Systemic corticosteroids for community‐acquired pneumonia: Reasons for use and lack of benefit on outcome

Polverino, Eva; Cillóniz, Catia; Dambrava, Póvilas; Gabarrús, Albert; Ferrer, Miquel; Agustı́, Carlos; Prina, Elena; Montull, Beatriz; Menéndez, Rosário; Niederman, Michael S.

doi:10.1111/resp.12013

Cited by 31 publications

(31 citation statements)

References 27 publications

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“…Earlier studies involving relatively small numbers of adult patients with severe CAP [60-62], and more recently in children [63], reported a benefit of adjunctive intravenous corticosteroid therapy with respect to duration of hospital stay or mortality or both. Somewhat disappointingly, however, the promise of this adjunctive strategy has not been confirmed in one large, randomized, double-blinded, placebo-controlled trial in adults with severe CAP [64] or in another large retrospective study [65]. Although the reasons for the apparent lack of efficacy of systemic administration of corticosteroids are unknown, it is noteworthy that neutrophils are relatively insensitive to the anti-inflammatory actions of corticosteroids [66].…”

Section: Adjuvant Anti-inflammatory Strategies In Severe Pneumococcalmentioning

confidence: 99%

Recent advances in our understanding of Streptococcus pneumoniae infection

Feldman

2014

F1000Prime Rep

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A number of significant challenges remain with regard to the diagnosis, treatment, and prevention of infections with Streptococcus pneumoniae (pneumococcus), which remains the most common bacterial cause of community-acquired pneumonia. Although this infection is documented to be extremely common in younger children and in older adults, the burden of pneumonia it causes is considerably underestimated, since the incidence statistics are derived largely from bacteremic infections, because they are easy to document, and yet the greater burden of pneumococcal pneumonias is non-invasive. It has been estimated that for every bacteremic pneumonia that is documented, three non-bacteremic infections occur. Management of these infections is potentially complicated by the increasing resistance of the isolates to the commonly used antibiotics. Furthermore, it is well recognized that despite advances in medical care, the mortality of bacteremic pneumococcal pneumonia has remained largely unchanged over the past 50 years and averages approximately 12%. Much recent research interest in the field of pneumococcal infections has focused on important virulence factors of the organism, on improved diagnostic and prognostication tools, on defining risk factors for death, on optimal treatment strategies involving both antibiotics and adjunctive therapies, and on disease prevention. It is hoped that through these endeavors the outlook of pneumococcal infections will be improved.

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Section: Adjuvant Anti-inflammatory Strategies In Severe Pneumococcalmentioning

confidence: 99%

Recent advances in our understanding of Streptococcus pneumoniae infection

Feldman

2014

F1000Prime Rep

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“…While some authors advise five days of glucocorticoid treatment in critically ill patients without tapering [49-51], others recommend tapering of glucocorticoids to avoid a rebound of inflammatory markers with consecutive rebound pneumonia [37,45,46,52]. However, it has been shown that glucocorticoids given > seven days lead to a worse clinical course measured by length of stay, clinical stability and mechanical ventilation, and more systemic complications when looking at shock and cardiac arrhythmia [53]. From COPD studies, there is evidence that stopping glucocorticoids without tapering is safe without an increased recurrence rate [54].…”

Section: Discussionmentioning

confidence: 99%

Corticosteroid treatment for community-acquired pneumonia - the STEP trial: study protocol for a randomized controlled trial

Blum

Nigro

Winzeler

et al. 2014

Trials

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BackgroundCommunity-acquired pneumonia (CAP) is the third-leading infectious cause of death worldwide. The standard treatment of CAP has not changed for the past fifty years and its mortality and morbidity remain high despite adequate antimicrobial treatment. Systemic corticosteroids have anti-inflammatory effects and are therefore discussed as adjunct treatment for CAP. Available studies show controversial results, and the question about benefits and harms of adjunct corticosteroid therapy has not been conclusively resolved, particularly in the non-critical care setting.Methods/DesignThis randomized multicenter study compares a treatment with 7 days of prednisone 50 mg with placebo in adult patients hospitalized with CAP independent of severity. Patients are screened and enrolled within the first 36 hours of presentation after written informed consent is obtained. The primary endpoint will be time to clinical stability, which is assessed every 12 hours during hospitalization. Secondary endpoints will be, among others, all-cause mortality within 30 and 180 days, ICU stay, duration of antibiotic treatment, disease activity scores, side effects and complications, value of adrenal function testing and prognostic hormonal and inflammatory biomarkers to predict outcome and treatment response to corticosteroids. Eight hundred included patients will provide an 85% power for the intention-to-treat analysis of the primary endpoint.DiscussionThis largest to date double-blind placebo-controlled multicenter trial investigates the effect of adjunct glucocorticoids in 800 patients with CAP requiring hospitalization. It aims to give conclusive answers about benefits and risks of corticosteroid treatment in CAP. The inclusion of less severe CAP patients will be expected to lead to a relatively low mortality rate and survival benefit might not be shown. However, our study has adequate power for the clinically relevant endpoint of clinical stability. Due to discontinuing glucocorticoids without tapering after seven days, we limit duration of glucocorticoid exposition, which may reduce possible side effects.Trial registration7 September 2009 on ClinicalTrials.gov: NCT00973154.

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“…Several earlier studies and one recent randomized trial have suggested that steroids have the benefit of leading to a more rapid resolution of fever and hypoxemia and less need for mechanical ventilation [37]. Polverino and colleagues [38], in a retrospective study, found that routine steroid therapy had no benefit in patients with CAP if it was not used for another established indication. In a population of 3,257 patients with CAP, 260 received corticosteroids, generally because of chronic respiratory illness or a severe clinical presentation, but there was no benefit in mortality and there was a longer length of stay (9 versus 6 days, P <0.01).…”

Section: New Insights Into Treatment Strategiesmentioning

confidence: 99%

Year in review 2012: Critical Care - respiratory infections

Nair

Niederman

2013

Critical Care

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Over the last two decades, considerable progress has been made in the understanding of disease mechanisms and infection control strategies related to infections, particularly pneumonia, in critically ill patients. Patient-centered and preventative strategies assume paramount importance in this era of limited health-care resources, in which effective targeted therapy is required to achieve the best outcomes. Risk stratification using severity scores and inflammatory biomarkers is a promising strategy for identifying sick patients early during their hospital stay. The emergence of multidrug-resistant pathogens is becoming a major hurdle in intensive care units. Cooperation, education, and interaction between multiple disciplines in the intensive care unit are required to limit the spread of resistant pathogens and to improve care. In this review, we summarize findings from major publications over the last year in the field of respiratory infections in critically ill patients, putting an emphasis on a newer understanding of pathogenesis, use of biomarkers, and antibiotic stewardship and examining new treatment options and preventive strategies.

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Systemic corticosteroids for community‐acquired pneumonia: Reasons for use and lack of benefit on outcome

Cited by 31 publications

References 27 publications

Recent advances in our understanding of Streptococcus pneumoniae infection

Recent advances in our understanding of Streptococcus pneumoniae infection

Corticosteroid treatment for community-acquired pneumonia - the STEP trial: study protocol for a randomized controlled trial

Year in review 2012: Critical Care - respiratory infections

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