Mini-CAT

Matt Lemieszewski
PA Portfolio I – Spring 2022
Mini-CAT

Clinical Scenario:
A 47-year-old male comes into the clinic, and it suspected of having a case of community acquired pneumonia. The medical provider refers him out for a chest x-ray as ours was not in working condition but considers prescribing an adjunctive corticosteroid in addition to antibiotic use of azithromycin.

Search Question:
What is the efficacy of adjunctive corticosteroids on duration of symptoms in patients diagnosed with community acquired pneumonia?

PICO Table:

PopulationInterventionComparisonOutcome(s)
PneumoniaCorticosteroidsPlaceboShortened duration of symptoms
CAPDexamethasoneAntibiotic treatmentDecreased morbidity
Community-acquired PNAPrednisoneMacrolidesLower follow-up visits
 Adjunctive corticosteroidTetracyclines 
    

Search Strategy and Databases Used:

  • PubMed:
    • Community acquired pneumonia and corticosteroids: 452
    • Community acquired pneumonia and corticosteroids and outcome: 17
  • JAMA:
    • Community acquired pneumonia and corticosteroids and outcome: 6
    • CAP and corticosteroids and antibiotics: 14
  • Science Direct:
    • CAP and corticosteroids with antibiotics: 502
    • CAP and corticosteroids with antibiotics AND outcomes: 294
  • Medicine (Baltimore)
    • Steroid use AND community acquired pneumonia: 5

I narrowed down the initial list of hundreds of articles by choosing the studies that were most relevant to my clinical scenario and question. Because my search question included both patient therapy and prognosis, I screened for articles that were either meta-analyses, systematic reviews, or randomized control trials if neither of the former were available. A randomized controlled trial (RCT) can give evidence of efficacy and efficiency while minimizing or eliminating bias. A randomized controlled trial (RCT) is a well-designed and well-executed experiment that allows for direct comparisons of interventions and controls despite numerous variables. To assure the most up-to-date treatment for community-acquired pneumonia, I also considered studies with a large subject group and those that were recently conducted.

Research Used:

