Tuesday, June 21, 2016

Steroids for severe community-acquired pneumonia: ready for prime time?

A generation ago, one of the major controversies in treatment of infectious diseases was whether or not to prescribe early adjunctive corticosteroids in addition to antibiotics for AIDS patients with presumed pneumocystis pneumonia. Advocates of steroids argued that they would improve outcomes by reducing the body's damaging inflammatory response, but opponents expressed concerns that further suppressing an already impaired immune system could increase the risk for other opportunistic infections. The advocates turned out to be right, as summarized in a 1990 National Institutes of Health consensus statement and this more recent FPIN Clinical Inquiry based on a Cochrane review of six randomized controlled trials that showed decreased mortality in patients receiving steroids.

The debate occurring today is whether steroids benefit patients with severe community-acquired pneumonia (CAP) from other causes. Commenting on a 2015 meta-analysis of 12 trials published in the Annals of Internal Medicine, Dr. Marcos Restrepo and colleagues asserted that it was "time to change clinical practice" and routinely use steroids in patients with severe CAP, with the major research question being how to identify these patients accurately and efficiently. On the other hand, the authors of the Medicine By The Numbers on this topic in the June 1st issue of American Family Physician felt that the supporting evidence was less definitive:

No large, multicenter, methodologically rigorous trials on this topic have been published, making results inconclusive. Small trials like the ones included [in the
Annals review] have significant potential to exaggerate effects, suggesting that large, well-designed trials have the potential to override the findings.

In exchange for 1 in 29 patients developing transient hyperglycemia due to steroids, 1 in 20 avoided mechanical ventilation, 1 in 16 avoided acute respiratory distress syndrome, and there was a nonsignficant trend toward mortality reduction. Drs. Jonathan Fu and Gary Green concluded that "improvements in two patient-oriented outcomes, and no major patient-oriented harms established thus far suggest it may be reasonable to use corticosteroids in patients with CAP while awaiting further data."

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This post first appeared on the AFP Community Blog.

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