Steroid therapy in community-acquired pneumonia what is the answer!
محمد ال عبدالله
Hi
Last week infectious disese team were consulted for a female patient with sever community acquired pneumonia with acute lung injury ,required ICU without a need for mechanical ventilation ,post Antibiotic and intravenous steroid ,patient recovered and became better although all cultures negative.
I was discussing with Dr.Immad Hassan her MRP about possibility of acute pnumonitis secondary to CTD but he ask me to go to review the evidence of steroid and sever community acquired pneumonia
I did rapid review and found the following:
Moderate-quality evidence suggests that adjunctive steroid therapy for adults hospitalized with CAP reduced the length of hospital stay but did not alter mortality.
Adjuvant steroid therapy in community-acquired pneumonia: A systematic review and meta-analysis
Majid Shafiq MD1,*,
Article first published online: 26 NOV 2012
--------------------------------------------------------------------------------------------------------------------------
The use of corticosteroids was associated with improved mortality in severe CAP
. Corticosteroids in the Treatment of Community-Acquired Pneumonia in Adults: A Meta-Analysis
Wei Nie,#1 Yi Zhang,#2 Jinwei Cheng,#3 and Qingyu Xiu
Low-dose corticosteroid therapy
administered within 14 days of disease onset may reduce all cause
mortality in patients with ALI, ARDS, or severe
pneumonia. In contrast, high doses of corticosteroids did not
seem to affect mortality. We also found that the number of
days alive and off mechanical ventilation increased in studies
of low-dose corticosteroids administered for at least 7 days
and that infection rates increased in trials that used high doses of corticosteroids.
Corticosteroid therapy for acute lung injury, acute
respiratory distress syndrome, and severe pneumonia:
A meta-analysis of randomized controlled trials☆
François Lamontagne MD, MSca,b,⁎, Matthias Briel MDa,c,1,
Dexamethasone can reduce length of hospital stay when added to antibiotic treatment in nonimmunocompromised patients with community-acquired pneumonia.
Dexamethasone and length of hospital stay in patients
with community-acquired pneumonia: a randomised,
double-blind, placebo-controlled trial
Sabine C A Meijvis, Hans Hardeman, Hilde H F Remmelts, Rik Heijligenberg, Ger T Rijkers, Heleen van Velzen-Blad, G Paul Voorn,
Glucocorticoids decrease systemic and lung inflammatory responses in mechanically ventilated patients with severe pneumonia receiving antimicrobial treatment
Role of glucocorticoids on inflammatory response in
nonimmunosuppressed patients with pneumonia: a pilot study
C. Monto n*, S. Ewig{*
Hydrocortisone infusion in severe communityacquired pneumonia attenuates systemic inflammation and leads to earlier resolution of pneumonia and a reduction in sepsis-related
complications .
November 19, 2004
Hydrocortisone Infusion for Severe
Community-acquired Pneumonia
A Preliminary Randomized Study
Marco Confalonieri, Rosario Urbino, Alfredo Potena, Marco Piattella, Piercarlo Parigi, Giacomo Puccio,
Rossana Della Porta, Carbone Giorgio, Francesco Blasi, Reba Umberger, and G. Umberto
What IDSA guidelines said
Infectious Diseases Society of America/American
Thoracic Society Consensus Guidelines on the
Management of Community-Acquired Pneumonia
in Adults 2007
A large, multicenter trial has suggested that stress-dose (200–
300 mg of hydrocortisone per day or equivalent) steroid treatment
improves outcomes of vasopressor-dependent patients
with septic shock who do not have an appropriate cortisol
response to stimulation . Once again, patients with CAP
made up a significant fraction of patients entered into the trial.
In addition, 3 small pilot studies have suggested that there is
a benefit to corticosteroid therapy even for patients with severe
CAP who are not in shock . The small sample size
and baseline differences between groups compromise the conclusions.
