CAP, systemic corticosteroid therapy is associated with a 5% absolute reduction in the need for mechanical ventilation and the rate of ARDS
- possible reduction in mortality (driven by severe pneumonia groups)
Meduri et al. 2022 (ESCAPe)
- This RCT examines methylprednisolone for severe pneumonia (CAP/HCAP) patients admitted or the ICU or stepdown unit.
- Negative trial with regards to mortality at 60 days
- underpowered, underrecruited, and lower risk than estimated
- NOT able to say that steroids reduce mortality in this context. However, further trials are needed
Mild to Moderate CAP
- There is no evidence that corticosteroids reduce mortality rates in patients with mild to moderate CAP.
- People with CAP treated with corticosteroids had lower clinical failure rates (death, worsening of imaging studies, or no clinical improvement), shorter time to cure, a shorter hospital stay, and fewer complications
Adverse Effects
Hyperglycemia risk is increased (4% more requiring treatment).
References
- Corticosteroids in Community-Acquired Pneumonia | Guidelines | JAMA | JAMA Network
- Siemieniuk RAC, Meade MO, Alonso-Coello P, et al. Corticosteroid Therapy for Patients Hospitalized With Community-Acquired Pneumonia. Ann Intern Med. 2015;163(7):519-528. doi:10.7326/M15-0715
- Rochwerg B. Corticosteroids for severe community-acquired pneumonia: a story without an ending. Intensive Care Med. 2022;48(8):1053-1055. doi:10.1007/s00134-022-06699-w
- Meduri GU, Shih MC, Bridges L, et al. Low-dose methylprednisolone treatment in critically ill patients with severe community-acquired pneumonia. Intensive Care Med. 2022;48(8):1009-1023. doi:10.1007/s00134-022-06684-3
- Saleem N, Kulkarni A, Snow TAC, Ambler G, Singer M, Arulkumaran N. Effect of Corticosteroids on Mortality and Clinical Cure in Community-Acquired Pneumonia: A Systematic Review, Meta-analysis, and Meta-regression of Randomized Control Trials. Chest. Published online September 7, 2022. doi:10.1016/j.chest.2022.08.2229