Corticosteroids for Hospitalized Community-Acquired Pneumonia — Time to Change Practice?

Year in Review |
December 30, 2015

Corticosteroids for Hospitalized Community-Acquired Pneumonia — Time to Change Practice?

  1. Daniel D. Dressler, MD, MSc, SFHM, FACP

Randomized trials and meta-analyses both demonstrate improved outcomes when hospitalized CAP patients receive corticosteroids.

  1. Daniel D. Dressler, MD, MSc, SFHM, FACP

As many as 20% of patients with community-acquired pneumonia (CAP) worsen despite guideline-adherent antimicrobial therapy. Systemic corticosteroids might reduce cytokine and inflammatory responses that can lead to some CAP treatment failures. In 2015, researchers published two new randomized, controlled trials in which systemic corticosteroids were evaluated in hospitalized CAP patients.

A Spanish trial of 120 patients with severe CAP who received steroids showed that these patients were significantly less likely to experience a multicomponent treatment-failure endpoint that included both adverse clinical outcomes (mechanical ventilation, shock, death) and radiographic progression (13% vs. 31%); when the radiographic outcome was excluded, a clinical benefit remained (3% vs. 14%; P=0.04; NEJM JW Gen Med Mar 15 2015 and JAMA 2015; 313:677). In a Swiss trial of 785 patients that included patients with less-severe CAP, steroids significantly shortened time to clinical stability from 4.4 days to 3.0 days (NEJM JW Gen Med Mar 1 2015 and Lancet 2015; 385:1511).

The randomized trials were not powered to demonstrate mortality differences, but a new meta-analysis — involving 13 randomized trials, including the two 2015 trials, and 2005 hospitalized CAP patients — showed that moderate systemic corticosteroid doses (20–60 mg of prednisone or equivalent total daily dose) significantly lowered incidences of acute respiratory distress syndrome (0.4% vs. 3.0%; number needed to treat, 38) and mechanical ventilation (3.1% vs. 5.7%; NNT, 38) and shortened hospital length of stay (by 2.9 days) compared with placebo. Lower all-cause mortality with steroids was of borderline significance in the entire treatment population (5.3% vs. 7.9%; NNT, 38), but a significant mortality benefit occurred in patients with severe pneumonia (7.4% vs. 22.0%; NNT, 7). Hyperglycemia that required treatment during hospitalization was more common in corticosteroid groups, whereas other adverse events were similar in corticosteroid and placebo groups (NEJM JW Gen Med Nov 1 2015 and Ann Intern Med 2015; 163:519).

Additional evidence for patients with severe CAP might be available by 2018 from the Extended Steroid in Community Acquired Pneumonia(e) (ESCAPe) trial. Until that time, this high-quality evidence establishes corticosteroids as a valuable intervention in hospitalized CAP patients, especially those with severe pneumonia. Clinicians should consider a brief course (5–7 days) of daily moderate-dose systemic corticosteroids (20–60 mg of prednisone or equivalent) for hospitalized CAP patients.

Editor Disclosures at Time of Publication

  • Disclosures for Daniel D. Dressler, MD, MSc, SFHM, FACP at time of publication Editorial boards Hospital Medicine Practice (EBMedicine); Journal of Hospital Medicine (Wiley); Principles and Practice of Hospital Medicine (McGraw-Hill) Leadership positions in professional societies American College of Physicians, Georgia Chapter (Hospitalist Committee Chair)

Reader Comments (4)

Mikhail Litinski Physician, Pulmonary Medicine

I don't think so, as some data on h1n1 related hypoxemic respiratory failure showed worse survival outcome with steroids

DANIEL DRESSLER Physician, Hospital Medicine, Emory University

Agree that the anti-inflammatory component is likely impacting the outcomes seen in this data.

With respect to outpatient management of CAP, I don't believe that this data supports this practice for the use of corticosteroids as an adjunct in outpatient management of CAP (as patients summarized here were inpatients). I'm also not aware of other data or outcomes (e.g. progression to hospital admission or requiring other escalation of care) supporting the use of coriticosteroids in outpatient CAP management, and I'm not aware of guidelines or summary evidence that would support use of corticosteroids for managing outpatients with CAP.

DONALD BROWN Physician, Family Medicine/General Practice, private practice

Could it be that since the majority of cases of pneumonia are not caused by bacteria (~2/3) that the steroid are at least addressing the inflammatory aspect of the disease since the antibiotics in most cases apparently do very little/or nothing at all?

J. Garich, Pharm.d. Other Healthcare Professional, Pharmacology/Pharmacy, Vista clinic

I'm seeing this use of steroid tx in the ambulatory population. I'm curious if there are data that support this strategy in am care as well where patients are more stable anyway and outcomes are not measured in decreased LOS And ARDS episodes?

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