Clinical question: Do steroids improve outcomes in patients with severe community-acquired pneumonia and a high inflammatory response?
In patients with severe community-acquired pneumonia (CAP) who have elevated levels of C-reactive protein (CRP), a short course of methylprednisolone decreases treatment failure, mainly by reducing radiographic progression of pulmonary infiltrates within 3 days to 5 days of treatment initiation. The patient population studied here represents a fraction of the patients with severe CAP, so this finding cannot be generalized. Moreover, this study was small and the findings require replication before they can be applied to this population.
Reference: Torres A, Sibila O, Ferrer M, et al. Effect of corticosteroids on treatment failure among hospitalized patients with severe community-acquired pneumonia and high inflammatory response. JAMA 2015;313(7):677-686.
Design: Randomized controlled trial (double-blinded); LOE: 1b
Setting: Inpatient (any location)
A previous meta-analysis of randomized controlled trials showed that the addition of steroids for treatment of community-acquired pneumonia decreases hospital length of stay but does not affect other clinical outcomes such as mortality or need for mechanical ventilation (J Hosp Med 2013;8:68-75).
In this study, investigators enrolled patients hospitalized with severe CAP (either risk class V by the Pneumonia Severity Index or as defined by American Thoracic Society) and a CRP level of greater than 15 mg/dL. Immunosuppressed patients or those with diabetes or recent major gastrointestinal bleeding were excluded.
Patients were randomized, using concealed allocation, to receive either methylprednisolone (0.5 mg per kg) every 12 hours (n = 61) or matching placebo (n = 59) for 5 days. The primary outcome was treatment failure. Early treatment failure was defined as clinical deterioration within 72 hours of treatment, whereas late failure was defined as radiographic progression of pulmonary infiltrates by more than 50%, respiratory failure, shock, or death between 3 days and 5 days.
Baseline characteristics were similar in the 2 groups, except for lower procalcitonin levels and less septic shock in the steroid group. Antibiotic treatment on admission was similar in both groups (most commonly ceftriaxone combined with either levofloxacin or azithromycin). The majority of patients were initially admitted to the intensive care unit. In the intention-to-treat analysis, the steroid group had less treatment failure than the placebo group (13% vs 31%; P = .02). This was driven by a higher rate of late treatment failure in the placebo group, primarily due to a greater incidence of radiographic progression of infiltrates. Results were similar after adjusting for potential confounders and imbalances in baseline characteristics (hazard ratio = 0.33, 95% CI 0.12 – 0.90; P = .03). There were no significant differences in length of stay, in-hospital mortality, or adverse events between the 2 groups.
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.