Steroids for Community Acquired Pneumonia
The Article: Siemieniuk RA, Meade MO, Alonso-Coello P, Briel M, Evaniew N, Prasad M, Alexander PE, Fei Y, Vandvik PO, Loeb M, Guyatt GH. Corticosteroid therapy for patients hospitalized with community-acquired pneumonia: a systematic review and meta-analysis. Ann Intern Med 2015 Oct 6;163(7)519-28.
The systematic inflammatory response that occurs as a result of pneumonia may account for worsening pulmonary dysfunction leading to ARDS and failed pneumonia treatment. Systemic adjunctive steroids may attenuate ARDS. A previous Cochrane review by Chen et al. 2011 investigated the use of steroids for pneumonia and showed a possible mortality benefit, however this study had a small number of patients and used studies of fairly low quality.
In an expansion of this prior review given the addition of several new randomized controlled trials, Siemieniuk published a systematic review and meta-analysis of 13 randomized controlled trials comparing the use of steroids versus placebo in the management of hospitalized adults with community acquired pneumonia. They included randomized controlled trials of any language in which adults were assigned to oral or IV steroids versus placebo. Exclusion criteria included studies of those with ventilator-associated pneumonia, aspiration pneumonia, PCP pneumonia and studies enrolling only COPD patients. The studies themselves excluded patients at risk for GI bleed, immunosuppressed or pregnant. They then split the data into 2 subgroups, those with less severe pneumonia and severe pneumonia given that those with more severe pneumonia would likely have a great inflammatory response and thus derive more benefit from steroids. This classification was based on various pneumonia severity scoring systems (PSI, CURB-65, ATS). Most studies used multiple doses of steroids.
This study demonstrated a mortality benefit for those patients with severe pneumonia, a reduction in mechanical ventilation and ARDS in cases of less severe pneumonia and a decreased length of stay by approximately 1 day for all pneumonia patients.. The major adverse effect identified was the need to treat hyperglycemia in 6% of cases with no long-term adverse outcomes.
This study suggests that steroids may benefit patients admitted with community-acquired pneumonia. However, the inconsistency across outcomes for the subgroup effect in the more severe pneumonia makes it unclear which patients derive the most benefit.