BACKGROUND: Adjunctive glucocorticoids may reduce mortality among patients with severe community-acquired pneumonia (CAP) in well-resourced settings. Whether these drugs are beneficial in low-resource settings with limited diagnostic and treatment facilities is unclear.
METHODS: In this pragmatic, open-label, randomized, controlled trial conducted in 18 public hospitals in Kenya, we assigned adult patients who had received a diagnosis of CAP and who did not have a clear indication for glucocorticoids to receive either standard care for CAP or oral low-dose glucocorticoids for 10 days in addition to standard care. The primary outcome was death from any cause at 30 days after enrollment.
RESULTS: A total of 2180 patients underwent randomization (1089 assigned to the glucocorticoid group and 1091 to the standard-care group). The median age of the patients was 53 years (interquartile range, 38 to 72); 46% were women. At day 30, deaths were reported in 530 patients (24.3%): 246 patients (22.6%) in the glucocorticoid group and 284 patients (26.0%) in the standard-care group (hazard ratio, 0.84; 95% confidence interval, 0.73 to 0.97; P = 0.02). The frequencies of adverse events and serious adverse events were similar in the two trial groups. Serious adverse events that were considered to be related to glucocorticoid administration occurred in 5 patients (0.5%).
CONCLUSIONS: In patients with CAP in a low-resource setting, adjunctive glucocorticoid therapy was associated with a lower risk of death than standard care. (Funded by Wellcome Trust and others; SONIA PACTR number, PACTR202111481740832; ISRCTN number, ISRCTN36138594.).
| Discipline Area | Score |
|---|---|
| Infectious Disease |  |
| Respirology/Pulmonology | Coming Soon... |
| Hospital Doctor/Hospitalists | Coming Soon... |
| Internal Medicine | Coming Soon... |
Several issues to consider: limited access to ICU modifies mortality (evenly between groups). There is limited data on the accuracy of the CAP diagnosis or the etiology, which can also affect prognosis (in terms of matched versus unmatched treatment options).
As a general internist, this large pragmatic RCT provides compelling evidence that adjunctive low-dose glucocorticoids reduce 30-day mortality in adults hospitalized with community-acquired pneumonia in low-resource settings without increasing serious adverse events. It meaningfully extends prior ICU-based evidence to general ward care and demonstrates feasibility using oral formulations. The study highlights the potential for a simple, low-cost, and widely-accessible therapy to globally improve survival in community-acquired pneumonia.
This study using steroids plus antibiotics for CAP in Kenya demonstrated a modest but statistically improved in-hospital and 30-day survival rate. Impressive, well-designed study given the limitations of services and resources available there. The results add to our knowledge base but are not directly relevant to practice in economically well-off locations.
This pragmatic RCT done in sub-Saharan Africa found that steroids added to standard care for community-acquired pneumonia reduced mortality. It confirms that steroids can be safe and effective as part of treatment for suspected pneumonia in resource-limited settings with a high prevalence of HIV and TB. A majority of patients did not have a chest x-ray, so it's possible that steroids could have been treating things other than pneumonia, but that reflects the reality of practice in those settings.
