Relationship between corticosteroid use and incidence of ventilator-associated pneumonia in COVID-19 patients: a retrospective multicenter study

Abstract

Background Ventilator-associated pneumonia (VAP) is common in patients with severe SARS-CoV-2 pneumonia. The aim of this ancillary analysis of the coVAPid multicenter observational retrospective study is to assess the relationship between adjuvant corticosteroid use and the incidence of VAP. Methods Planned ancillary analysis of a multicenter retrospective European cohort in 36 ICUs. Adult patients receiving invasive mechanical ventilation for more than 48 h for SARS-CoV-2 pneumonia were consecutively included between February and May 2020. VAP diagnosis required strict definition with clinical, radiological and quantitative microbiological confirmation. We assessed the association of VAP with corticosteroid treatment using univariate and multivariate cause-specific Cox’s proportional hazard models with adjustment on pre-specified confounders. Results Among the 545 included patients, 191 (35%) received corticosteroids. The proportional hazard assumption for the effect of corticosteroids on the incidence of VAP could not be accepted, indicating that this effect varied during ICU stay. We found a non-significant lower risk of VAP for corticosteroid-treated patients during the first days in the ICU and an increased risk for longer ICU stay. By modeling the effect of corticosteroids with time-dependent coefficients, the association between corticosteroids and the incidence of VAP was not significant (overall effect p = 0.082), with time-dependent hazard ratios (95% confidence interval) of 0.47 (0.17–1.31) at day 2, 0.95 (0.63–1.42) at day 7, 1.48 (1.01–2.16) at day 14 and 1.94 (1.09–3.46) at day 21. Conclusions No significant association was found between adjuvant corticosteroid treatment and the incidence of VAP, although a time-varying effect of corticosteroids was identified along the 28-day follow-up.

Statistics on steroids: How recognizing competing risks gets us closer to the truth about COVID-19-associated VAP

“…Additionally, survival over time selects for a unique set of patients who, by virtue of some still unidentified intrinsic “sturdiness,” may not face the same chance for VAP as others. This fact is confirmed by their finding that the relationship between corticosteroids and VAP shifted over time [ 10 ].…”

“…In contrast to other sets of authors, Saura et al noted that the impact of corticosteroids on VAP varied based on the duration of MV [8][9][10]. In other words, they made the crucial observation that one could not assume that the risk for VAP as a function of corticosteroid treatment was constant over the entire duration of MV [10]. For example, a patient who does not receive corticosteroids and dies early cannot be at further risk for VAP.…”

“…In contrast to other sets of authors, Saura et al noted that the impact of corticosteroids on VAP varied based on the duration of MV [ 8 – 10 ]. In other words, they made the crucial observation that one could not assume that the risk for VAP as a function of corticosteroid treatment was constant over the entire duration of MV [ 10 ]. For example, a patient who does not receive corticosteroids and dies early cannot be at further risk for VAP.…”

“…A third report in Critical Care , however, questions this conclusion. Saura and colleagues scrutinized the impact of corticosteroids on VAP during the period before routine use of these agents [ 10 ]. Unlike other investigators, they ascertained that corticosteroid treatment did not lead to higher rates of VAP.…”

“…The conclusions of Saura et al should serve to reassure clinicians that if corticosteroid use comes with a cost in terms of VAP, it is, at most, a small cost [ 10 ]. Similarly, clinicians should not leap to believe that patients on corticosteroids for SARS-CoV-2 reflexively merit antibiotics for VAP if they decompensate—rather they should utilize rigorous diagnostic techniques to confirm VAP before embarking on a protracted course of treatment.…”