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Hydrocortisone for Severe Pneumonia – Can It Stop the Coffin? CAPE COD RCT

April 18, 2023

Written by Sam Parnell

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Hydrocortisone treatment for patients with severe community-acquired pneumonia was associated with reduced 28-day mortality and no increase in major adverse events.

Why does this matter?
Community-acquired pneumonia (CAP) is the leading cause of infectious death in the United States and a common reason for hospitalization.1 Glucocorticoids have significant anti-inflammatory and immunomodulatory effects and have been postulated to improve outcomes for patients with pneumonia and other systemic infections. However, the data on steroids and pneumonia have been mixed, and the jury is still out on the benefits of steroids for community-acquired pneumonia.2-5

Steroids at CAPE COD?
The CAPE COD study was a double-blind, randomized, placebo-controlled trial at 31 medical centers in France. Adult patients admitted to the ICU with severe community-acquired pneumonia (i.e., invasive or noninvasive mechanical ventilation, high flow nasal cannula, nonrebreather mask, or a Pulmonary Severity Index score > 130) were included. Patients with septic shock, influenza, and a do-not-intubate order were excluded.

Within 24 hours of being diagnosed with severe CAP, patients in the intervention group received intravenous hydrocortisone 200 mg per day administered continuously for the first 4 days. After 4 days, the medical team used predefined criteria to determine whether hydrocortisone would continue to be administered for a total of 8 or 14 days, depending on the patient’s clinical course. All patients received standard of care with antibiotics and supportive measures.

A total of 795 patients were included in the study. Overall, 6.2% (25/400) of patients in the hydrocortisone group (HG) died within 28 days compared to 11.9% (47/395) in the control group (CG) (p=0.006). Secondary outcomes, such as mortality by 90 days (9.3% HG vs 14.7% CG), subsequent endotracheal intubation by 28 days (18% HG vs 29.5% CG), and vasopressor use by 28 days (15.3% HG vs 25% CG) all favored the hydrocortisone group.

There was no significant difference in major safety outcomes such as hospital acquired infections or gastrointestinal bleeding. However, patients in the hydrocortisone group did receive higher insulin doses, likely due to hyperglycemia associated with glucocorticoid administration.

This study indicates that early treatment with hydrocortisone therapy is beneficial for patients with severe CAP. I think we still need more data before hydrocortisone becomes standard of care. However, based on these promising results, consider hydrocortisone the next time you care for a patient with severe CAP.

Hydrocortisone in Severe Community-Acquired Pneumonia. N Engl J Med. 2023 Mar 21. doi: 10.1056/NEJMoa2215145. Online ahead of print.

Works Cited:

  1. Heron M. Deaths: leading causes for 2019. Natl Vital Stat Rep 2021; 70: 1-114.
  2. Snijders D, Daniels JMA, de Graaff CS, van der Werf TS, Boersma WG. Efficacy of corticosteroids in community acquired pneumonia: a randomized double- blinded clinical trial. Am J Respir Crit Care Med 2010; 181: 975-82.
  3. 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: 1511-8.
  4. 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: 677-86.
  5. Stern A, Skalsky K, Avni T, Carrara E, Leibovici L, Paul M. Corticosteroids for pneumonia. Cochrane Database Syst Rev 2017; 12(12): CD007720.

What are your thoughts?