Medicine by the Numbers

A Collaboration of TheNNT.com and AFP

Corticosteroids for Community-Acquired Pneumonia

 

Am Fam Physician. 2016 Jun 1;93(11):online.

image

 Enlarge     Print

CORTICOSTEROIDS FOR COMMUNITY-ACQUIRED PNEUMONIA

Number needed to treat = 20 to avoid mechanical ventilation; 16 to avoid ARDS Number needed to harm = 29 for developing hyperglycemia
BenefitsHarms

1 in 20 avoided mechanical ventilation

1 in 29 developed hyperglycemia requiring treatment

1 in 16 avoided ARDS

No deaths were prevented


ARDS = acute respiratory distress syndrome.

CORTICOSTEROIDS FOR COMMUNITY-ACQUIRED PNEUMONIA

Number needed to treat = 20 to avoid mechanical ventilation; 16 to avoid ARDS Number needed to harm = 29 for developing hyperglycemia
BenefitsHarms

1 in 20 avoided mechanical ventilation

1 in 29 developed hyperglycemia requiring treatment

1 in 16 avoided ARDS

No deaths were prevented


ARDS = acute respiratory distress syndrome.

Details for This Review

Study Population: Adults with community-acquired pneumonia (CAP)1

Efficacy End Points: All-cause mortality; need for mechanical ventilation; rate of acute respiratory distress syndrome (ARDS); length of hospital stay

Harm End Points: Hyperglycemia requiring treatment; gastrointestinal bleeding

Narrative: Pneumonia is common, is associated with significant morbidity, and is a leading cause of death.24 In response to infection, the body generates an adaptive inflammatory response.5 Systemic corticosteroids may blunt the potentially harmful effects of this response.68

This review summary assesses the benefits and harms of systemic corticosteroids in hospitalized patients with CAP. Patients received placebo or systemic corticosteroids ranging from a single dose to 10 days of treatment. Twelve studies of 1,974 patients demonstrated no statistically significant reduction in mortality, although there was a trend toward mortality reduction: 7.9% in the placebo group and 5.3% in the corticosteroid group (relative risk [RR] = 0.7; 95% confidence interval [CI], 0.5 to 1.0). Five studies of 1,060 patients demonstrated a 5% absolute risk reduction (number needed to treat [NNT] = 20) in mechanical ventilation (RR = 0.5; 95% CI, 0.3 to 0.8), whereas four trials of 945 patients demonstrated a 6.2% absolute risk reduction in ARDS (NNT = 16; RR = 0.2; 95% CI, 0.1 to 0.6). Effects appeared to increase with the severity of pneumonia. Corticosteroids also reduced time to clinical stability and discharge (mean difference = −1.0 day; 95% CI, −1.8 to −0.2 days). In terms of adverse effects, six trials including 1,534 patients demonstrated a 3.5% absolute increased risk (number needed to harm = 29) of hyperglycemia with corticosteroid use (RR = 1.49; 95% CI, 1.01 to 2.19).

Caveats: The trials compared different corticosteroid preparations, doses, routes of administration, and durations. All but one study used multiple-day regimens (most used seven to 10 days). Moreover, varying proportions of patients in each trial had chronic obstructive pulmonary disease, a condition known to benefit from corticosteroid use. Based on problems with allocation concealment, blinding, and other methodology elements, eight of 13 trials were at high risk of bias.

No large, multicenter, methodologically rigorous trials on this topic have been published, making results inconclusive. Small trials like the ones included here have significant potential to exaggerate effects, suggesting that large, well-designed trials have the potential to override the findings in this review. In the meantime, a trend toward mortality benefit, improvements in two patient-oriented outcomes, and no major patient-oriented harms established thus far suggest it may be reasonable to use corticosteroids in patients with CAP while awaiting further data.

This series is coordinated by Dean A. Seehusen, MD, MPH, AFP Contributing Editor, and Daniel Runde, MD, from the NNT Group.

A collection of Medicine by the Numbers published in AFP is available at http://www.aafp.org/afp/mbtn.

Author disclosure: No relevant financial affiliations.

REFERENCES

show all references

1. Siemieniuk RA, Meade MO, Alonso-Coello P, et al. Corticosteroid therapy for patients hospitalized with community-acquired pneumonia: a systematic review and meta-analysis. Ann Intern Med. 2015;163(7):519–528....

2. Mizgerd JP. Acute lower respiratory tract infection. N Engl J Med. 2008;358(7):716–727.

3. Xu J, Murphy SL, Kochanek KD, Bastian BA. Deaths: final data for 2013. Natl Vital Stat Rep. 2016;64(2):1–119.

4. Thomas CP, Ryan M, Chapman JD, et al. Incidence and cost of pneumonia in Medicare beneficiaries. Chest. 2012;142(4):973–981.

5. Rittirsch D, Flierl MA, Ward PA. Harmful molecular mechanisms in sepsis. Nat Rev Immunol. 2008;8(10):776–787.

6. Remmelts HH, Meijvis SC, Biesma DH, et al. Dexamethasone downregulates the systemic cytokine response in patients with community-acquired pneumonia. Clin Vaccine Immunol. 2012;19(9):1532–1538.

7. Torres A, Sibila O, Ferrer M, et al. Effect of corticosteroids on treatment failure among hospitalized patients with severe community-acquired pneumonia and high inflammatory response: a randomized clinical trial. JAMA. 2015;313(7):677–686.

8. Blum CA, Nigro N, Briel M, et al. Adjunct prednisone therapy for patients with community-acquired pneumonia: a multicentre, double-blind, randomised, placebo-controlled trial. Lancet. 2015;385(9977):1511–1518.

 

 

Copyright © 2016 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions


More in AFP


Editor's Collections


Related Content


More in Pubmed

MOST RECENT ISSUE


Aug 15, 2017

Access the latest issue of American Family Physician

Read the Issue


Email Alerts

Don't miss a single issue. Sign up for the free AFP email table of contents.

Sign Up Now

Navigate this Article