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

This clinical content conforms to AAFP criteria for CME.

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.)

OutcomesRisk with controlRisk with corticosteroids (95% CI)NNT (95% CI)* Participants (studies)Quality of evidence (GRADE)
30-day mortality in adults82 per 1,00053 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 1,00076 per 1,000 (52 to 110)18 (13 to 48)995 (9 RCTs)Moderate
30-day mortality in adults with nonsevere CAP29 per 1,00028 per 1,000 (13 to 58)868 (4 RCTs)Moderate
Early clinical failure in adults373 per 1,000149 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 1,000135 per 1,000 (63 to 296)4 (3 to 8)419 (5 RCTs)High
Early clinical failure in adults with nonsevere CAP352 per 1,000240 per 1,000 (197 to 292)9 (7 to 17)905 (2 RCTs)High
Early clinical failure in children659 per 1,000270 per 1,000 (158 to 461)3 (2 to 5)88 (2 RCTs)High

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 used in the inpatient treatment of CAP. The included trials were conducted in Europe (eight studies), the Middle East (three studies), China (two studies), Japan (two studies), South Africa (one study), and Australia (one study). Thirteen of the 17 studies began in 2000 or later. For the main outcomes reported in the Cochrane review, the findings were generally consistent across the studies.

Definitions of pneumonia severity varied across studies, but for this review the authors defined severe CAP as a Pneumonia Severity Index (PSI) score of more than 4.7 There was variation among trials in corticosteroid duration (one to 10 days) and dosing, but most trials in adults used intravenous corticosteroid dosages equivalent to 40 to 50 mg of prednisone per day for five to 10 days, whereas the trials in children used varied doses of prednisolone, methylprednisolone, or dexamethasone. The studies in this review were assessed as being at low risk of attrition bias; low or unclear risk of selection bias; low, unclear, or high risk of performance and detection bias; and overall high risk of reporting bias.

The reviewers found moderate-quality evidence that prescribing corticosteroids to 18 patients would prevent one death (with mortality measured within 30 days of randomization) and high-quality evidence that prescribing corticosteroids to four patients would prevent one episode of early clinical failure (e.g., death from any cause, radiographic progression, clinical instability at day 5 to 8). For adults with nonsevere CAP, the estimates of effect size for preventing mortality by treating with corticosteroids were too broad to allow for any firm conclusion of risk or benefit, but there was high-quality evidence that treating nine patients with corticosteroids would prevent one episode of early clinical failure. Hyperglycemia was more common with corticosteroid treatment, but no differences were noted between groups in rates of gastrointestinal bleeding, neuropsychiatric events, or adverse cardiac events.

The two studies of treatment in children did not report any deaths, but high-quality evidence showed that using corticosteroids to treat three children with CAP would prevent one episode of early clinical failure. The two studies also reported no adverse events, and one trial reported that there were no cases of hyperglycemia.

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