Corticosteroids for community-acquired pneumonia: a critical view of the evidence

Abstract

@ERSpublicationsThe current evidence raises more questions than answers, and does not support routine use of corticosteroids for CAP http://ow.ly/t01g302QDhGCommunity acquired pneumonia (CAP) remains a leading cause of morbidity and mortality, with mortality rates between 5% and 15% in hospitalised patients, rising to up to 30% in patients admitted to the intensive care unit (ICU) [1][2][3].There has been little progress in the management of CAP since the widespread introduction of antibiotics in the 1950s, with no new classes of drugs licensed specifically for CAP and little progress in reducing mortality. The focus of international guidelines for CAP have been on "doing the simple things well", since early antibiotic administration, appropriate fluid resuscitation, early mobilisation and guideline-concordant antibiotics have been associated with improved outcomes, albeit with low-quality evidence [3][4][5].Some of the lack of progress reflects the fact that, in many cases, mortality from CAP may be unavoidable. A third of patients admitted to hospital have "do not attempt resuscitation" orders, while only a quarter of patients dying from CAP receive mechanical ventilation before death, indicating a very high frequency of treatment restrictions [6,7].Nevertheless, there is a group of patients the CAP, usually with acute respiratory failure and septic shock, who die or experience prolonged and disabling hospital admissions despite antibiotic treatment and appropriate quality of care. These patients have marked systemic and pulmonary inflammation, providing the rationale for anti-inflammatory therapy.This background is essential to understanding the current debate around the use of oral or intravenous corticosteroid treatment in CAP.Two recent randomised controlled trials (RCTs), using very different steroid preparations and studying different patient populations, reported positive results in 2015 [8,9]. These were followed by a series of meta-analyses all suggesting positive data in favour of corticosteroid use [10].

Community-Acquired Pneumonia

“…50 Despite this evidence in favor of steroids, there are many high-quality studies showing no benefit. 51 The case for adjunctive steroids is stronger in severe CAP. 50 Steroids should be trialed in patients with vasopressor-dependent shock and selectively in patients with severe CAP and evidence of inadequate cortisol response.…”

Steroid use in critical care

“…14 However, these meta-analyses have included trials with low numbers of patients and significant heterogeneity, leading to the view that the evidence is currently inadequate for the routine use of steroids in CAP. 15 In addition, because the pathogenic aetiology of pneumonia is so varied, it is possible that the subsequent disease processes may not respond in a consistent fashion, making any beneficial effect of steroids extremely difficult to elucidate.…”

The past decade in bench research into pulmonary infectious diseases: What do clinicians need to know?

“…Although it has long been known that the host response is the major determinant of outcome from CAP, there have been no accepted additional therapies beyond antibiotics approved for the treatment of CAP. Recently, intense interest has focused on corticosteroids, with a series of trials showing no benefit, modest benefit in terms of reduction in length of stay or modest benefit in terms or radiological improvement from treatment with different corticosteroids in randomized controlled trials . A plausible explanation for the apparent variability in response is that pneumonia is a complex disorder characterized by multiple different inflammatory patterns associated with different pathogens and different hosts.…”

“…Recently, intense interest has focused on corticosteroids, with a series of trials showing no benefit, modest benefit in terms of reduction in length of stay or modest benefit in terms or radiological improvement from treatment with different corticosteroids in randomized controlled trials. 61 A plausible explanation for the apparent variability in response is that pneumonia is a complex disorder characterized by multiple different inflammatory patterns associated with different pathogens and different hosts. Therefore, a biomarker or markers that could identify responsive patients would be exceptionally valuable.…”