CitationJiang S, Liu T, Hu Y, et al. Efficacy and safety of glucocorticoids in the treatment of severe community-acquired pneumonia: A meta-analysis. Medicine (Baltimore). 2019;98(26):e16239. doi:10.1097/MD.0000000000016239
AbstractBackground: Recent clinical trials have shown that adjunctive glucocorticoids is associated with inhibiting excessive inflammatory response and modulating cytokines release offering several advantages over conventional therapy on relieving clinical symptoms, reducing mortality, and improving prognosis. However, given the severe complications triggered by glucocorticosteroid, whether similar benefits may be achieved by patients undergoing glucocorticosteroid intervention remains controversial. Our meta-analysis aimed to investigate the efficacy and safety of adjunctive glucocorticoids in the treatment of severe community acquired pneumonia.   Methods: A search of PubMed, EMBASE, Cochrane Library, EBASO, Medline, Google Scholar, Science Dicet, CBM, and CNKI databases was performed to analyze all relevant randomized controlled trials (RCTs) of corticosteroids in patients with severe community acquired pneumonia (CAP) up to January 2018. All-cause mortality, C-reactive protein (CRP) level, incidence of septic shock, and requirement of mechanical ventilation were selected as efficacy outcomes. Major adverse events involving super infection, upper gastrointestinal bleeding, and hyperglycemia were safety outcomes. Meta-analysis was conducted with RevMan 5.3 software.   Results: A total of 10 RCTs comprising 665 patients were included for analysis. Regarding efficacy outcomes, adjunctive corticosteroid seemed to be superior compared with conventional treatment in terms of all-cause mortality (relative risk [RR]: 0.47, 95% confidence interval [CI], 0.3–0.74, P = .001), CRP level on day 8 after administration (standard mean difference [SMD]: −0.8, 95% CI, −1.11 to −0.5, P < .001), incidence of septic shock (odds ratio [OR] 0.15, 95% CI, 0.07–0.29, P < .001) and requirement for mechanical ventilation (OR: 0.32, 95% CI, 0.20–0.52, P < .001). Meanwhile, we found that low dose (≤86 mg) (RR: 0.41, 95% CI, 0.21–0.82, P = .01) and prolonged (>5 days) (RR: 0.35, 95% CI, 0.15–0.81, P = .01) use of corticosteroids in dosage modus of a maintenance dose after a bolus (RR: 0.28, 95% CI, 0.14–0.55, P = .002) obtained better results in death through subgroup analysis. Regarding safety outcomes, no difference was observed between 2 groups in terms of upper gastrointestinal bleeding (OR: 0.83, 95% CI, 0.27–2.52, P = .74), hyperglycemia (OR: 1.3, 95% CI, 0.68–2.49, P = .42), and super infection (OR: 1.11, 95% CI, 0.14–9.13, P = .92).   Conclusion: Adjunctive corticosteroid yielded favorable outcomes in the treatment of severe community acquired pneumonia (SCAP) as evidenced by decreased all-cause mortality, incidence of septic shock, and requirement for mechanical ventilation without increasing risk of adverse events. Low dose (≤86 mg/d), prolonged use (>5 days) of corticosteroid in dosage modus of a maintenance dose after a bolus can be recommended as preferred regimen to guard against SCAP.
Link:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6616855/
CitationStern A, Skalsky K, Avni T, Carrara E, Leibovici L, Paul M. Corticosteroids for pneumonia. Cochrane Database Syst Rev. 2017 Dec 13;12(12):CD007720. doi: 10.1002/14651858.CD007720.pub3. PMID: 29236286; PMCID: PMC6486210.
AbstractBackground: 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.   Search Methods and Selection Criteria: 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. 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.   Results: 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).   Corticosteroids 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).   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.
Link:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6486210/
CitationHuang, Jing, et al. “Efficacy and Safety of Adjunctive Corticosteroids Therapy for Patients with Severe Community-Acquired Pneumonia.” Medicine, vol. 98, no. 13, Mar. 2019, doi:10.1097/md.0000000000014636.
AbstractBackground: The systemic use of corticosteroids for patients in severe community-acquired pneumonia (CAP) remains disputed in clinical practice. We undertook a systematic review and meta-analysis to assess the efficacy and safety of corticosteroids in patients with severe CAP.   Methods: We searched MEDLINE (1946 to June 2018), EMBASE (1966 to June 2018), and the Cochrane Library database for randomized controlled trials (RCTs) conducted for severe CAP. The endpoints of the study included total mortality, length of intensive care unit (ICU) stay and mechanical ventilation.   Results: Nine trials which contained 914 patients were included for final meta-analysis. Of the 488 patients in the corticosteroid group, there were 37 deaths (7.58%) and 56 deaths occurred in 426 patients in the control group (13.1%). Corticosteroid therapy was associated with a lower rate of all-cause mortality compared to control (odd ratio [OR] 0.63, 95% confidence interval [CI] 0.42–0.95, P = .03). Subgroup analysis was conducted to show that the drug type modified the effect of steroids for mortality rate: prednisolone or methylprednisolone therapy (OR 0.37, 95% CI 0.19–0.72) reduced total mortality, whereas hydrocortisone use did not (OR 0.90, 95% CI 0.54–1.49). We found the length of ICU stay was significantly shorter in the steroid group compared to control (MD −2.52 days, 95% CI −4.88 to −0.15; P = .04). And there was a reduction trend in the need for mechanical ventilation in corticosteroid group (OR 0.53, 95% CI 0.28–1.02; P = .06). There was no trend towards more adverse events in the corticosteroid arm compared to control (OR 0.92, 95% CI 0.58–1.47; P = .74).   Conclusion: Overall, adjunctive systemic corticosteroids therapy was effective and safe for patients with severe CAP. In addition, the effects of mortality may differ according to the type of corticosteroids.
Link:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6456091/
CitationTorres A, Sibila O, Ferrer M, et al. Effect of Corticosteroids on Treatment Failure Among Hospitalized Patients With Severe Community-Acquired Pneumonia and High Inflammatory Response: A Randomized Clinical Trial. JAMA. 2015;313(7):677–686. doi:10.1001/jama.2015.88
AbstractDesign, Setting, and Participants:  Multicenter, randomized, double-blind, placebo-controlled trial conducted in 3 Spanish teaching hospitals involving patients with both severe community-acquired pneumonia and a high inflammatory response, which was defined as a level of C-reactive protein greater than 150 mg/L at admission. Patients were recruited and followed up from June 2004 through February 2012.   Interventions: Patients were randomized to receive either an intravenous bolus of 0.5 mg/kg per 12 hours of methylprednisolone (n = 61) or placebo (n = 59) for 5 days started within 36 hours of hospital admission.   Results: There was less treatment failure among patients from the methylprednisolone group (8 patients [13%]) compared with the placebo group (18 patients [31%]) (P = .02), with a difference between groups of 18% (95% CI, 3% to 32%). Corticosteroid treatment reduced the risk of treatment failure (odds ratio, 0.34 [95% CI, 0.14 to 0.87]; P = .02). In-hospital mortality did not differ between the 2 groups (6 patients [10%] in the methylprednisolone group vs 9 patients [15%] in the placebo group; P = .37); the difference between groups was 5% (95% CI, −6% to 17%). Hyperglycemia occurred in 11 patients (18%) in the methylprednisolone group and in 7 patients (12%) in the placebo group (P = .34).   Conclusions and Relevance: Among patients with severe community-acquired pneumonia and high initial inflammatory response, the acute use of methylprednisolone compared with placebo decreased treatment failure. If replicated, these findings would support the use of corticosteroids as adjunctive treatment in this clinical population.
Link:https://jamanetwork.com/journals/jama/fullarticle/2110967

