Clinical question: Are adjunctive corticosteroids beneficial for patients hospitalized with community-acquired pneumonia (CAP)?
Background: Numerous studies have tried to determine whether or not adjunctive corticosteroids for CAP treatment in hospitalized patients improve outcomes. Although recent trials have suggested that corticosteroids may improve morbidity and mortality, prior meta-analyses have failed to show a benefit, and steroids are not currently routinely recommended for this population.
Study design: Systematic review and meta-analysis of 13 RCTs, predominantly from Europe.
Synopsis: Analysis of 1,974 patients suggested a decrease in all-cause mortality (relative risk (RR) 0.67, 95% CI 0.45-1.01) with adjunctive corticosteroids. Subgroup analysis for severe CAP (six studies, n=388) suggested a greater mortality benefit (RR 0.39, 95% CI 0.2-0.77). There was a decrease in the risk of mechanical ventilation (five studies, n=1060, RR 0.45, CI, 0.26-0.79), ICU admission (three studies, n=950, RR 0.69, 95% CI, 0.46-1.03), and development of acute respiratory distress syndrome (four studies, n=945, RR 0.24, 95% CI 0.10-0.56).
Both hospital length of stay (LOS) and time to clinical stability (hemodynamically stable with no hypoxia) were significantly decreased (mean decrease LOS one day; time to clinical stability 1.22 days). Adverse effects were rare but included increased rates of hyperglycemia requiring treatment (RR 1.49, 95% CI 1.01-2.19). There was no increased frequency of gastrointestinal hemorrhage, neuropsychiatric complications, or rehospitalization.
Bottom line: Adjunctive corticosteroids for inpatient CAP treatment decrease morbidity and mortality, particularly in severe disease, and decrease LOS and time to clinical stability with few adverse reactions.
Citation: Siemieniuk RA, Meade MO, Alonso-Coello P, et al. Corticosteroid therapy for patients hospitalized with community-acquired pneumonia: a systematic review and meta-analysis. Ann Intern Med. 2015;163(7):519-528.