Cochrane for Clinicians

Putting Evidence into Practice

Corticosteroids for Hospitalized Patients with Community-Acquired Pneumonia

 

Am Fam Physician. 2020 Sep 1;102(5):272-273.

Author disclosure: No relevant financial affiliations.

Clinical Question

Are corticosteroids safe and effective at reducing rates of mortality and clinical failure (i.e., death, worsening of imaging studies, or no clinical improvement) in adults and children hospitalized with community-acquired pneumonia (CAP)?

Evidence-Based Answer

For adults hospitalized with severe CAP, the use of corticosteroids may reduce the likelihood of mortality. (Strength of Recommendation [SOR]: B, based on inconsistent or limited-quality patient-oriented evidence.) For adults and children hospitalized with CAP, the use of corticosteroids may reduce the likelihood of early clinical failure. The risk of hyperglycemia is transient and of limited clinical significance.1 (SOR: A, based on consistent, good-quality patient-oriented evidence.)

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SUMMARY TABLE

Corticosteroids vs. Control for Hospitalized Patients with CAP

OutcomesRisk with controlRisk with corticosteroids (95% CI)NNT (95% CI)*Participants (studies)Quality of evidence (GRADE)

30-day mortality in adults

82 per 1,000

53 per 1,000 (38 to 74)

34 (24 to 125)

1,863 (11 RCTs)

Moderate

30-day mortality in adults with severe CAP (PSI > 4)7

131 per 1,000

76 per 1,000 (52 to 110)

18 (13 to 48)

995 (9 RCTs)

Moderate

30-day mortality in adults with nonsevere CAP

29 per 1,000

28 per 1,000 (13 to 58)

868 (4 RCTs)

Moderate

Early clinical failure in adults

373 per 1,000

149 per 1,000 (86 to 261)

5 (4 to 9)

1,324 (6 RCTs)

Moderate

Early clinical failure in adults with severe CAP (PSI > 4)7

422 per 1,000

135 per 1,000 (63 to 296)

4 (3 to 8)

419 (5 RCTs)

High

Early clinical failure in adults with nonsevere CAP

352 per 1,000

240 per 1,000 (197 to 292)

9 (7 to 17)

905 (2 RCTs)

High

Early clinical failure in children

659 per 1,000

270 per 1,000 (158 to 461)

3 (2 to 5)

88 (2 RCTs)

High


Note: The terms adults and children could not be uniformly defined because various age cutoffs were used across studies.

CAP = community-acquired pneumonia; NNT = number needed to treat; PSI = Pneumonia Severity Index; RCTs = randomized controlled trials.

*—The NNTs were calculated by the author based on raw data provided in the original Cochrane review.

Information from references 1 and 7.

SUMMARY TABLE

Corticosteroids vs. Control for Hospitalized Patients with CAP

OutcomesRisk with controlRisk with corticosteroids (95% CI)NNT (95% CI)*Participants (studies)Quality of evidence (GRADE)

30-day mortality in adults

82 per 1,000

53 per 1,000 (38 to 74)

34 (24 to 125)

1,863 (11 RCTs)

Moderate

30-day mortality in adults with severe CAP (PSI > 4)7

131 per 1,000

76 per 1,000 (52 to 110)

18 (13 to 48)

995 (9 RCTs)

Moderate

30-day mortality in adults with nonsevere CAP

29 per 1,000

28 per 1,000 (13 to 58)

868 (4 RCTs)

Moderate

Early clinical failure in adults

373 per 1,000

149 per 1,000 (86 to 261)

5 (4 to 9)

1,324 (6 RCTs)

Moderate

Early clinical failure in adults with severe CAP (PSI > 4)7

422 per 1,000

135 per 1,000 (63 to 296)

4 (3 to 8)

419 (5 RCTs)

High

Early clinical failure in adults with nonsevere CAP

352 per 1,000

240 per 1,000 (197 to 292)

9 (7 to 17)

905 (2 RCTs)

High

Early clinical failure in children

659 per 1,000

270 per 1,000 (158 to 461)

3 (2 to 5)

88 (2 RCTs)

High


Note: The terms adults and children could not be uniformly defined because various age cutoffs were used across studies.