Summary of Evidence:

Author (Date)Level of EvidenceSample/Setting (# of subjects/ studies, cohort definition etc. )Outcomes StudiedKey FindingsLimitations and Biases
Jiang S., et al (2019)Meta-analysis10 RCTs comprising of 665 patients   Inclusion criteria: clinical randomized controlled trials published at home and abroad in English and Chinese which compared antimicrobial therapy and adjunctive systematic glucocorticoids therapy with antimicrobial therapy alone in patients with severe community acquired pneumonia.   Patients aged >18 years old who were diagnosed with SCAP that met the definition and diagnostic criteria formulated by the American Association of Infectious Diseases and American Thoracic Society   Diagnostic criteria for severe CAP in IDSA/ATS: At least 1 major or 3 minor criteria were satisfied. Major criteria: necessity of tracheal intubation and mechanical ventilation; occurrence of septic shock or still requiring vasoactive drugs after active fluid resuscitation. Minor criteria: respiratory rate≥30 bpm; oxygenation index≤250 mm Hg; radiological multilobar involvement; disturbance of consciousness or disorientation; blood urea nitrogen ≥7.14 mmol/L; systolic blood pressure <90 mm Hg, requiring active fluid resuscitation.Primary: All-cause mortality.   Secondary: Inflammatory index outcome (CRP), the risk of septic shock (which need vasopressors), need for mechanical ventilation (invasive or not invasive), and occurrence of adverse reaction, including the risk of super infection, hyperglycemia, and upper gastrointestinal bleeding.  Despite the fact that glucocorticoids can help individuals with severe CAP, they can also cause major adverse effects, including super infection, upper gastrointestinal hemorrhage, and hyperglycemia. As a result, the question of whether systemic glucocorticoids can enhance the prognosis and safety of patients with severe CAP has become very controversial.   In patients with severe CAP, adjunctive corticosteroid treatment was superior to antimicrobial therapy in lowering all-cause death.   In individuals with severe CAP, corticosteroids were linked to a lower risk of serious sequelae (such as septic shock and the need for mechanical ventilation).The collected studies have a limited sample size, which has a considerable impact on the results’ reliability.   The clinical variability among the included studies could not be resolved because there is no broad agreement on a common definition of a scoring system in severe CAP.   A single standard is difficult to achieve due to the severity, complexity, and laboratory evaluation of the included patients.   Due to a lack of long-term follow-up data, it is difficult to determine the risk of death, as revealed by analysis.    
Stern A,. et al (2017)Meta-analysisA total of 2264 participants were randomized (1122 to the intervention arm), of whom 1954 (86%) were adults (n = 13 trials, mean age 69.8 years) and 307 (14%) were children (n = 4 trials, mean age 5.6 years, Luo 2014; Nagy 2013; Van Woensel 2003; Wu 2014). Of the adult trials, three reported that no people with chronic lung disease were included (Mikami 2007; Nafae 2013; Sabry 2011); in six trials reporting data between 11.2% and 35.9% of participants had chronic lung disease. A single trial reported that people with diabetes mellitus were not included (McHardy 1972), and in five trials between 10.3% and 19.7% of participants had diabetes.   The intervention included oral prednisone in three trials, and intravenous dexamethasone, hydrocortisone, or methylprednisolone in 13 trials.Primary: All‐cause mortality within 30 days after randomization. If not reported at day 30, outcome closest to 30 days was used.   Secondary: Early clinical failure (clinical failure at 5 to 7 days), defined as death from any cause, radiographic progression, or clinical instability, as defined in the study.   Time to clinical cure, defined at least by no fever, hemodynamic stability, and return to baseline respiratory condition.   Development of respiratory failure not present initially, defined as need for non‐invasive or invasive mechanical ventilation that was not present at onset of pneumonia.   Development of shock not present initially.   Transfer to ICU among participants not admitted initially to the ICU.  The results support the use of corticosteroids in adults with severe community‐acquired pneumonia (CAP) using either the Infectious Diseases Society of America and American Thoracic Society guidelines or British Thoracic Society criteria for severe CAP   People with non‐severe CAP may benefit from corticosteroid therapy as well, but with no survival advantage.   