Severe Community Acquired Pneumonia – A Role for Corticosteroids?
Resident Clinical Pearl – March 2016
Kalen Leech-Porter, PGY1 iFMEM, Dalhousie University, Saint John, New Brunswick
Reviewed by Dr Cherie-Lee Adams and Dr David Lewis
Case:
A 66 yo female presents in respiratory distress following 3 days of productive cough and fever. Fever 39.7 degrees, HR 120, RR 32, SP02 91% on100% O2 via non re-breather mask BP 85/50 on with deteriorating mental status, no urine output in the ED (CXR below)Sepsis protocol has been invoked and she is currently on IV ceftriaxone and IV azithromycin with 2L bolus of NS just finishing being bolused. As you consider RSI, you wonder is there a role for steroids in this community acquired pneumonia (CAP)?
Image 1 (radiopedia.org)
Discussion
A recent meta-analysis (1) suggests steroids may be a useful adjunct to antibiotic therapy in patients with community-acquired pneumonia (CAP). The meta-analysis looked at 12 different randomized control trials with a total of 1,974 patients. Hospitalized patients were found to have a decreased length of stay (1 day on average, see Figure 1) and improved time to clinical stabilization (defined by vital signs within normal limits, normal mental status and no hypoxia for 24 hours) by 1.2 days. The analysis also found a decreased risk of mechanical ventilation (5 trials, relative risk [RR] = 0.45) and acute respiratory distress syndrome (4 trials, [RR]= 0.24). In patients with severe CAP, overall mortality was reduced by 3% (RR, 0.67 [95% CI, 0.45 to 1.01]. On the surface it would appear corticosteroids are useful, particularly in severe CAP.
Figure 1
Unfortunately, diving deeper, the results are more ambiguous than they appear. There was significant heterogeneity in the studies used; “Eligible studies reported on at least 1 of the following outcomes: duration of hospitalization, time to clinical stability, all-cause mortality, need for mechanical ventilation, need for intensive care unit (ICU) admission, or development of ARDS”; they did not all report the same end points and used different risk stratification modules. Furthermore the CI for overall mortality crossed 1, making this result of questionable reliability. When stratified into subgroups, more severe pneumonias did seem to have greater benefit from corticosteroids: (6 studies; 388 patients; RR, 0.39 [CI, 0.20 to 0.77]; P = 0%). However, this could be due to selection bias.
A previous meta-analysis (2) found no mortality benefit in most CAP but an increased incidence of hyperglycemia with steroids. This analysis did not find any benefit to adding corticosteroids but its only primary clinical outcome was overall mortality. Other outcomes such as length of stay were not examined.
Complicating conclusions of both meta-analyses was a lack of consistency in steroid prescribed; a wide range of steroids, doses and routes were used.
Bottom line
When excluding disease states that may be worsened by steroids (ie diabetes), Corticosteroids may be a useful adjunct for severe CAP providing modest benefit; they may reduce length of stay in hospital and may slightly reduce overall mortality. The current literature is inadequate to determine the best dose/route for steroid administration. There is insufficient data to suggest corticosteroid should be used in non-severe CAP, given the potential steroid related complications.
References
1. Nie W, Zhang Y, et al. Corticosteroids in the treatment of community-acquired pneumonia in adults: a meta-analysis. PLoS One 2012; 8(1):e47296
2. Siemieniuk RAC, Meade MO, Alonso-Coello P, et al. Corticosteroid therapy for patients hospitalized with community-acquired pneumonia. Ann Intern Med 2015;163(7):519-528.
