Corticosteroids may lessen mechanical ventilation use in patients with CAP

In critically ill patients with community-acquired pneumonia (CAP), treatment with corticosteroids has significantly reduced the need for mechanical ventilation, while use of hydrocortisone has prevented many hospital deaths.

“After conducting our Bayesian analysis, we found that current evidence does not support the conclusion that corticosteroids significantly reduce mortality in bacterial CAP,” the investigators said. “Nevertheless, the posterior probability of effect is >90 percent, and a subgroup analysis found that hydrocortisone significantly reduced mortality.”

This systematic review and meta-analysis utilized the databases of Medline, Embase, and the Cochrane Library to identify randomized controlled trials (RCTs) published from database inception to February 2024. The investigators included RCTs that examined the effect of systemic corticosteroids on mortality compared with standard of care in adult bacterial CAP patients admitted to ICU.

A Bayesian meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Independent reviewers assessed the study eligibility, extracted data, and gauged the risk of bias in duplicate, with discrepancies referred to senior reviewers.

Six RCTs including a total of 1,585 patients met the eligibility criteria. Neither in-hospital mortality (risk ratio [RR], 0.70, 95 percent confidence interval [CI], 0.39‒1.14; certainty of evidence: low) nor all-cause mortality (RR, 0.68, 95 percent CI, 0.34‒1.22; certainty of evidence: low) significantly decreased in ICU patients with severe CAP who received corticosteroids. [Ann Acad Med Singap 2024;53:683-693]

Mechanical ventilation

However, the use of corticosteroids led to a significant reduction in mechanical ventilation requirements after intervention (RR, 0.58, 95 percent CI, 0.37‒0.86; certainty of evidence: high) relative to placebo.

“Reducing the need for mechanical ventilation has considerable resource implications, but it also protects patients from the potentially harmful effects of mechanical ventilation itself,” the investigators said. “It is an important finding because the need for mechanical ventilation in CAP predicts increased mortality (odds ratio 18.4, 95 percent CI, 8.65–39.1; p<0.001).” [Crit Care Med 2012;40:199-207]

In addition, a subgroup analysis revealed that patients treated with hydrocortisone had significantly lower hospital mortality (RR, 0.45, 95 percent CI, 0.20‒0.88; certainty of evidence: low) compared with those who received placebo.

No significant increase was observed in gastrointestinal bleeding, secondary infections, or hyperglycaemia among patients treated with corticosteroids.

“Our study found no significant decrease in hospital mortality rate with corticosteroid use, while the posterior probability of 94.3 percent suggests—without meeting statistical significance—that corticosteroids are more likely than not to be beneficial, which encourages further investigation,” the investigators said.

Reduced mortality

Conversely, a recent meta-analysis by Wu and colleagues (seven studies, 1,689 patients) found a significantly lower 30-day mortality among patients with severe CAP who received corticosteroids versus placebo. [Crit Care 2023;27:274]

“Our study may have drawn different conclusions because we defined severe CAP as requiring ICU admission, whereas Wu [and colleagues] defined severe CAP more broadly using the American Thoracic Society/Infectious Diseases Society of America criteria, the Pneumonia Severity Index, or ICU admission,” the investigators said. [Chest 2023;163:484-497]

“Further work is required to determine whether other corticosteroids reduce mortality among ICU patients with CAP,” they added.