Although the criteria for steroid replacement therapy
remain controversial, the frequency of intermittent steroid
treatment in patients at risk for severe CAP, such as those with
severe COPD, suggests that screening of patients with severe
CAP is appropriate with replacement if inadequate cortisol levels
are documented. If corticosteroids are used, close attention
to tight glucose control is required
What BTS guidelines said :
Guidelines for the Management of
Community Acquired Pneumonia in Adults
Update 2009
Steroids are not recommended in the routine treatment of high
severity CAP
What European Respiratory Society guidelines said
European Respiratory Society
Guidelines for the management of adult lower respiratory tract
infections
Steroids are not recommended in the treatment of pneumonia
What dynamed said Updated 2013 Apr 03
corticosteroids have inconsistent evidence for improving or worsening clinical course in adults hospitalized with community-acquired pneumonia
corticosteroids may not reduce mortality in adults with community-acquired pneumonia but may reduce mortality in subgroup with severe pneumonia (level 2 [mid-level] evidence)
IV dexamethasone for 4 days may reduce hospital stay without affecting mortality or readmission rates in patients hospitalized for community-acquired pneumonia (level 2 [mid-level] evidence)
oral prednisolone for 1 week may increase treatment failure rates in hospitalized patients with community-acquired pneumonia (level 2 [mid-level] evidence)
corticosteroids might reduce need for mechanical ventilation in adults with severe pneumonia (level 2 [mid-level] evidence)
What Uptodate said This topic last updated: Oct 23, 2012
There has been interest in using glucocorticoids as adjunctive therapy to antibiotics in hospitalized patients with CAP. However, there are conflicting data on the potential benefit of this approach:
- A small randomized trial of 46 patients and a retrospective study of 308 patients, 70 of whom received glucocorticoids suggested improvement in survival among patients with severe CAP .
- In contrast, a much larger randomized trial of 213 immunocompetent patients did not demonstrate improved outcomes (clinical cure or mortality) in hospitalized patients . Most of these patients did not have severe CAP, but there was also no benefit in the subset of patients with severe disease. In addition, the patients who received glucocorticoids had a higher rate of late failure, which was defined as a recurrence of signs and symptoms of pneumonia >72 hours after admission; this may have been due at least in part to abrupt discontinuation of glucocorticoids, leading to a rebound inflammatory response.
- A third randomized trial included 304 immunocompetent patients with CAP who were admitted to the hospital but did not require immediate ICU admission; almost one-half had more severe disease as defined by a PSI class of IV or V . The patients who received glucocorticoids had a significantly shorter median length of hospital stay of one day (6.5 versus 7.5 days). In-hospital mortality was infrequent and not different between the two groups.
The above data do not provide convincing evidence of benefit from glucocorticoid therapy. Whether or not there is a benefit of glucocorticoids in severe CAP is being evaluated in a large Veteran Administration cooperative study, which is investigating prolonged low-dose methylprednisolone treatment in patients admitted to the ICU . Pending these results and based upon the available data, glucocorticoids are not
recommended as adjunctive therapy for CAP
imadsahassan
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محمد ال عبدالله
Thank you a lot Dr.Hassan
This is regarding Varicella pneumonia, TB bronchopneumonia with ARDS
1st study was systematic review
The Lancet Infectious Diseases, Volume 13, Issue 3, Pages 223 - 237, March 2013
Steroids could be effective in reducing mortality for all forms of tuberculosis, including pulmonary tuberculosis. However, further evidence is needed since few recent trials have assessed the effectiveness of corticosteroids in patients with pulmonary tuberculosis.
Corticosteroids for prevention of mortality in people with tuberculosis: a systematic review and meta-analysis
The Lancet Infectious Diseases, Volume 13, Issue 3, Pages 223 - 237, March 2013
The second study
Eur Respir J 2008; 32: 1625–1630
Pulmonary tuberculosis with acute respiratory failure
The aim of the present study was to evaluate the clinical characteristics, prognoses and predictors of mortality of patients with pulmonary tuberculosis (TB) with acute respiratory failure (ARF), and to investigate the adjunctive use of corticosteroids in such cases.
TB patients with ARF requiring mechanical ventilation (n = 90) were enrolled retrospectively during 1989–2006. The patients were divided into two groups: tuberculous pneumonia (TBP; n = 66), and miliary TB (MTB; n = 24).