Analysis of pediatric trials was not included in the clinical recommendations here as the trials themselves showed different inclusion criteria. In the bacterial pneumonia trials though, corticosteroids did reduce early clinical failure rates which is promising.In the subgroups of severe and nonsevere pneumonia, only two trials provided mortality data per research arm.   According to the death rate in the control arm, we categorized the remaining trials as having severe or nonsevere pneumonia individuals.   The majority of trials are classified at the trial level rather than at the participant level.   Although mortality reflects the severity of pneumonia, it can also be impacted by other factors such as the antibiotic regimens employed or the level of medical care provided in a given center.
Huang J,. et al (2019)Meta-analysisRelevant studies were identified by searching the following data sources: MEDLINE by OVID (from 1950 to June 2018), Embase (from 1970 to June 2018) and the Cochrane Library database (Cochrane Central Register of Active controlled Trials; no date restriction).   Nine trials, 914 patients included.Primary: Mortality   Secondary: Length of ICU stay   Necessity of mechanical ventilation  Nine trials which contained 914 patients were included for final meta-analysis. Of the 488 patients in the corticosteroid group, there were 37 deaths (7.58%) and 56 deaths occurred in 426 patients in the control group (13.1%).   Adjunctive systemic corticosteroids therapy was effective and safe for patients with severe CAP.   The effects of mortality may differ according to the type of corticosteroids.The corticosteroid regimens for severe CAP were not thoroughly explained; there was some variation in corticosteroid prescription in these trials.   The criteria of severe CAP used in these research differed, affecting the severity of disease and consequences reported. As a result, in clinical practice, the diagnosis of severe CAP should be better clarified.
Torres A., et al (2015)Randomized control trialInclusion criteria: (1) were aged 18 years or older (2) had clinical symptoms suggesting community-acquired pneumonia (cough, fever, pleuritic chest pain, or dyspnea) (3) had a new chest radiographic infiltrate (4) met severe community-acquired pneumonia criteria (defined by modified American Thoracic Society criteria16 or risk class V for the Pneumonia Severity Index17) (5) had a C-reactive protein (CRP) level of greater than 150 mg/L at admission (to convert CRP to mmol/L, multiply by 9.524).   Exclusion Criteria:
(1) prior treatment with systemic corticosteroids (2) nosocomial pneumonia (3) reported severe immunosupression (HIV infection, immunosuppressive conditions or medications) (4) preexisting medical condition with a life expectancy of less than 3 months (5) uncontrolled diabetes mellitus		Primary: Treatment failure (composite outcome of early treatment failure defined as: [1] clinical deterioration indicated by development of shock [2] need for invasive mechanical ventilation not present at baseline, or [3] death within 72 hours of treatment   Composite outcome of late treatment failure defined as [1] radiographic progression, [2] persistence of severe respiratory failure, [3] development of shock, [4] need for invasive mechanical ventilation not present at baseline, [5] death between 72 hours and 120 hours after treatment initiation   Secondary: In-hospital mortality12% to 36% of patients admitted to the ICU die within a short period. Furthermore, patients in the Pneumonia Severity Index risk class V have a significantly higher fatality rate. This highlights the importance of developing an effective adjunctive treatment plan.   The rate of treatment failure in the control group was 31% in patients with severe community-acquired pneumonia. Treatment failure was reduced from 31% to 13% in patients treated with methylprednisolone. Additionally, they found a more than 50% decrease of progression in the pulmonary infiltrates.There was no assessment of adrenal function, thus it’s possible that methylprednisolone helped those with relative adrenal insufficiency but was less useful in those without.   Methylprednisolone was only given for 5 days; however, other studies have found that corticosteroid treatment given for longer than 5 days in individuals with community-acquired pneumonia has a favorable effect.   The sample size was calculated using data from a previous study that took place in 15 hospitals and employed comparable inclusion criteria as the current investigation. However, the treatment failure rate in this study’s placebo group (31%) was lower than in the previous study’s control group. The current trial has less statistical power than expected due to the observed treatment failure in the placebo group.

