Adjunctive Corticosteroids May Improve Outcomes in Adults Hospitalized with Community-Acquired Pneumonia
EBM Focus - Volume 10, Issue 16
Community-acquired pneumonia is a major public health concern leading to millions of primary care and hospital visits each year in the United States alone. The Infectious Disease Society of America and American Thoracic Society (IDSA/ATS) 2007 guidelines recommend empiric antibiotic for treatment of community-acquired pneumonia (Clin Infect Dis 2007 Mar 1;44 Suppl 2:S27). Adjunctive corticosteroids are not currently recommended, but a growing body of evidence suggests they may provide clinical benefit. Two randomized trials published in 2015 compared adjunctive corticosteroids vs. placebo in adults hospitalized with community-acquired pneumonia.
The first trial from Torres et al. published in February (JAMA 2015 Feb 17;313(7):677) examined the effect of corticosteroid treatment on treatment failure and in-hospital mortality in adults with severe community acquired pneumonia. Treatment failure was evaluated as a composite outcome, with early treatment failure defined as shock, new need for invasive mechanical ventilation, or death within 3 days and late treatment failure defined as radiographic progression, persistent severe respiratory failure, shock, new need for invasive mechanical ventilation, or death between 3 and 5 days. In this trial, 120 adults (mean age 65 years) with severe community-acquired pneumonia were randomized to methylprednisolone (0.5 mg/kg per 12 hours IV bolus) vs. placebo for 5 days in addition to antibiotic treatment. All patients had a high inflammatory response at admission, defined as C-reactive protein levels > 150 mg/L . Septic shock was present in 17% of patients randomized to methylprednisolone and 31% of patients randomized to placebo (no p value reported). While there was no difference between groups in early treatment failure (10% per group), methylprednisolone was associated with a significantly decreased risk of late treatment failure compared to placebo (3% vs. 25%, p = 0.001, NNT 5). There were also no significant differences in in-hospital mortality, length of hospital or intensive care unit stay, time to clinical stability, or adverse events.
The second trial by Blum et al. recently published in The Lancet (Lancet 2015 Apr 18;385(9977):1511) evaluated oral corticosteroids in a larger population of adults hospitalized with pneumonia of any severity. The primary outcome of this trial was time to clinical stability, a composite outcome defined as time until vital signs were stable for ≥ 24 hours. Here, 802 adults (mean age 74 years) were randomized to prednisone (50 mg daily) vs. placebo for 7 days in addition to antibiotic treatment. Patients presented with a number of comorbidities, including renal insufficiency in 32%, antibiotic pretreatment in 23%, diabetes mellitus in 20%, heart failure in 18%, chronic obstructive pulmonary disease in 17%, and coinfection in 12%. Comparing prednisone to placebo, time to clinical stability was 3 days vs. 4.4 days (p < 0.0001) and length of hospital stay was 6 days vs. 7 days (p = 0.012). Consistent results were reported in subgroup analyses by age, median C-reactive protein concentration, history of chronic obstructive pulmonary disease, severity of pneumonia, or blood culture positivity. There were no significant differences in recurrent pneumonia, hospital readmission, or pneumonia-associated mortality.
Together, the results of these trials suggest that the addition of corticosteroids to antibiotic treatment may improve the clinical course of disease in patients hospitalized with pneumonia, regardless of disease severity. These trials have several limitations, however. Neither trial considered patients with community-acquired pneumonia treated in an outpatient setting. The trial by Torres et al. evaluated corticosteroids in a very specific population of patients with severe pneumonia plus high inflammatory responses, therefore these results may not be generalizable. Also, the decreased rate of late treatment failure observed in the methylprednisolone group in this trial may have been influenced by the lower percentage of patients with septic shock at baseline randomized to this treatment. While the trial by Blum et al. evaluated the use of adjunctive corticosteroids in a broader patient population, the individual components of the time to clinical stability composite outcome were not reported. One component of this outcome is a temperature of 37.8⁰C (100⁰F) or lower. Treatment with corticosteroids can result in a decrease in fever and a change in body temperature alone cannot be ruled out. Absence of fever is also a common component of discharge criteria, questioning the effect of corticosteroids on decreasing the length of hospital stay as well. The results of these trials show potential benefit for adjunctive corticosteroid use in hospitalized patients with community-acquired pneumonia, but further analysis is required to determine at what dose and in which patient populations they are truly effective.
For more information, see the Community-acquired pneumonia in adults topic in DynaMed.