COMMENTARY

Steroids in CAP: Beneficial, Harmful, or Inconsequential?

Greg Martin, MD

Disclosures

January 26, 2016

Corticosteroid Therapy for Patients Hospitalized With Community-Acquired Pneumonia: A Systematic Review and Meta-analysis

Siemieniuk RA, Meade MO, Alonso-Coello P, et al
Ann Intern Med. 2015;163:519-528.

Study Summary

Corticosteroids are commonly tried in treating acute illnesses, particularly when the illness is severe and the patient requires admission to the intensive care unit (ICU). Corticosteroids have been tried in community-acquired pneumonia (CAP), but their role remains unclear despite several studies.[1,2] This study used meta-analytic techniques to aggregate the data and determine whether corticosteroids may be beneficial or harmful for large populations of patients with CAP.

In the analysis were 13 randomized controlled trials including 2005 patients, with a median age in the 60s and approximately 60% of patients being male. Corticosteroids were associated with possible reductions in all-cause mortality (12 trials; 1974 patients; risk ratio [RR], 0.67; 95% confidence interval [CI], 0.45 to 1.01), need for mechanical ventilation (five trials; 1060 patients; RR, 0.45; 95% CI, 0.26 to 0.79), and the acute respiratory distress syndrome (four trials; 945 patients; RR, 0.24; 95% CI, 0.10 to 0.56). Corticosteroids also reduced time to clinical stability (five trials; 1180 patients; mean difference, -1.22 days; CI, -2.08 to -0.35 days) and duration of hospitalization (six trials; 1499 patients; mean difference, -1.00 day; 95% CI, -1.79 to -0.21 days). Adjunctive corticosteroids increased the frequency of hyperglycemia requiring treatment (six trials; 1534 patients; RR, 1.49; 95% CI, 1.01 to 2.19) but did not the increase frequency of gastrointestinal hemorrhage.

For hospitalized patients with CAP, systemic corticosteroid therapy may reduce mortality by approximately 3%, need for mechanical ventilation by approximately 5%, and hospital stay by approximately 1 day.

Viewpoint

Current clinical practice guidelines for CAP do not recommend corticosteroid therapy,[3,4] yet corticosteroids are given for many reasons, particularly in such potentially fatal conditions as severe pneumonia.[1,2] This large and well-conducted meta-analysis provides good evidence that corticosteroid therapy reduces the time to clinical stability by 1 day (which should translate into 1 fewer day in the hospital) and may reduce the risk for deterioration (need for mechanical ventilation, development of acute respiratory distress syndrome), and even mortality.

The main adverse effect of corticosteroid therapy seems to be hyperglycemia. The challenge of applying systematic analyses such as these is for the individual patient needing care: Which hospitalized patients with CAP should receive corticosteroid therapy? On the basis of the relative improvements, corticosteroids should perhaps be most often used in more severely ill patients with CAP—those at higher risk for mechanical ventilation, acute respiratory distress syndrome, or death. Ideally, an adequately powered randomized trial will be conducted to definitively answer this question for us.

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