1. Use of acute corticosteroids versus placebo in patients with severe community-acquired pneumonia (CAP) and a high initial inflammatory response resulted in a decrease in treatment failure.
2. There was no statistically significant difference in in-hospital mortality between the two groups.
Evidence Rating Level: 1 (Excellent)
Study Rundown: The mortality of patients with community-acquired pneumonia (CAP) is high, with severe CAP and treatment failure being two factors associated with increased mortality. A high host inflammatory response is linked to treatment failure in patients with CAP. While corticosteroids may have a potential beneficial role in this disease process, given their ability to modulate cytokines and anti-inflammatory properties, their role in CAP has not been well elucidated.
This study aimed to examine the effect of corticosteroids on treatment failure in patients with severe CAP and a high initial inflammatory response. The primary outcome was rate of treatment failure. Patients were randomized to either a placebo group or an intervention of methylprednisolone. It was found that acute administration of methylprednisolone did in fact decrease treatment failure in this population of patients affected by CAP. A major strength of this study is that it targeted a subset of patients most likely to benefit from steroids – those with severe disease and with a high inflammatory state. This study is, however, limited by its applicability to a subset of patients affected by CAP, long duration and sub-optimal statistical power. Nevertheless, the findings support methylprednisolone use as a potential adjunctive treatment for CAP.
In-Depth [randomized controlled trial]: This study was a randomized, placebo-controlled trial. Patients with severe CAP and a high initial inflammatory response (i.e., C-reactive protein >150 mg/L) were randomized to placebo (n=59) or to receive an IV bolus of 0.5 mg/kg of methylprednisolone every 12 hours for 5 days within 36 hours of admission (n=61). The primary outcome was rate of treatment failure. The methylprednisolone group had less treatment failure compared to the placebo group (13% vs. 31%, respectively; p=0.02). It was found that there was a significant reduction in late treatment failure due to a decrease in radiographic progression when comparing the two groups (p=0.04). However, the benefit of steroids remained in post-hoc analyses excluding radiographic progression. There were no significant differences in in-hospital mortality, clinical stability, and length of ICU and hospital stays when comparing the two groups.
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