September 2023
In a meta-analysis, steroids did not lower mortality in patients with community- acquired pneumonia

However, a new randomised trial – not included in the meta-analysis – did show a mortality benefit.

The cornerstone of treating patients with community-acquired pneumonia (CAP) is early and appropriate antibiotics. For several decades, clinicians have wondered whether treating the inflammation that often contributes to more-severe disease would be beneficial. Corticosteroids are the most common adjunctive therapy studied, and results have been mixed.

Investigators performed a meta-analysis of 16 trials that involved nearly 4000 patients hospitalised with CAP who were randomised to receive either corticosteroids or placebo. Seven studies included patients with severe CAP. The specific corticosteroid administered and the duration of therapy varied between trials. Mortality was similar between groups, even when the effect of higher average daily dose or cumulative dose was considered. In eight studies that reported need for mechanical ventilation, risk was lower in patients who received corticosteroids. The investigators did not specifically examine patients with severe CAP, but mortality between groups did not differ in the trials that included data on mechanical ventilation. Hyperglycaemia was more common in patients who were treated with corticosteroids.

Comment: These data do not support routine administration of corticosteroids for CAP. However, the lesser need for mechanical ventilation among corticosteroid recipients is interesting – raising the question of whether patients with more severe disease derive some benefit. In fact, in a new, large, intensive care unit-based randomised trial that was not included in this meta-analysis (NEJM JW Gen Med Apr 15 2023 and N Engl J Med 2023; 388: 1931-1941), corticosteroid therapy did lower 28-day mortality. At the moment, guidelines from the Infectious Diseases Society of America/American Thoracic Society recommend reserving corticosteroids for patients with CAP and septic shock (NEJM JW Gen Med Dec 1 2019 and Am J Respir Crit Care Med 2019; 200: 45-67). But it will be interesting to see whether the guidelines change, based on the results of the new randomised trial.

Patricia Kritek, MD, EdM, Professor of Medicine, Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, USA.

Saleem N, et al. Effect of corticosteroids on mortality and clinical cure in community- acquired pneumonia. Chest 2023; 163: 484-497.

This summary is taken from the following Journal Watch titles: General Medicine, Hospital Medicine.