- Paolo Balzaretti
- Commentaries
Corticosteroids for pneumonia
- 3/2018-Ottobre
- ISSN 2532-1285
- https://doi.org/10.23832/ITJEM.2018.030

Paolo Balzaretti

S.C. Medicina e Chirurgia d’Accettazione e Urgenza, A.O. “Ordine Mauriziano”, (Torino) Italy

What we already know about this topic
Studio |
Patients included |
N° of studies / N° of patients |
30 days-mortality |
Chen 2011 (3) |
Patients with pneumonia |
6 / 437 |
Odds Ratio 0,26 (95% C.I. 0,05 – 1,37) |
Nie 2012 (4) |
Hospitalized adults for CAP |
9 / 1001 |
Odds ratio 0,62 (95% C.I. 0,37 – 1,04) |
Subgroup analysis: patients with severe CAP |
4 / 214 |
Odds Ratio 0,26 (95% C.I.0,11 – 0,64) |
|
Subgroup analysis: mixed severity CAP patients |
4 / 756 |
Odds Ratio 0,95 (95% C.I. 0,50 – 1,78) |
|
Shafiq 2013 (5) |
Hospitalized adults for CAP |
8 / 1119 |
Relative risk 0,73 (95% C.I. 0,42 – 1,27) |
Cheng 2014 (6) |
Patients with severe CAP |
4 / 268 |
Relative risk 0,39 (95% C.I. 0,17 – 0,90) |
Marti 2015 (7) |
Hospitalized adults for CAP |
14 / 2077 |
Risk ratio 0,84 (95% C.I. 0,55 – 1,29) |
Subgroup analysis: patients with severe CAP |
5 / 334 |
Risk ratio 0,47 (95% C.I. 0,23 – 0,96) |
|
Subgroup analysis: mixed severity CAP patients |
8 / 1712 |
Risk ratio 1,04 (95% C.I. 0,66 – 1,64) |
|
Horita 2015 (8) |
Hospitalized adults for CAP |
10 / 1780 |
Odds ratio 0,80 (95% C.I. 0,53 – 1,21) |
Subgroup analysis: patients with severe CAP |
5 / 321 |
Odds Ratio 0,41 (95% C.I.0,19 – 0,90) |
|
Subgroup analysis: mixed severity CAP patients |
6 / 1459 |
Odds Ratio 1, 02 (95% C.I. 0,63 – 1,65) |
|
Semeniuk 2015 (9) |
Hospitalized adults for CAP |
12 / 1974 |
Risk ratio 0,67 (95% C.I.0,45 – 1,01) |
Subgroup analysis: patients with severe CAP |
6 / 388 |
Risk ratio 0,39 (95% C.I.0,20 – 0,77) |
|
Subgroup analysis: less severe pneumonia |
6 / 1586 |
Risk ratio 1,00 (95% C.I. 0,79 – 1,26) |
|
Bi 2016 (10) |
Patients with severe CAP |
8 / 528 |
Risk Ratio 0,46 (95% C.I. 0,28 – 0,77) |
Wan 2016 (11) |
Hospitalized adults for CAP |
9 / 1667 |
Relative risk 0,72 (95% C.I., 0,43 – 1,21) |
Subgroup analysis: patients with severe CAP |
5 / 347 |
Relative risk 0,72 (95% C.I., 0,43 – 1,21) |
Altogether, these data show corticosteroids are not useful for the management of unselected patients with pneumonia. Metanalyses of small sized RCTs suggest a possible effect in patients with severe CAP. Accordingly, none of the latest guidelines regarding pneumonia recommend routine use of steroids (12,13,14).
What can a new systematic review add in this context?
The Cochrane review
Outcome |
No. of studies / No. of patients |
Risk Ratio (95% C.I.) |
Quality of evidence |
Mortality |
11 / 1863 |
0,66 (0,47 – 0,92) |
Moderate |
Mortality – severe CAP |
9 / 995 |
0,58 (0,40 – 0,84) |
Moderate |
Mortality – non-severe CAP |
4 / 868 |
0,95 (0,45 – 2,00) |
Moderate |
Early clinical failure |
6 / 1324 |
0,40 (0,23 – 0,70) |
Moderate |
Early clinical failure – severe CAP |
5 / 419 |
0,32 (0,15 – 0,70) |
High |
Early clinical failure – non severe CAP |
2 / 905 |
0,68 (0,56 – 0,68) |
High |
Adverse events |
3 / 1028 |
1,21 (0,99 – 1,47) |
|
Hyperglycemia |
7 / 1578 |
1,72 (1,38 – 2,14) |
Comment and conclusions
Results from this systematic review demonstrate a beneficial impact of adjuvant corticosteroids therapy in adult patients hospitalized for pneumonia, with a 34% relative reduction in mortality and a 60% decrease of early clinical failure risk. Efficacy in preventing mortality appears stronger in subject affected by severe pneumonia (Pneumonia Severity Index class IV or higher), disappearing in those presenting with less severe disease (Risk Ratio 0,95 [95% C.I. 0,45 – 2,00]). The beneficial effect on early clinical failure was registered in both the disease severity classes.
Number of patients in the subgroup analysis relative to severe CAP was higher than in previous systematic reviews because additional data from two large RCTs (which originally presented their data only in an aggregate form) were used. Even though using mortality estimates for treatment and control groups in the metanalysis the sample size of the subgroup analysis appears large enough for reaching a study power > 80%, some perplexities remain, related to the heterogeneity of definitions of severity of the patients in the studies, the differences in therapeutic regimens adopted (on average a dose equivalent to 40 – 50 mg of prednisone a day for 5 to 10 days, mainly iv) and the small size of the majority of studies focusing on severe CAP patients.
In conclusion, moderate quality evidence shows that corticosteroid may be useful in the treatment of patients hospitalized with severe CAP. We will see whether future guidelines on pneumonia patients will incorporate these results to modify current recommendations.
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