Nonantibiotic Adjunctive Therapies for Community-Acquired Pneumonia (Corticosteroids and Beyond): Where Are We with Them?

Abstract

Community-acquired pneumonia (CAP) is a leading cause of hospitalization, morbidity, and mortality. Despite advances in antibiotic treatments, mortality among patients with CAP is still high. For this reason, interest has been focused on nonantibiotic therapeutic measures directed to the host response rather than the microorganism. The development of an efficacious adjunctive treatment has important implications for reducing mortality in CAP. Some clinical studies performed in the last decade have shown a clinically beneficial effect of corticosteroids, possibly by diminishing local and systemic inflammatory host response. Recent meta-analyses showed faster resolution of symptoms, shorter time to clinically stability, reduction of mechanical ventilation needed, and reduction of mortality in the most severe population, although some methodological limitations must be taken into account. In addition, some studies using statins also suggested improved outcomes due to its anti-inflammatory effect in CAP, although this requires further research. Other adjunctive therapies such as immunoglobulins and stem cells are being explored, but are not yet in the stage of clinical trials. In summary, the use of corticosteroids and other adjuvant treatments are promising in CAP, but more studies are needed to determine their impact on mortality.

Challenges in severe community-acquired pneumonia: a point-of-view review

“…Conversely, corticosteroid use in patients with versus CAP has been related to increased mortality [84]. There is currently insufficient evidence to support other adjuvant therapies in SCAP, such as immunoglobulins, G-CSF or statins [85].…”

Unmet needs in pneumonia research: a comprehensive approach by the CAPNETZ study group

“…Current setting An excessive inflammatory response seems to be partly responsible for treatment failure in some patients and has been associated with poor clinical outcomes [95]. Different immunomodulatory and barrier-enhancing agents have been discussed and tested for potential adjunctive therapy to antimicrobial agents in the treatment of CAP.…”

Appropriate antibiotic management of bacterial lower respiratory tract infections

“…It is interesting to briefly mention non-antibiotic adjunctive therapies, which—though clearly beyond the scope of this review—continue to be evaluated in critically ill patients with CAP, in whom the mortality remains high despite apparently appropriate antibiotic treatment. A number of such therapies have been studied, of which the use of corticosteroids (CSs) appears to be most promising, and a number of positive randomized controlled trials and systematic literature reviews have been published in recent years 52 , 53 . Most recently, the Cochrane database of systematic reviews updated its 2011 review of randomized controlled trials of systemic CS therapy, as adjunct to antibiotic therapy versus placebo or no CS, and concluded that CS therapy significantly reduces morbidity (various end-points) and mortality (relative risk 0.58, 95% CI 0.40–0.84) in adults with severe CAP; the number needed to treat for additional beneficial outcome was 18 patients (95% CI 12–49) to prevent one death 54 .…”