New Meta-Analysis – Steroids Lower CAP Mortality

Written by Caitlin Nicholson

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This meta-analysis found a reduction in all-cause mortality in patients hospitalized with severe CAP who received adjunctive corticosteroid therapy.

Steroids for the win…
A prior meta-analysis in CHEST, which had 2 studies not included in this study and which did not include CAPE-COD, showed no mortality improvement with steroids. This study was a meta-analysis and meta-regression with the primary outcome being 30-day all-cause mortality in the intention-to-treat population. Secondary outcomes included ICU admission, hospital readmission, length of ICU stay, length of hospitalization, development of acute respiratory distress syndrome, and time to clinical stability.

15 RCTs were included, comprising 3,367 patients including a corticosteroid and control group. All-cause mortality was significantly lower in the corticosteroid group (104/1,690, 6.2%) than the control group (152/677, 9.1%): RR 0.67 (95%CI 0.53-0.85).

Regarding secondary outcomes, corticosteroid therapy resulted in a RR reduction of developing ARDS (RR 0.24, p=.002), reduction in time to clinical stability (1.5 days, p<0.001), and was not associated with an increase in adverse events (RR 0.90, p=0.5). On the other hand, adjunctive corticosteroid therapy was not associated with lower risk of hospital readmission (RR 1.28, p=0.2) or lower risk of ICU admission (RR 0.82, p=0.5) compared with the control group. The number needed to prevent 1 death was 34.

Primary limitations included various corticosteroids and dosages and lack of clarity regarding causal relationship between adverse events and medication use.

How will this change my practice?
This was the first meta-analysis to show overall reduced mortality in patients being treated inpatient for severe CAP with adjunctive corticosteroid therapy.  I reflexively consider steroids in patients with COPD exacerbation with concern for pneumonia but don’t always consider it for CAP. While overall benefit was shown in this study, corticosteroids are not completely benign. I will continue to have hesitancy adding steroids as adjunctive therapy for patients with hyperglycemia, immunosuppression, or significant history of gastrointestinal hemorrhage.

Source
Efficacy and Safety of Corticosteroid Therapy for Community-Acquired Pneumonia: A Meta-Analysis and Meta-Regression of Randomized, Controlled Trials. Clin Infect Dis. 2023 Dec 15;77(12):1704-1713. doi: 10.1093/cid/ciad496.