COMMENTARY

Childhood CAP: Would Adding Dexamethasone Hasten Recovery?

William T. Basco, Jr., MD, MS

Disclosures

September 18, 2017

Can Dexamethasone Shorten Recovery Time?

Up to 13% of children hospitalized for pneumonia experience a parapneumonic effusion, and it is unclear whether anti-inflammatory treatments such as systemic steroids would improve the trajectory of these patients.[1] In a multicenter, randomized clinical trial conducted in Spain, Tagarro and colleagues[1] tested the hypothesis that cotreatment with antimicrobial agents and early dexamethasone would shorten recovery time in children with community-acquired pneumonia and pleural effusion.[1]

Nine hospitals participated in the trial. The children were aged 1 month to 14 years, and all had community-acquired pneumonia with fever, cough, parenchymal infiltrate on x-ray, and pleural effusion. Treatment patients were given eight intravenous doses of dexamethasone (0.25 mg/kg) every 6 hours, and control patients received placebo. All children received standard antibiotics (switched from intravenous to oral therapy after the child became afebrile) for a total of 15 days. The primary outcome was "recovery," defined as having an oxygen saturation of at least 93%, being afebrile, exhibiting no respiratory distress, and tolerating oral feedings.

From 2011 to 2015, a total of 60 children were randomly assigned in an equal distribution to the treatment or placebo group. The median age of the children was 4.7 years, 58% were girls, and 40% had an underlying chronic diagnosis. The children had exhibited an average of 4 days of symptoms prior to enrollment. Video-assisted thorascopic surgery was necessary for 8.3% of the children, and 35% received a chest tube.

The median duration of treatment was lower in children treated with dexamethasone (109 hours) compared with children who received placebo (177 hours). This finding appeared to be driven by the patients with a simple effusion, rather than by the smaller number of patients with a complicated effusion, among whom there was no difference in recovery time.

Other variables (eg, pulmonary complications, mortality) did not differ between the two groups. For the most part, rates of secondary outcomes (including complications) were not different between the two groups with the exception of hyperglycemia, which occurred in 50% of the dexamethasone group compared with only 20% of the placebo group.

The investigators concluded that systemic treatment with dexamethasone, along with standard antibiotic therapy, reduced the recovery time of children with parapneumonic pleural effusion by almost 3 days.

Viewpoint

These important preliminary results suggest a substantial clinical benefit, not just a statistical benefit. Similar data from a larger sample or even a truly international sample would be very helpful and could benefit a large number of patients given how many children are admitted each year with pneumonia. If these findings could be substantiated in a broader sample, the difference in recovery time seen here would represent a substantial leap forward.

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