|Family Medicine (FM)/General Practice (GP)|
|General Internal Medicine-Primary Care(US)|
Background: Our aim was to evaluate the benefits and harms of adjunctive corticosteroids in adults hospitalized with community-acquired pneumonia (CAP) using individual patient data from randomized, placebo-controlled trials and to explore subgroup differences.
Methods: We systematically searched Medline, Embase, Cochrane Central, and trial registers (all through July 2017). Data from 1506 individual patients in 6 trials were analyzed using uniform outcome definitions. We investigated prespecified effect modifiers using multivariable hierarchical regression, adjusting for pneumonia severity, age, and clustering effects.
Results: Within 30 days of randomization, 37 of 748 patients (5.0%) assigned to corticosteroids and 45 of 758 patients (5.9%) assigned to placebo died (adjusted odds ratio [aOR], 0.75; 95% confidence interval [CI], .46 to 1.21; P = .24). Time to clinical stability and length of hospital stay were reduced by approximately 1 day with corticosteroids (-1.03 days; 95% CI, -1.62 to -.43; P = .001 and -1.15 days; 95% CI, -1.75 to -.55; P < .001, respectively). More patients with corticosteroids had hyperglycemia (160 [22.1%] vs 88 [12.0%]; aOR, 2.15; 95% CI, 1.60 to 2.90; P < .001) and CAP-related rehospitalization (33 [5.0%] vs 18 [2.7%]; aOR, 1.85; 95% CI, 1.03 to 3.32; P = .04). We did not find significant effect modification by CAP severity or degree of inflammation.
Conclusions: Adjunct corticosteroids for patients hospitalized with CAP reduce time to clinical stability and length of hospital stay by approximately 1 day without a significant effect on overall mortality but with an increased risk for CAP-related rehospitalization and hyperglycemia.
This IPD meta-analysis did not confirm the reduction in mortality associated with steroids shown in recent Cochrane meta-analysis, presumably because the investigators of three trials showing a larger mortality effect did not provide data. A large definitive trial, powered for appropriate subgroup analysis, is required.
It's very important to disseminate this result.
Kudos to the authors for getting study data to do individual patient data meta-analysis on this topic. It is timely in that it contradicts recent aggregate meta-analyses recommending corticosteroids in CAP based mainly on small studies with high likelihood of bias (such as the Confalonieri et al. study included here). More (and larger and better) study is needed before jumping on this bandwagon.
Critical care physicians won't be as interested in this study given the very low number of patients in this meta-analysis which were initially admitted to the ICU. It evaluates few of those patients admitted primarily to the ICU, and more secondarily transferred to the ICU -- and the clinical question posed to the intensivist ("should I start steroids in this patient who has decompensated on the ward?") wasn't addressed in this manuscript.
Although interesting, this meta-analysis didn't include well known RCTs about steroids and PNA. Perhaps these were excluded because individual patient data was not included, as the PRISMA diagram of this meta-analysis indicates.
This is useful information. There is a reduction in time to clinical stability as well as hospital length of stay which is important, however the most useful information is rehospitalizations, so clinicians have to balance giving corticosteroids. Also there are many future avenues for research. I don't think the question of use is more severe cases has been answered yet.