Clinical question: Among patients hospitalized with community-acquired pneumonia (CAP), does the addition of corticosteroids reduce mortality?
Dr. Salline
Background: Corticosteroids are used as an adjunctive treatment in infections like bacterial meningitis and COVID-19-related pneumonia. Previous trials and meta-analyses have been mixed in their findings of whether mortality and clinical outcomes are improved with the addition of steroids to standard antibiotic therapy for the treatment of CAP.
Study design: Systematic review and meta-analysis of randomized controlled trials
Setting: The included studies were conducted in hospital wards and intensive care units (ICUs) in the U.S., Europe, the Middle East, and Asia.
Synopsis: 16 studies comprising almost 4,000 patients met inclusion criteria. Seven studies had populations that included ICU patients. Steroid interventions were diverse and included both intravenous and oral corticosteroids, ranging in duration from 1 to 20 days. The primary outcome of all-cause mortality was 9.5% versus 10.8% for those with and without steroid therapy, respectively. The 95% confidence interval was wide and included a possibility of a 33% relative reduction and a 7% relative increase in mortality. In six trials that reported on ICU admission post-randomization, corticosteroids showed benefit, with 3.1% requiring ICU admission versus 4.7% in the standard care group (RR, 0.66; 95% CI, 0.45 to 0.97).
In eight trials that reported on need for mechanical ventilation post-randomization, adjunctive corticosteroids again showed benefit, with 4.2% in the steroid group requiring intubation versus 7.1% in the standard care group (RR, 0.51; 95% CI, 0.33 to 0.77).
Major limitations of this meta-analysis include heterogeneity in disease severity between study populations and steroid treatment intensity. Nine studies included only hospital ward patients, three studies included only ICU patients, and four studies included a mix of ward and ICU patients. The study authors did not perform a subgroup analysis pooling ICU and non-ICU studies separately.
Bottom line: Corticosteroids may benefit patients more severely ill from CAP as evidenced by lower rates of ICU admission and need for mechanical ventilation. The effect estimate for mortality reduction had a wide confidence interval, indicating continued uncertainty and the need for more studies.
Citation: Saleem N, Kulkarni A, et al. Effect of corticosteroids on mortality and clinical cure in community-acquired pneumonia: A systematic review, meta-analysis, and meta-regression of randomized control trials. Chest. 2023;163(3):484-97.
Dr. Salline is an instructor in the division of hospital medicine at the University of Colorado Anshutz Medical Campus in Aurora, Colo.