Risks/Mortality/Outcomes
Impact of systemic corticosteroids on the clinical course and outcomes of patients with severe community-acquired pneumonia: A cohort study

https://doi.org/10.1016/j.jcrc.2010.07.014Get rights and content

Abstract

Introduction

Our aim was to evaluate the impact of corticosteroids on clinical course and outcomes of patients with severe community-acquired pneumonia (CAP) requiring invasive mechanical ventilation.

Methods

This was a cohort study of patients with severe CAP from 2 intensive care units in tertiary hospitals in Brazil and Portugal.

Results

A total of 111 patients were included (median age, 69 years; 56% men; 34% hospital mortality). Corticosteroids were prescribed in 61 (55%) patients. Main indications for their use were bronchospasm (52.5%) and septic shock (36%). Mortality rate of patients treated with and without corticosteroids was comparable (29.5% vs 32%, P = .837). No significant differences were observed on clinical course from day 1 to day 7 as assessed by the Sequential Organ Failure Assessment score (P = .95). Furthermore, C-reactive protein declined similarly in both groups (P = .147). In a multivariate analysis, mortality was associated with older age and higher Acute Physiology and Chronic Health Evaluation II score.

Conclusions

In patients with severe CAP requiring invasive mechanical ventilation, adjunctive therapy with corticosteroids did not influence intensive care unit and hospital mortality. In addition, no changes were observed on weaning from vasopressors, on recovery from organ failure/dysfunction as assessed by the Sequential Organ Failure Assessment score, as well as on C-reactive protein course.

Introduction

Community-acquired pneumonia (CAP) is the most common cause of death associated with infectious disease and a major cause worldwide [1], [2]. More than 1 million patients with CAP require hospitalization annually, 10% of whom will be admitted to an intensive care unit (ICU) [1]. Despite improvements in critical care support [1], [3] and antimicrobial therapy [1], [4], mortality rates remain exceedingly high. Among ICU patients, it can be as high as 50% in those requiring mechanical ventilation (MV) or vasopressors [5]. To date, few adjunctive therapies are associated with improved outcomes in patients with severe infections [3]. In recent years, the use of corticosteroids has been suggested to be effective in selected patients with CAP [6], [7], [8]. Nevertheless, recent reviews concluded that available studies cannot support recommendation for the use of corticosteroids as standard of care for all patients with severe CAP [9], [10]. Finally, data from a recent prospective randomized controlled trial (RCT) showed absence of corticosteroids impact on outcome in a cohort of hospitalized non-ICU CAP patients [11]. Therefore, further studies evaluating a large number of severe CAP patients are needed. We hypothesized that the use of corticosteroids could reduce mortality and hasten the resolution of systemic inflammation, organ dysfunction, and gas exchange in patients with severe CAP requiring invasive MV.

Section snippets

Design and setting

This cohort prospective observational study was performed in 2 medical-surgical ICUs at tertiary hospitals (Barra D'Or Hospital, Rio de Janeiro, Brazil, and Garcia de Orta Hospital, Almada, Portugal). The institutional review boards approved the study design and waived the need for informed consent. There were no patient interventions performed for the study.

Selection of participants, data collection, and definitions

Patients with CAP that required ICU admission were consecutively included between November 2001 and December 2002 at Garcia de Orta

Characteristics of the study population

A total of 111 patients who fulfilled the entry criteria, severe CAP and invasive MV, were enrolled in the study (Fig. 1). The main characteristics of the study population are presented in Table 1. Overall, 86 (78%) patients had relevant comorbidities; and 28 (25%) had a diagnosis of COPD. All patients were directly admitted to the ICU from the emergency department. Antimicrobial therapy was prescribed in accordance with the ATS guidelines [15] to all patients. In our group of CAP patients, we

Discussion

To date, only a few studies evaluated the impact of systemic corticosteroid administration on the outcomes of patients with severe CAP [7], [8], [24], [25], [26], most involving small samples and only one evaluated exclusively critically ill patients [7]. Our study is the largest cohort of severe CAP patients requiring invasive MV (N = 111) where the impact of systemic corticosteroids on mortality, organ failures, and the evolution of systemic inflammation, assessed by serial measurements of

Conclusions

In the present study involving a large cohort of patients with severe CAP who required invasive MV, adjunctive corticosteroid therapy had no influence on mortality; on clinical course, evaluated both by SOFA score and P/F ratio; or on the resolution of the systemic inflammatory process, assessed by serial CRP measurements.

Acknowledgments

We would like to express our gratitude to Prof Michael Niederman for the critical reading of this manuscript.

MS receives an individual research grant from CNPq. Financial support was provided by FAPERJ, CNPq, and PRONEX-MCT.

References (31)

  • ConfalonieriM. et al.

    Hydrocortisone infusion for severe community-acquired pneumonia: a preliminary randomized study

    Am J Respir Crit Care Med

    (2005)
  • Garcia-VidalC. et al.

    Effects of systemic steroids in patients with severe community-acquired pneumonia

    Eur Respir J

    (2007)
  • SibilaO. et al.

    Corticosteroids in severe pneumonia

    Eur Respir J

    (2008)
  • SalluhJ.I. et al.

    The role of corticosteroids in severe community-acquired pneumonia: a systematic review

    Crit Care

    (2008)
  • SnijdersD. et al.

    Efficacy of corticosteroids in community-acquired pneumonia—a randomized double blinded clinical trial

    Am J Respir Crit Care Med

    (2010)
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    Authors' contributions: JIFS, PP, MS, and LMC contributed to the study conception and design, carried out and participated in data analysis, and drafted the manuscript. JRLS, FAB, PTB, JCRV, and HCFN conceived the study, participated in its design and coordination, supervised data analysis, and helped to draft the manuscript. All authors read and approved the final manuscript.

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