Dexamethasone in treatment of community acquired pneumonia in children: a randomised control trial

Abstract

Background: An inflammatory response is a two edge sword in pneumonia as reasonable inflammatory response is required for microorganism clearance but excessive inflammation can cause ongoing local and systemic damage. Because of this, despite appropriate antibiotic therapy, adjuvant therapy that can positively modify the immune response has become a relevant approach to improve pneumonia prognosis. The objectives of this study was to document the beneficial effects of adjunctive dexamethasone therapy in patients admitted with community-acquired pneumonia (in terms of length of hospital stay) and to study what patients admitted with CAP benefit most from dexamethasone therapy, based on predefined subgroup of disease severity (PSI 1-5) and C-reactive protein level at admission as well to evaluate utility of CRP in monitoring resolution of CAP. Methods: In this prospective case-control trial, 100 children aged 1 to 14 years were enrolled randomly with confirmed community-acquired pneumonia, who presented to emergency department of paediatrics PMCH Patna. We randomly allocated patients on a one-to-one basis to adjuvant dexamethasone with antibiotics and antibiotics alone groups by drawing lots. Results: The median length of hospital-stay in both the adjuvant dexamethasone group and antibiotics alone group was 7 days with IQR in adjuvant dexamethasone group of 6.0-8.0 days and antibiotics group of 7.0-9.0 days (95% CI of difference in means 0.3-1.2 days; p = 0.001931 and was significant at p value of ≤ 0.01). There was a positive correlation between length of hospital-stay and CRP at the time of admission in adjuvant dexamethasone and antibiotics alone group with R value = 0.0261 and 0.3541 respectively. There also exist a positive correlation between length of hospital-stay and PSI at admission in adjuvant dexamethasone and antibiotics alone group with R value = 0.3555 and 0.1196 respectively. Median length of hospital-stay in those admitted with high PSI (PSI 4-5) and high CRP were 8.0 days in antibiotics alone group compared to 7.0 days in adjuvant dexamethasone group. The mean CRP on day 1, 3 and 5 was 7.734 (SEM 0.664), 3.974 (SEM 0.412) and 1.440 (SEM 0.133) respectively. Conclusions: There was no significant difference in length of hospital-stay in CAP patient treated with adjuvant dexamethasone with antibiotics and antibiotics alone. However it is clearly evident from this study that using adjuvant dexamethasone reduced the length of hospital-stay in those who admitted with higher PSI as well as higher CRP compared to antibiotics alone group. Moreover there was a definite decremental relationship between CRP and resolution of CAP. So use of adjuvant dexamethasone in those presenting with high PSI and high CRP can be consider. Since the sample size of our study was small, further evaluation is warranted.