Real-world corticosteroid use in severe pneumonia: a propensity-score-matched study

Abstract

Background Community-acquired pneumonia (CAP) is a leading cause of morbidity and mortality worldwide despite correct antibiotic use. Corticosteroids have long been evaluated as a treatment option, but heterogeneous effects on survival have precluded their widespread implementation. We aimed to evaluate whether corticosteroids might improve clinical outcomes in patients with severe CAP and high inflammatory responses. Study design and methods We analyzed two prospective observational cohorts of patients with CAP in Barcelona and Rome who were admitted to intensive care with a high inflammatory response. Propensity score (PS) matching was used to obtain balance among the baseline variables in both groups, and we excluded patients with viral pneumonia or who received hydrocortisone. Results Of the 610 patients admitted with severe CAP, 198 (32%) received corticosteroids and 387 had major criteria for severe CAP. All patients had a baseline serum C-reactive protein above 15 mg/dL. Patients who received corticosteroids were more commonly male, had more comorbidities (e.g., cancer or chronic obstructive pulmonary disease), and presented with significantly higher sequential organ failure assessment scores. Eighty-nine patients met major severity criteria (invasive mechanical ventilation and/or septic shock) and were matched per group. Twenty-eight-day mortality was lower among patients receiving corticosteroids (16 patients, 18%) than among those not receiving them (28 patients, 31%; p = 0.037). After PS matching, corticosteroid therapy reduced the 28-day mortality risk in patients who met major severity criteria (hazard ratio (HR) 0.53, 95% confidence interval (CI) 0.29–0.98) (p = 0.043). In patients who did not meet major severity criteria, no benefits were observed with corticosteroid use (HR 0.88 (95%CI 0.32–2.36). Conclusions Corticosteroid treatment may be of benefit for patients with CAP who have septic shock and/or a high inflammatory response and requirement for invasive mechanical ventilation. Corticosteroids appear to have no impact on mortality when these features are not present.

The effect of low-molecular-weight heparin combined with amikacin on the coagulation function and bacterial clearance in the treatment of patients with severe senile pneumonia

“…SP is one of the clinical high incidence diseases, which is mostly caused by Inflammatory reaction caused by pulmonary infection is considered one of the major causes of SP and SP-associated high mortality. 13 The inflammatory response in patients with SP leads to the injury of pulmonary vascular endothelial cells, the increase of the expression of fibrinolytic inhibitory factors and procoagulant factors, resulting in the activation of the coagulation system, the occurrence of hypercoagulability and local micro thrombosis. The increase in fiber composition of lung tissue, and the occurrence of hypoxemia, hypoxemia and uncontrolled lung inflammation can lead to lung tissue injury, and in severe cases, to life threatening septic shock.…”

Respiratory infections and acute respiratory distress syndrome

“…Nonetheless, concerns about the reproducibility of these results have limited applicability thereof [79]. Recently, in a propensity score matching study using real-life data [102], our group observed significantly lower mortality in those patients with severe CAP criteria per ATS/IDSA guidelines [79]. Corticosteroids also reduced the risk of disease progression to ARDS [97].…”

Severe community-acquired pneumonia

“…A recent multicentre study from Spain and Italy [ 67 ] compared patients with sCAP who did and did not receive corticosteroids. Investigators excluded patients receiving hydrocortisone and/or with a CRP level of <15 mg·dL −1 in the blood.…”