Adjunct corticosteroids beneficial for some children with community-acquired pneumonia

Weiss AK. Pediatrics. 2011;doi:10.1542/peds.2010-0983.

Issue: February 2011

Corticosteroids and concomitant beta-agonist therapy may shorten hospital duration for children who are hospitalized with community-acquired pneumonia and acute wheezing, according to a study.

Anna K. Weiss, MD, and colleagues of The Children’s Hospital of Philadelphia reviewed data of 20,703 patients aged 1 to 18 years with community-acquired pneumonia and found that 7,234 patients received this therapy for a median length of stay of 3 days. The researchers looked at the main outcome measures of length of stay, readmission and total hospitalization cost to determine if systemic corticosteroids were associated with better outcomes in these patients.

The researchers said patients who received systemic corticosteroid therapy and beta-agonist therapy had shorter hospital stays (adjusted HR=1.36; 95% CI, 1.28–1.45). However, they found that patients who received corticosteroid therapy without beta-agonist therapy had longer hospital lengths of stay than those who received neither. They also found that corticosteroids were associated with readmission in those patients who did not also receive concomitant beta-agonist therapy (adjusted OR=1.97; 95% CI, 1.09–3.57).

“If beta-agonist therapy is considered a proxy for wheezing, our findings suggest that among patients admitted to the hospital with a diagnosis of [community-acquired pneumonia], only those with acute wheezing benefit from adjunct systemic corticosteroid therapy,” the researchers wrote.

This is an interesting study but it has some limitations. This was a large retrospective multi-institution cohort study using administrative data. There is no information about the organisms causing CAP. There is no validation of the diagnosis of pneumonia. There is no information about the standards for discharge. There appears to be considerable inter-institution variability in treatment as the range in the percent of patients receiving corticosteroids as an adjunct for treating CAP was between 1% and 51% (median 32%). As we don't know the requirements for discharge we can speculate that fever and oxygenation were likely endpoints. If so, steroids can reduce fever so this may be part of why such patients were discharged earlier. Or, the deciders may have been looking at the oxygen saturation monitors and steroids and beta-agonists may have improved oxygenation in those who patients who wheezed. In any case, the use of corticosteroids in CAP appears to be one of those issues best answered by a protocol-driven prospective, randomized trial.

—Robert S. Baltimore, MD
Professor of Pediatrics and Epidemiology, Yale University School of Medicine

Disclosure: Dr. Baltimore reports no relevant financial disclosures.

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