Study: Hydrocortisone Associated With Lower Risk of All-Cause Mortality for Community-Acquired Pneumonia

Corticosteroids can reduce the need for mechanical ventilation, incidence of shock, and length of hospital stay, especially for younger patients with community-acquired pneumonia.

Corticosteroids can reduce the risk of all-cause mortality, especially in younger patients with community-acquired pneumonia (CAP), according to a meta-analysis published in the Journal of Critical Care. Investigators indicated that anti-inflammatory medications could likely decrease the need for mechanical ventilation, incidence of shock, length of hospital stay (ICU), and length of intensive care unit stays for those with CAP.

Minerva Studio - stock.adobe.com

According to the study authors, the mortality rate for CAP could be due to “cytokine-mediated uncontrolled inflammatory response,” so anti-inflammatories like corticosteroids could be beneficial. However, although there have been positive data, current guidelines do not recommend the use of corticosteroids for the management of those with severe CAP, according to the study authors.

Investigators of the study aimed to provide an updated meta-analysis that included the CAPE COD trial (NCT02517489), demonstrating a significant reduction in mortality at 28 days for individuals who used hydrocortisone as treatment. They also wanted to explore factors that could impact the effectiveness of such therapy, according to the study authors.

3 Key Takeaways

A meta-analysis published in the Journal of Critical Care suggests that corticosteroids can significantly reduce the risk of all-cause mortality in patients with community-acquired pneumonia (CAP), especially among younger individuals.
Corticosteroids were linked to reduced lengths of hospital and ICU stays, lower need for mechanical ventilation, and decreased use of vasopressors. However, there was an increased risk of hyperglycemia.
The study authors emphasize the need for large-scale randomized control trials to investigate subpopulations of interest further.

The study investigators used an electronic search of the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, ClinicalTrials.gov, and the World Health Organization Clinical Trials Registry Platform portal, according to the study. The times of the studies ranged from inception to November 2022, and updated to March 2023, according to the investigators. Studies were included if they were randomized control trials, had a patient population of adults older than 18 years who had CAP (defined by the trial), and interventions that included corticosteroids with the type, dosing regimen, and route of administration. All studies also needed to use a placebo or the standard of care, according to the study authors.

Investigators used the risk of all-cause mortality within 30 days post-randomization as the primary endpoint. Secondary endpoints included the “length of hospital stay, length of ICU stay, need for mechanical ventilation, rate of clinical failure, development of shock (need for vasopressors), development of acute respiratory distress syndrome, any adverse events, adverse cardiac events, gastrointestinal bleeding, hyperglycemia, secondary infection, and neuropsychiatric effects,” according to the study authors.

There were 15 studies selected by investigators, including a total of 3252 individuals with severe or non-severe CAP. Approximately 1829 individuals received a corticosteroid therapy and 1824 received the control group. A total of 6 used hydrocortisone while the remaining studies used another type of corticosteroid. Out of the studies, 9 had low risk of bias and 2 had some concerns regarding randomization and selection of the results reported. Four studies had high risk of bias, including lack of blinding and personnel delivering interventions, according to the study investigators.

Investigators found that there was a statistically significant association between corticosteroid treatment and a lower all-cause mortality rate when compared to the various control groups. The overall quality evidence was determined to be high, according to the study investigators.

Furthermore, the length of hospital stay was decreased with moderate quality evidence, the length of ICU stays decreased with moderate quality evidence, the need for mechanical ventilation was lower with moderate quality evidence, and the need for vasopressors decreased with moderate quality evidence. Clinical failure had an insignificant difference with low quality of evidence and the risk of hyperglycemia increased high quality of evidence, according to the study investigators. All other secondary endpoints had no change in mortality.

In sub-analyses, hydrocortisone reduced the risk of all-cause mortality. However, the other corticosteroids did not. Corticosteroids also reduced the risk of mortality in patients with severe CAP, but not for non-severe CAP. Loading dose and length of therapy did not affect mortality. Investigators also noted that a greater benefit was seen for younger patients compared to those with increasing age, according to the study authors.

The study authors call for large scale randomized control trials to further investigators the subpopulations of interest, according to the study.

Reference

Cheema HA, Musheer A, Ejaz A, Parcha AA, et al. Efficacy and safety of corticosteroids for the treatment of community-acquired pneumonia: A systematic review and meta-analysis of randomized controlled trials. J Crit Care. 2024;80:154507. doi:10.1016/j.jcrc.2023.154507