Introduction
Materials and methods
Selection of participants, data collection, and definitions
Results
Reference | Study design | Sample size, number | Patient selection | Corticosteroids (drug/regimen) | Primary endpoints | Level of evidence and recommendation |
---|---|---|---|---|---|---|
Marik, et al. [21] | Single-center RCT | 30 | Severe CAP | Hydrocortisone 10 mg/kg versus placebo 30 minutes before antibiotics | Mortality, clinical course, and serum TNF-α levels | Weak recommendation, moderate-quality evidence |
Confalonieri, et al. [6] | Multicenter RCT | 46 | Severe CAP | Hydrocortisone 200 mg + hydrocortisone 10 mg/hour for 7 days versus placebo | Mortality, clinical course, and systemic inflammation | Strong recommendation, moderate-quality evidence |
Mikami, et al. [20] | Open-label RCT | 31 | Moderate and severe CAP | Prednisolone 40 mg qd for 3 days versus placebo | Mortality and clinical course | Weak recommendation, low-quality evidence |
Garcia-Vidal, et al. [19] | Retrospective cohort study | 308 | Severe CAP | Methylprednisolone 14.5 mg (or equivalent) qd for 11.4 days | Mortality | Strong recommendation, low-quality evidence |
Reference | Mortality, percentage | Clinical course | Systemic inflammation | ||
---|---|---|---|---|---|
LOS, days | MODS | AB duration, days | |||
Marik, et al. [21] | 7.1 versus 18.8 (P = NS) | 4.6 versus 4.3 | N/A | N/A | Plasma TNF-α concentrations; no effect |
Confalonieri, et al. [6] | 0 versus 30 (P = 0.009) | 10 versus 18 (P = 0.01) | 0.3 versus 1.0 (P = 0.003) | N/A | Lower CRP levels at day 8 18 versus 34 mg/dL (P = 0.01) |
Mikami, et al. [20] | 6 versus 0 (P = 0.99) | 11.3 versus 15.5 (P = 0.182) | N/A | 8.5 versus 12.3 (P = 0.026) | CRP Faster normalization of CRP levels (7.6 versus 11.7 days; P = 0.02) |
Garcia-Vidal, et al. [19] | OR, 0.287; 95% CI, 0.113 to 0.732 | 7.1 versus 13.8 (P = 0.005) | N/A | N/A | N/A |
Design and patient selection
Validation of available studies
Discussion
Patient selection bias
Safety issues
Possible explanations for the reported outcomes
Duration of corticosteroid therapy
The role of critical illness-related corticosteroid insufficiency
Hemodynamic effects of corticosteroids
Immunomodulatory effects of corticosteroids
Conclusion
Key messages
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Few studies have evaluated the use of systemic corticosteroids in patients with severe community-acquired pneumonia (CAP). On the basis of their results, the use of corticosteroids as adjunctive therapy in severe CAP should be categorized as a weak recommendation (two studies) and a strong recommendation (two studies) with either low- or moderate-quality evidence.
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No evidence of adverse outcomes or harm is present in the studies that evaluated the use of systemic corticosteroids in patients with severe CAP. Thus, in patients with chronic obstructive pulmonary disease or asthma receiving antimicrobial therapy for severe CAP, concomitant administration of moderate doses of systemic corticosteroids may be considered safe.
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In view of the recent results of the CORTICUS (Corticosteroid Therapy of Septic Shock) study, which evaluated the use of corticosteroids in septic shock, future randomized controlled trials should overcome the methodological flaws in the designs of the currently available studies. To determine the risks and benefits of adding corticosteroids to the treatment of patients with severe CAP, large prospective randomized studies involving a more homogeneous group of patients are necessary.