The TBP patients were older than the MTB patients (mean age 68.0 versus 54.5 yrs), and the mean±SD interval from hospital admission to start of anti-TB treatment was longer for the TBP than for the MTB group (5.0±7.0 versus 2.8±2.5 days). However, there was no difference in in-hospital mortality rate between the two groups (68.2 versus 58.3%). In the TBP patients, multivariate analysis showed that advanced age and shock unrelated to sepsis were associated with poor outcomes. Even though corticosteroid use was a predictor of survival in TBP patients, it was difficult to conclusively determine the efficacy of corticosteroids in TBP with ARF because of the retrospective study design.
The present study reveals the need for randomised controlled trials to clarify the role of corticosteroids as adjunctive therapy in the management of tuberculous pneumonia with acute respiratory failure.
o Updated 2013 May 21 01:49:00 PM:
osteroids may reduce mortality in patients with tuberculous meningitis but not pulmonary tuberculosis (Lancet Infect Dis 2013 Mar) view update
oreview of pyrosequencing for rapid detection of rifampicin resistance in Mycobacterium tuberculosis (Int J Tuberc Lung Dis 2013 Mar 25 early online) view update
Dynamed
Corticosteroids in TB:
o steroids may reduce mortality in patients with tuberculous meningitis but not pulmonary tuberculosis (level 2 [mid-level] evidence)
· based on systematic review limited by clinical heterogeneity
· systematic review of 41 randomized or quasi-randomized trials comparing adjunctive corticosteroids to placebo or no treatment in 6,542 patients with tuberculosis
· analyses limited by variation in antituberculosis regimen and steroid type, dose, and duration of administration
· steroids associated with reduced mortality in patients with
o any type of tuberculosis in analysis of 24 trials with 4,956 patients
§ risk ratio 0.83 (95% CI 0.74-0.92)
§ NNT 21-66 with mortality 19% in controls
o tuberculous meningitis in analysis of 9 trials with 1,313 patients
§ risk ratio 0.85 (95% CI 0.75-0.96)
§ NNT 9-56 with mortality 45% in controls
· steroids associated with nonsignificantly reduced mortality (p = 0.06) in patients with tuberculous pericarditis in analysis of 4 trials with 645 patients
· no significant differences in mortality in patients with
o pulmonary tuberculosis in analysis of 10 trials with 2,804 patients
o pleurisy in 1 trial with 194 patients
· in sensitivity analysis including only studies involving modern rifampicin-containing antituberculosis regimens
o steroids associated with reduced mortality overall and in patients with tuberculosis pericarditis (p < 0.05 for each)
o steroids associated with nonsignificantly reduced mortality in patients with meningitis (p = 0.07)
o no significant differences in mortality in patients with pulmonary tuberculosis or pleurisy
o CDC recommendations for use of corticosteroids in extrapulmonary TB(2)
· corticosteroids strongly recommended for
o tuberculous pericarditis (CDC Grade A, Level I)
o central nervous system TB, including meningitis (CDC Grade A, Level I)
· corticosteroids not recommended for TB of
o lymph node (CDC Grade D, Level III)
o bone and joint (CDC Grade D, Level III)
o pleural disease (CDC Grade D, Level I)
o disseminated disease (CDC Grade D, Level III)
o genitourinary (CDC Grade D, Level III)
o peritoneal (CDC Grade D, Level III)
For Varicella pneumonia
corticosteroids appear beneficial in patients with life-threatening varicella pneumonia based on preliminary evidence (level 2 [mid-level] evidence)
o combined retrospective and prospective study of 15 patients ages 23-63 years admitted to intensive care unit (ICU) with varicella pneumonia
o 13 patients given acyclovir IV for at least 7 days, 5 patients given hydrocortisone 200 mg IV every 6 hours for 48 hours within 24 hours of ICU admission
o comparing 5 steroid patients vs. 10 non-steroid patients
§ median 10 vs. 20 day hospital stay
§ median 5.5 vs. 12 day ICU stay
§ 0 vs. 40% mortality (not statistically significant)
o Reference - Chest 1998 Aug;114(2):426 PDF in Am Fam Physician 1999 Jan 1;59(1):166