Reduced mechanical ventilation risk with corticosteroids in community-acquired pneumonia
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Key takeaways:
- Corticosteroids reduced the need for mechanical ventilation.
- Rates of mortality, treatment failure and adverse events did not significantly differ between treatment groups.
Fewer patients with community-acquired pneumonia using corticosteroids vs. standard care needed mechanical ventilation, but mortality rates did not differ between both groups, according to study results published in CHEST.
“In this up-to-date meta-analysis ... no association was found between corticosteroid use and mortality,” Naveed Saleem, MSc, of the Bloomsbury Institute of Intensive Care Medicine at University College London, and colleagues wrote. “However, adjuvant corticosteroids may be associated with a reduction in disease progression, that is, the need for mechanical ventilation. The reduction in the requirement for mechanical ventilation associated with corticosteroid use in community-acquired pneumonia (CAP) did not translate to a reduction in mortality, although the TSA suggests that more trial data are required.”
In a systematic review of three databases, Saleem and colleagues analyzed 16 randomized controlled trials (n = 3,863) of hospitalized patients with CAP to see how systemic corticosteroid use vs. standard care use impacts the risk for all-cause mortality.
Researchers additionally compared ICU admission, need for mechanical ventilation, treatment failure, readmission rates and adverse events between the two treatment groups.
To evaluate the degree of heterogeneity, researchers used the I2 statistic, in which minimal heterogeneity is represented when I2 equals 0% and considerable heterogeneity is represented when I2 is greater than 75%.
The most frequently used corticosteroid was IV hydrocortisone (six trials), followed by IV methylprednisolone (three trials), oral prednisone (two trials) and IV prednisolone (two trials). Oral dexamethasone, IV dexamethasone and an unclear administration of prednisolone each appeared in only one trial.
Assessing the 16 studies with data on all-cause mortality (n = 3,842), researchers found that this outcome did not significantly differ when comparing those receiving corticosteroids to those receiving standard care (RR = 0.85; 95% CI, 0.67-1.07; I2 = 14%).
Notably, the ability of corticosteroids to decrease mortality was related to baseline risk for mortality in meta-regression analysis (P = .04), according to researchers.
Similar to the above finding, two secondary outcomes did not significantly differ between the corticosteroid group and the standard care group, according to researchers: treatment failure (n = 2,093; RR = 0.78; 95% CI, 0.37-1.67; I2 = 68%) and adverse events (n = 2,487; RR = 1.1; 95% CI, 0.97-1.25; I2 = 53%).
However, when assessing the types of experienced adverse events, researchers found that new-onset hypoglycemic events occurred more often in patients using corticosteroids than in patients receiving standard care (17.6% vs. 9.5%; RR = 1.68; 95% CI, 1.3-2.16; I2 = 37%).
In terms of ICU admissions, fewer patients on corticosteroids were admitted into the ICU than patients given standard care (3.1% vs. 4.7%) based on six studies (n = 2,619; RR = 0.66; 95% CI, 0.45-0.97; I2 = 0%).
Data on mechanical ventilation were found in eight studies (n = 1,457) and demonstrated that fewer patients in the corticosteroid group vs. the standard care group needed ventilation (4.2% vs. 7.1%; RR = 0.51; 95% CI, 0.33-0.77; I2 = 0%).
One negative outcome observed to be possibly higher among those taking corticosteroids was readmission rates. Researchers found that more patients on corticosteroids were readmitted to the hospital than patients receiving standard care (21.5% vs. 17.7%; RR = 1.2; 95% CI, 1.05-1.38; I2 = 0%) based on data from five studies (n = 2,853).
“Larger masked randomized controlled trials are required to determine any mortality benefit, as are trials stratifying patients by illness severity,” Saleem and colleagues wrote. “Longer-term follow-up is required because data on the incidence and causes of hospital readmission are needed. The optimal type of corticosteroid, dose and duration are yet to be determined.”