Conclusion:

Research Article 1: (Jiang 2019) This meta-analysis looked at the data from 10 randomized controlled trials that directly looked into the intervention comparison laid out in my question. However, it should be noted that this study evaluated the efficacy of corticosteroid therapy in terms of secondary infection.  The inflammatory response of the host is a critical factor in determining the prognosis of severe CAP. In addition, any given patient may have a different level of adrenal function which can impact the effect of corticosteroids. Because this cannot ever be standardized among patients, the results should be taken with some caution

Research Article 2: Stern (2017) Another meta-analysis showed that 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 hyperglycemia, but the harms did not seem to outweigh the benefits.

Research Article 3: (Huang 2019) In a prospectively identified sample of patients with severe community-acquired pneumonia and a high inflammatory response, immediate methylprednisolone therapy was linked with reduced treatment failure and a lower inflammatory response. Treatment failure was 31 percent in the control group, which is similar to a prior study that found a 35 percent treatment failure rate in patients with severe community-acquired pneumonia. Patients given methylprednisolone had a lower rate of treatment failure, dropping from 31% to 13%. The main effect of this trial was the reduction in radiographic advancement (pulmonary infiltrates progressed by more than 50%). In prior studies of community-acquired pneumonia, this characteristic was demonstrated to be an independent surrogate marker of death.

Research Article 4: (Torres, 2015) In this double-blind RCT, the primary outcome was not one that I had searched for and that was looking at treatment failure as opposed to treatment success and lower morbidity and mortality. In-hospital mortality was a secondary outcome and adverse events were assessed. However, I believe this study’s biggest limitation is the long duration of the inclusion period. We all know that medicine and treatment is constantly involving, so conducting research for close to a decade, I feel many things could have changed in management over this period of time.

Weight of the evidence – summarize the weaknesses/strengths of the articles and explain how they factored into your clinical bottom line (this may recap what you discussed in the criteria for choosing the articles)

  1. Jiang, 2019: I would weight this article as the strongest of the 4. A meta-analysis that, while it did not have the largest sample size, did have the strictest inclusion criteria while also defining illness and severity based on the recommendations of both the Infectious Disease Society of America (IDSA) and the American Thoracic Society (ATS).

  2. Stern, 2017: Another meta-analysis, I would weigh this the next strongest study. With the largest sample size of almost 2000 adult patients, this study was conducted to assess my exact search question as systemic corticosteroid therapy given adjunctively to antibiotic treatment, compared to placebo as well as no treatment. Additionally, they only included patients with community acquired pneumonia as patients that developed in hospital or already using assisted mechanical ventilation are cared for differently.

  3. Huang, 2019: Another meta-analysis, had the largest range of collected data, with collections from 1950-2018. Additionally, this study defined the most primary outcomes and adverse events to be studied. Finally, their inclusion criteria was very selective, completed by 2 independent authors and including a third if a disagreement had occurred.

