Clinical question: Does early administration of glucocorticoids to intensive care unit (ICU) patients with severe community-acquired pneumonia (CAP) reduce mortality?
Ms. Harakal
Background: Previous, randomized, controlled trials have shown efficacy in using glucocorticoids in CAP treatment as far as clinical stabilization and reduction in length of stay. However, there is no substantial evidence regarding a reduction in mortality due to the use of glucocorticoids.
Study design: Double-blind, randomized, placebo-controlled trial
Setting: 31 French ICUs
Synopsis: The study randomized 795 ICU patients with severe CAP to continuous infusion of 200 mg hydrocortisone daily versus saline infusion in a 1:1 ratio within 24 hours of meeting the severity criteria. All patients received standard-of-care CAP treatment, including antibiotics and supportive measures. At baseline, respiratory support included mechanical ventilation (44%, half of them non-invasive), high-flow nasal cannula (42%), and non-rebreather mask (14%). The primary outcome was 28-day all-cause mortality, which occurred for 6.2% of patients treated with hydrocortisone and 11.9% receiving the placebo. Absolute risk reduction (ARR) was 5.6% (95% CI, 1.7 to 9.6%, P = 0.006), and the number needed to treat (NNT) was 18 to prevent one death. Notable secondary outcomes included 11.5% ARR in the need for endotracheal intubation (NNT = 9) and 10% ARR in the need for vasopressors (NNT = 10). The only statistically significant difference in safety outcomes was higher mean insulin requirements for those assigned to hydrocortisone. Some limitations include the exclusion of patients with septic shock, no standardized isolation of causative microbes, and the inclusion of only a small number of immunocompromised patients.
Bottom line: Early administration of hydrocortisone in severe CAP is associated with a lower risk of all-cause 28-day mortality.
Citation: Dequin PF, Meziani F, et al. Hydrocortisone in severe community-acquired pneumonia. N Engl J Med. 2023;388(21):1931-41.
Ms. Harakal is an instructor in the division of hospital medicine at the University of Colorado Anshutz Medical Campus in Aurora, Colo.