Pitre T, Abdali D, Chaudhuri D, et al. Corticosteroids in Community-Acquired Bacterial Pneumonia: a Systematic Review, Pairwise and Dose-Response Meta-Analysis. J Gen Intern Med. 2023 Apr 19:1-14. doi: 10.1007/s11606-023-08203-6. (Systematic review)

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.

Discipline Area Score
Hospital Doctor/Hospitalists 6 / 7
Internal Medicine 6 / 7
Infectious Disease 5 / 7
Comments from MORE raters

Hospital Doctor/Hospitalists rater

Using corticosteroids in pneumonia continues to be debated. This review serves as a useful summation of the literature and supports the increasing trend of using adjuvant steroids in severe pneumonia.

Infectious Disease rater

This complex meta-analysis estimated 56 fewer deaths with corticosteroid treatment per 1,000 severe pneumonia patients. Considering the complexity of this paper that includes extensive discussion of clinical trials with varied conclusions, I suspect most clinicians would wait for the revised national guidelines before altering their practice to add steroids.
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