|General Internal Medicine-Primary Care(US)|
|Pediatric Hospital Medicine|
|Family Medicine (FM)/General Practice (GP)|
|Pediatric Emergency Medicine|
BACKGROUND: Pneumonia is a common and potentially serious illness. Corticosteroids have been suggested for the treatment of different types of infection, however their role in the treatment of pneumonia remains unclear. This is an update of a review published in 2011.
OBJECTIVES: To assess the efficacy and safety of corticosteroids in the treatment of pneumonia.
SEARCH METHODS: We searched the Cochrane Acute Respiratory Infections Group's Specialised Register, CENTRAL, MEDLINE, Embase, and LILACS on 3 March 2017, together with relevant conference proceedings and references of identified trials. We also searched three trials registers for ongoing and unpublished trials.
SELECTION CRITERIA: We included randomised controlled trials (RCTs) that assessed systemic corticosteroid therapy, given as adjunct to antibiotic treatment, versus placebo or no corticosteroids for adults and children with pneumonia.
DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. Two review authors independently assessed risk of bias and extracted data. We contacted study authors for additional information. We estimated risk ratios (RR) with 95% confidence intervals (CI) and pooled data using the Mantel-Haenszel fixed-effect model when possible.
MAIN RESULTS: We included 17 RCTs comprising a total of 2264 participants; 13 RCTs included 1954 adult participants, and four RCTs included 310 children. This update included 12 new studies, excluded one previously included study, and excluded five new trials. One trial awaits classification.All trials limited inclusion to inpatients with community-acquired pneumonia (CAP), with or without healthcare-associated pneumonia (HCAP). We assessed the risk of selection bias and attrition bias as low or unclear overall. We assessed performance bias risk as low for nine trials, unclear for one trial, and high for seven trials. We assessed reporting bias risk as low for three trials and high for the remaining 14 trials.Corticosteroids significantly reduced mortality in adults with severe pneumonia (RR 0.58, 95% CI 0.40 to 0.84; moderate-quality evidence), but not in adults with non-severe pneumonia (RR 0.95, 95% CI 0.45 to 2.00). Early clinical failure rates (defined as death from any cause, radiographic progression, or clinical instability at day 5 to 8) were significantly reduced with corticosteroids in people with severe and non-severe pneumonia (RR 0.32, 95% CI 0.15 to 0.7; and RR 0.68, 95% CI 0.56 to 0.83, respectively; high-quality evidence). Corstocosteroids reduced time to clinical cure, length of hospital and intensive care unit stays, development of respiratory failure or shock not present at pneumonia onset, and rates of pneumonia complications.Among children with bacterial pneumonia, corticosteroids reduced early clinical failure rates (defined as for adults, RR 0.41, 95% CI 0.24 to 0.70; high-quality evidence) based on two small, clinically heterogeneous trials, and reduced time to clinical cure.Hyperglycaemia was significantly more common in adults treated with corticosteroids (RR 1.72, 95% CI 1.38 to 2.14). There were no significant differences between corticosteroid-treated people and controls for other adverse events or secondary infections (RR 1.19, 95% CI 0.73 to 1.93).
AUTHORS' CONCLUSIONS: Corticosteroid therapy reduced mortality and morbidity in adults with severe CAP; the number needed to treat for an additional beneficial outcome was 18 patients (95% CI 12 to 49) to prevent one death. Corticosteroid therapy reduced morbidity, but not mortality, for adults and children with non-severe CAP. Corticosteroid therapy was associated with more adverse events, especially hyperglycaemia, but the harms did not seem to outweigh the benefits.
Although previous well done meta-analyses have found essentially exactly the same thing, this evidence seems slow to gain widespread translation into clinical practice. This most recent comprehensive Cochrane review found stronger evidence in support of corticosteroids to decrease "early treatment failure" in addition to the mortality benefit for severe pneumonia previously described. At this point, the evidence to support steroids in patients admitted with pneumonia is too robust to ignore.
What is the number needed to benefit?
I have followed the pendulum of steroids and sepsis for many years. Sounds like, at least for pneumonia, the swing is back toward benefit. This would make for a good editorial.
Community-acquired pneumonia and the benefits of steroid therapy is a common issue in the ED. Health care providers may be worried about steroid side effects, but the benefits outweigh the risks.
This review affirms usefulness of corticosteroids in patients with pneumonia, but lacks specific information about dose and duration of steroid therapy.
In terms of application, "the devil is in the details" as it looks like severity and age may have a large influence on the risk/benefit equation.
This is a compelling and well done SR/meta-analysis, which should change our practice for at least severe CAP.
Pneumonia is a common diagnosis in the emergency department, so emergency physicians commonly manage these patients. This review evaluated the utility of steroids in pneumonia. In this limited sample of RCTs, some improvement in symptoms and reduction in morbidity but no survival advantage was noted with corticosteroid therapy. There were more adverse effects such as hyperglycemia in patients treated with steroids. Further studies with high-quality evidence are needed.
I was waiting for a Cochrane on this topic to come out. I didn`t realize there had been that much work done in pediatrics with 310 kids in total in the meta-analysis. The studies seem very heterogeneous, so not sure it can be recommended for pediatrics yet and is still more hypothesis-generating. For adults, it should be practice-changing.
Another look at the use of steroids in conjunction with antibiotics for CAP. Mortality is improved in adults with severe pneumonia, and morbidity is improved in less severe cases without significant complication. Adjunctive use of steroids should be considered more frequently.
Corticosteroids in community-acquired pneumonia are still a very hot topic, so this is very useful information. The "results" continue to be nebulous. This Cochrane review helps clarify it some, but lots of things remain unknown: dose and duration are the two biggest questions still lingering. However, I think those are two very big questions and, before this can be implemented widely into clinical practice, those questions need to be better answered.