  4. Torres, 2015: Finally, a multicenter, randomized, double-blind, placebo-controlled trial prospectively enrolled patients and followed up from 2004 to 2012. This study is presented as the weakest study as it has a small sample size and only looks at the effects of one drug (methylprednisolone). However, this study still holds weight as they extensively showed results of over ten primary and secondary clinical outcomes.

Magnitude of Effect

  1. Jiang, 2019: Regarding efficacy outcomes, adjunctive corticosteroid seemed to be superior compared with conventional treatment in terms of all-causemortality (relative risk [RR]: 0.47, 95% confidence interval [CI], 0.3–0.74, P=.001), CRP level on day 8 after administration (standard mean difference [SMD]: -0.8, 95% CI, -1.11 to -0.5,P<.001), incidence of septic shock (odds ratio [OR] 0.15, 95%CI, 0.07–0.29, P<.001) and requirement for mechanical ventilation (OR: 0.32,95%CI, 0.20–0.52,P<.001).Meanwhile,we found that lowdose (<86mg) (RR: 0.41,95%CI, 0.21–0.82,P=.01) and prolonged (>5 days) (RR: 0.35, 95% CI, 0.15–0.81, P=.01) use of corticosteroids in dosagemodus of a maintenance dose after a bolus (RR: 0.28, 95%CI, 0.14–0.55, P=.002) obtained better results in death through subgroup analysis.

  2. Stern, 2017: 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 nonsevere 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. Hyperglycaemia was significantly more common in adults treated with corticosteroids (RR 1.72, 95% CI 1.38 to 2.14).

  3. Huang, 2019: Corticosteroid therapy was associated with a lower rate of all-cause mortality compared to control (odd ratio [OR] 0.63, 95% confidence interval [CI] 0.42–0.95, P=.03). Subgroup analysis was conducted to show that the drug type modified the effect of steroids for mortality rate: prednisolone or methylprednisolone therapy (OR 0.37, 95% CI 0.19–0.72) reduced total mortality, whereas hydrocortisone use did not (OR 0.90, 95% CI 0.54–1.49). The length of ICU stay was significantly shorter in the steroid group compared to control (MD -2.52 days, 95% CI -4.88 to -0.15; P=.04). And there was a reduction trend in the need for mechanical ventilation in corticosteroid group (OR 0.53, 95% CI 0.28–1.02; P=.06).

  4. Torres, 2015: There was less treatment failure among patients from the methylprednisolone group (8 patients [13%]) compared with the placebo group (18 patients [31%]) (P = .02), with a difference between groups of 18%(95%CI, 3%to 32%). Corticosteroid treatment reduced the risk of treatment failure (odds ratio, 0.34 [95%CI, 0.14 to 0.87]; P = .02). In-hospital mortality did not differ between the 2 groups (6 patients [10%] in the methylprednisolone group vs 9 patients [15%] in the placebo group; P = .37). Hyperglycemia occurred in 11 patients (18%) in the methylprednisolone group and in 7 patients (12%) in the placebo group (P = .34).

Clinical Bottom Line and Significance:

According to these studies, along with findings of the American Thoracic Society (ATS)/Infectious Diseases Society of America (IDSA), frequent use of glucocorticoids as an additional treatment for CAP is not supported. The goal of CAP treatment is to minimize the inflammatory response to pneumonia, which can lead to morbidity and mortality. However, the population that would benefit the most from this intervention isn’t well characterized, and there could be serious side effects. Risk factors for serious side effects, such as recent gastrointestinal bleeding, poorly controlled diabetes, or severe immunocompromise, are all reasons to avoid glucocorticoids in such patients.

Adjunctive corticosteroids can reduce mortality, length of hospital, and significantly lowered treatment failure rates in the treatment of severe community-acquired pneumonia. For that reason, it would be my recommendation to consider use only in patients with severe enough infection to require hospitalization. It was found that the mortality rate for individuals with higher risk of needing assisted ventilation or likelihood of developing shock was extremely high. It’s also worth noting that corticosteroid medication has been linked to side effects like hyperglycemia among other adverse reactions, so diabetic patients should take caution as none of the studies that I used looked at this specific patient population. Future research should strive to conduct a larger size study with more participants to ensure that the findings are more accurate. One other thing that I did not see it finding a way to decide on the correct dose for treatment.