CAP = community-acquired pneumonia; NNT = number needed to treat; PSI = Pneumonia Severity Index; RCTs = randomized controlled trials.

*—The NNTs were calculated by the author based on raw data provided in the original Cochrane review.

Information from references 1 and 7.

Practice Pointers

CAP is a significant cause of morbidity and mortality in the United States. There were 257,000 emergency department visits because of CAP in 2016 and 49,157 deaths (approximately 15.1 per 100,000 people) from CAP in 2017.2,3 The authors of a previous Cochrane review found that “in most patients with pneumonia, corticosteroids are generally beneficial for accelerating the time to resolution of symptoms,”4 but the evidence was not deemed strong enough to make firm recommendations. Subsequently, a 2015 systematic review found that corticosteroids for adults hospitalized with CAP might reduce mortality, use of mechanical ventilation, and length of hospital stay.5 However, the most recent guidelines from the American Thoracic Society (ATS) and the Infectious Diseases Society of America (IDSA) do not recommend using corticosteroids for adults with nonsevere or severe CAP, and they endorse the use of corticosteroids only for patients with CAP and refractory septic shock.6

The authors of this review incorporated 17 randomized controlled trials (RCTs) with a total of 2,264 patients: 15 RCTs including 1,954 adults (mean age = 69.8 years) and two RCTs including 310 children (mean age = 5.6 years).1 Although the authors searched broadly for studies examining all severities of pneumonia and all treatment settings, the only studies that met inclusion criteria were RCTs of corticosteroids

Author disclosure: No relevant financial affiliations.

References

show all references

1. Stern A, Skalsky K, Avni T, et al. Corticosteroids for pneumonia. Cochrane Database Syst Rev. 2017;(12):CD007720....

2. Rui P, Kang K, Ashman JJ. National Hospital Ambulatory Medical Care Survey: 2016 emergency department summary tables. 2016. Accessed December 2, 2019. https://www.cdc.gov/nchs/data/nhamcs/web_tables/2016_ed_web_tables.pdf

3. Kochanek KD, Murphy SL, Xu J, et al. Deaths: final data for 2017. Natl Vital Stat Rep. 2019;68(9):1–77.

4. Chen Y, Li K, Pu H, et al. Corticosteroids for pneumonia. Cochrane Database Syst Rev. 2011;(3):CD007720.

5. Siemieniuk RAC, 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.

6. Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019;200(7):e45–e67.

7. PSI/PORT Score: Pneumonia Severity Index for CAP. Accessed February 18, 2020. https://www.mdcalc.com/psi-port-score-pneumonia-severity-index-cap

8. Briel M, Spoorenberg SMC, Snijders D, et al.; Ovidius Study Group; Capisce Study Group; STEP Study Group. Corticosteroids in patients hospitalized with community-acquired pneumonia: systematic review and individual patient data metaanalysis. Clin Infect Dis. 2018;66(3):346–354.

9. Chen LP, Chen JH, Chen Y, et al. Efficacy and safety of glucocorticoids in the treatment of community-acquired pneumonia: a meta-analysis of randomized controlled trials. World J Emerg Med. 2015;6(3):172–178.

10. Horita N, Otsuka T, Haranaga S, et al. Adjunctive systemic corticosteroids for hospitalized community-acquired pneumonia: systematic review and meta-analysis 2015 update. Sci Rep. 2015;5:14061.

These are summaries of reviews from the Cochrane Library.

This series is coordinated by Corey D. Fogleman, MD, assistant medical editor.

A collection of Cochrane for Clinicians published in AFP is available at https://www.aafp.org/afp/cochrane.

 

 

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