Corticosteroids in Community-Acquired Bacterial Pneumonia: a Systematic Review, Pairwise and Dose-Response Meta-Analysis

Abstract

Introduction International guidelines provide heterogenous guidance on use of corticosteroids for community-acquired pneumonia (CAP). Methods We performed a systematic review of randomized controlled trials examining corticosteroids in hospitalized adult patients with suspected or probable CAP. We performed a pairwise and dose-response meta-analysis using the restricted maximum likelihood (REML) heterogeneity estimator. We assessed the certainty of the evidence using GRADE methodology and the credibility of subgroups using the ICEMAN tool. Results We identified 18 eligible studies that included 4661 patients. Corticosteroids probably reduce mortality in more severe CAP (RR 0.62 [95% CI 0.45 to 0.85]; moderate certainty) with possibly no effect in less severe CAP (RR 1.08 [95% CI 0.83 to 1.42]; low certainty). We found a non-linear dose-response relationship between corticosteroids and mortality, suggesting an optimal dose of approximately 6 mg of dexamethasone (or equivalent) for a duration of therapy of 7 days (RR 0.44 [95% 0.30 to 0.66]). Corticosteroids probably reduce the risk of requiring invasive mechanical ventilation (RR 0.56 [95% CI 0.42 to 74] and probably reduce intensive care unit (ICU) admission (RR 0.65 [95% CI 0.43 to 0.97]) (both moderate certainty). Corticosteroids may reduce the duration of hospitalization and ICU stay (both low certainty). Corticosteroids may increase the risk of hyperglycemia (RR 1.76 [95% CI 1.46 to 2.14]) (low certainty). Conclusion Moderate certainty evidence indicates that corticosteroids reduce mortality in patients with more severe CAP, the need for invasive mechanical ventilation, and ICU admission. Supplementary Information The online version contains supplementary material available at 10.1007/s11606-023-08203-6.

Adverse Effects Related to Corticosteroid Use in Sepsis, Acute Respiratory Distress Syndrome, and Community-Acquired Pneumonia: A Systematic Review and Meta-Analysis

“…The updated search yielded 6505 unique citations addressing patients with ARDS and 579 citations addressing patients with CAP. After screening, we did not find any new eligible trials beyond those included in the previous reviews (4)(5)(6). Overall, we included 47 trials (n = 13,893) (19,44,49,53,54).…”

“…The updated search yielded 6505 unique citations addressing patients with ARDS and 579 citations addressing patients with CAP. After screening, we did not find any new eligible trials beyond those included in the previous reviews (4–6). Overall, we included 47 trials ( n = 13,893) (17–61) that reported adverse effects related to corticosteroid use in critically ill patients with ARDS, CAP, and sepsis/septic shock, the details of which are presented in Supplementary Table 2 (http://links.lww.com/CCX/B327).…”

“…We included randomized controlled trials (RCTs) that compared corticosteroids to placebo or usual care in patients with ARDS, sepsis, or CAP. Previously published reviews and the Supplementary Materials (http://links.lww.com/CCX/B327) present more detail on the definition of the study conditions (4)(5)(6). We excluded any nonrandomized, quasirandomized, or observational studies.…”

“…However, the adverse effects associated with corticosteroid use in critically ill patients has not been well studied. Previous systematic reviews have examined corticosteroid-related side effects when administered for specific indications, however, differential reporting across trials and low event rates have resulted in very low-certainty evidence for most of these adverse outcomes (4)(5)(6).…”

Updates in Hospital Medicine

“…When and if corticosteroids should be used in communityacquired pneumonia (CAP) is a controversial, and a recent systematic review and meta-analysis provide some muchneeded clarification. 2 Investigators searched several databases in an unrestricted fashion, including updated clinical trial updates, from February 2020 to September 2022. Studies were eligible if they randomized adult patients hospitalized with probable or suspected bacterial CAP of all severities to treatment with corticosteroids versus standard care or placebo.…”