COMMENTARY

Treating Community-Acquired Pneumonia With Steroids

Aaron B. Holley, MD

Disclosures

November 06, 2015

Corticosteroids for CAP: Mounting Evidence of Efficacy?

A recent meta-analysis published in the Annals of Internal Medicine[1] summarized the data for using corticosteroids to treat community-acquired pneumonia (CAP). This was after two large, randomized, controlled trials published earlier in 2015 showed that using corticosteroids for CAP decreases time required to achieve clinical stability and reduces hospital stay.[2,3] Mortality was a secondary outcome for both studies, and neither showed a mortality difference.

A Cochrane review published in 2011 produced similar findings. There was evidence for accelerated clinical resolution with steroids with weak evidence against a mortality benefit.[4]

The Annals meta-analysis looked at a range of outcomes and included considerably more patients than the 2011 Cochrane review. If I were to briefly summarize the Annals results, I'd say that the findings confirm what we already know. Corticosteroids improve time to stability and reduce hospital stay at the cost of clinically insignificant hyperglycemia. From an evidence-based perspective, these results sound underwhelming, particularly because the oldest study in the meta-analysis was from 1972. It seems that we've been trying to figure out the effect corticosteroids have on CAP for a long time.

Reducing Uncertainty

On closer inspection, I think this study is important because it reduces uncertainty. Meta-analyses are full of complicated statistics that are difficult for the average clinician, including me, to understand. That said, I've published a few of these,[5,6] so I feel comfortable making basic comments. The authors of the Annals study were meticulous in their assessments of bias, heterogeneity, and quality. They provide estimates of certainty for all conclusions, and the discussion section of their paper is fair and balanced. They even pulled observational data to provide optimal information size calculations and estimates of absolute outcome effects.

While the authors did a great job statistically, individual study designs leave considerable uncertainty. The dosing, duration, and type of corticosteroid administered varied significantly. Patients received prednisone, hydrocortisone, methylprednisolone, or dexamethasone, ranging from a single dose to a continuous infusion over 9 days.

The investigators concluded with high certainty that corticosteroids are beneficial for CAP. Their data support this, in that studies with low bias showed moderate-to-high certainty that corticosteroids reduce hospital stay and development of acute respiratory distress syndrome. They also decrease time to clinical resolution and need for mechanical ventilation.

A small increase in glucose was the only adverse effect noted. Personally, I'd give 40 mg of prednisone per day for 5 days for a hospitalized CAP patient. I say this because durations averaged between 3 and 7 days, and dosing was 40-50 mg prednisone or 200 mg hydrocortisone per day for several studies. In addition, 40 mg per day is generally well tolerated, in my anecdotal experience.

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