Adjunctive treatment with oral dexamethasone in non-ICU patients hospitalised with community-acquired pneumonia: a randomised clinical trial

Abstract

BackgroundAdjunctive intravenous corticosteroid treatment has shown to reduce length of stay (LOS) in adults hospitalised with community-acquired pneumonia (CAP). We aimed to assess the effect of oral dexamethasone on LOS and whether this effect is disease severity dependent.MethodsIn this multicentre, stratified randomised, double-blind, placebo-controlled trial, immunocompetent adults with CAP were randomly assigned (1:1 ratio) to receive oral dexamethasone (6 mg once daily) or placebo for 4 days in four teaching hospitals in the Netherlands. Randomisation (blocks of four) was stratified by CAP severity (pneumonia severity index class I–III and IV-V). The primary outcome was LOS. This study is registered with ClinicalTrials.gov (NCT01743755).ResultsBetween December 2012 and November 2018, 401 patients were randomised to receive dexamethasone (n=203) or placebo (n=198). Median LOS was shorter in the dexamethasone group (4.5 days (95% CI 4.0–5.0)) than in the placebo group (5.0 days (95% CI 4.6–5.4); p=0.033). Within both CAP severity subgroups, differences in LOS between treatment groups were not statistically significant. Secondary ICU admission rate was lower in the dexamethasone arm (5 (3%) versus 14 (7%), p=0.030), 30-day mortality did not differ between groups. In the dexamethasone group rate of hospital readmission tended to be higher (20 (10%) versus 9 (5%); p=0.051) and hyperglycaemia (14 (7%) versus 1 (1%); p=0.001) was more prevalent.ConclusionOral dexamethasone reduced LOS and ICU admission rate in adults hospitalised with CAP. It remains unclear for which patients the risk-benefit ratio is optimal.

Glucocorticoid Therapy in COVID-19

“…Table 1 summarizes the main RCTs regarding the use of glucocorticoids in CAP. 15 16 17 18 19 20 21 22…”

“…►Table the main RCTs regarding the use of glucocorticoids in CAP. [15][16][17][18][19][20][21][22] Several systematic reviews and meta-analyses have reported that the use of corticosteroids in CAP improves outcomes. 8,[23][24][25][26][27] However, the benefit is inconsistent, partly related to the studies included and the heterogeneity of illness severity.…”

Efficacy of corticosteroids as an adjunctive therapy in the treatment of community-acquired pneumonia: a systematic review and meta-analysis

“…Nine RCTs on corticosteroids vs. placebo involving 2673 patients were included in this meta-analysis [41,[46][47][48][49][50][51][52][53]. The intervention group comprised 1335 individuals, and the control group comprised 1338 individuals.…”

“…Furthermore, several systematic reviews of such clinical questions have been conducted [37][38][39][40]. However, because most of the study search was performed more than 5 years ago, the results of recent studies such as Wittermans et al [41] were not included in those reviews. Here, we performed a new systematic review and meta-analysis of RCTs to assess the efficacy of corticosteroids for CAP.…”

Association between Glucocorticoids and Mortality in Patients with Severe Pneumonia: A Systematic Review and Meta-Analysis Based on Randomized Controlled Trials

“…All statistical results in this study were considered statistically significant at P ≤ 0:05, and the hypothesis tests were two-sided. [13][14][15][16][17][18][19][20][21][22][23][24] were finally included in the meta-analysis. The detailed literature retrieval and screening process is shown in the flowchart (Figure 1).…”