Clinical question: Does early hydrocortisone therapy reduce mortality among patients with severe community-acquired pneumonia (CAP) requiring admission to an intensive care unit (ICU) or intermediate care unit?
Background: Though there have been several small studies favoring the use of glucocorticoids in severe CAP, their data are mixed on mortality benefits. A recent, randomized, controlled trial (RCT) involving 586 patients showed no mortality benefit with the use of methylprednisolone, while a meta-analysis of multiple small RCTs has found mortality benefit from using glucocorticoids in severe CAP.
Study design: Multicenter, double-blind, randomized, controlled trial
Setting: 31 sites in France
Synopsis: From October 2015 to March 2020, 800 patients diagnosed with severe CAP were randomly assigned to the hydrocortisone group (401 patients) or placebo (399 patients). Patients in the hydrocortisone group received 200 mg per day intravenous hydrocortisone in continuous infusion for four to seven days followed by a taper within 24 hours of meeting eligibility criteria, including admission to an ICU or intermediate care unit. The trial excluded patients with septic shock treated with vasopressors. Antibiotics and other supportive treatments were left to the discretion of the treating team. Adverse events were similar in both groups except for a high incidence of hyperglycemia in the hydrocortisone group. All-cause 28-day mortality was significantly lower in the hydrocortisone group (6.2%) compared to the placebo group (11.9%). The use of invasive ventilation and vasopressors was also lower in the hydrocortisone group at 28 days.
Limitations of the study include a lower mortality rate in the control arm (11.9%) compared to predicted mortality of 27%, suggesting less severe illness in the cohort. Additionally, hydrocortisone was given in continuous infusion rather than bolus dosing.
Bottom line: Early hydrocortisone therapy reduces 28-day all-cause mortality and the need for mechanical ventilation and vasopressors in severe CAP.
Citation: Dequin PF, Meziani F, et al. Hydrocortisone in severe community-acquired pneumonia. N Engl J Med. 2023;388(21):1931-41.
Dr. Shinwa
Dr. Shinwa is an academic hospitalist in the division of hospital medicine at the Mount Sinai Health System, and an assistant professor of medicine at the Icahn School of Medicine at Mount Sinai in New York.