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Review
, 12 (12), CD007720

Corticosteroids for Pneumonia

Affiliations
Review

Corticosteroids for Pneumonia

Anat Stern et al. Cochrane Database Syst Rev.

Abstract

Background: Pneumonia is a common and potentially serious illness. Corticosteroids have been suggested for the treatment of different types of infection, however their role in the treatment of pneumonia remains unclear. This is an update of a review published in 2011.

Objectives: To assess the efficacy and safety of corticosteroids in the treatment of pneumonia.

Search methods: We searched the Cochrane Acute Respiratory Infections Group's Specialised Register, CENTRAL, MEDLINE, Embase, and LILACS on 3 March 2017, together with relevant conference proceedings and references of identified trials. We also searched three trials registers for ongoing and unpublished trials.

Selection criteria: We included randomised controlled trials (RCTs) that assessed systemic corticosteroid therapy, given as adjunct to antibiotic treatment, versus placebo or no corticosteroids for adults and children with pneumonia.

Data collection and analysis: We used standard methodological procedures expected by Cochrane. Two review authors independently assessed risk of bias and extracted data. We contacted study authors for additional information. We estimated risk ratios (RR) with 95% confidence intervals (CI) and pooled data using the Mantel-Haenszel fixed-effect model when possible.

Main results: We included 17 RCTs comprising a total of 2264 participants; 13 RCTs included 1954 adult participants, and four RCTs included 310 children. This update included 12 new studies, excluded one previously included study, and excluded five new trials. One trial awaits classification.All trials limited inclusion to inpatients with community-acquired pneumonia (CAP), with or without healthcare-associated pneumonia (HCAP). We assessed the risk of selection bias and attrition bias as low or unclear overall. We assessed performance bias risk as low for nine trials, unclear for one trial, and high for seven trials. We assessed reporting bias risk as low for three trials and high for the remaining 14 trials.Corticosteroids significantly reduced mortality in adults with severe pneumonia (RR 0.58, 95% CI 0.40 to 0.84; moderate-quality evidence), but not in adults with non-severe pneumonia (RR 0.95, 95% CI 0.45 to 2.00). Early clinical failure rates (defined as death from any cause, radiographic progression, or clinical instability at day 5 to 8) were significantly reduced with corticosteroids in people with severe and non-severe pneumonia (RR 0.32, 95% CI 0.15 to 0.7; and RR 0.68, 95% CI 0.56 to 0.83, respectively; high-quality evidence). Corstocosteroids reduced time to clinical cure, length of hospital and intensive care unit stays, development of respiratory failure or shock not present at pneumonia onset, and rates of pneumonia complications.Among children with bacterial pneumonia, corticosteroids reduced early clinical failure rates (defined as for adults, RR 0.41, 95% CI 0.24 to 0.70; high-quality evidence) based on two small, clinically heterogeneous trials, and reduced time to clinical cure.Hyperglycaemia was significantly more common in adults treated with corticosteroids (RR 1.72, 95% CI 1.38 to 2.14). There were no significant differences between corticosteroid-treated people and controls for other adverse events or secondary infections (RR 1.19, 95% CI 0.73 to 1.93).

Authors' conclusions: Corticosteroid therapy reduced mortality and morbidity in adults with severe CAP; the number needed to treat for an additional beneficial outcome was 18 patients (95% CI 12 to 49) to prevent one death. Corticosteroid therapy reduced morbidity, but not mortality, for adults and children with non-severe CAP. Corticosteroid therapy was associated with more adverse events, especially hyperglycaemia, but the harms did not seem to outweigh the benefits.

Conflict of interest statement

Anat Stern ‐ None known.

Keren Skalsky ‐ None known.

Tomer Avni ‐ None known.

Elena Carrara ‐ None known.

Leonard Leibovici ‐ None known.

Mical Paul ‐ None known.

Figures

Figure 1
Figure 1
Study flow diagram.
Figure 2
Figure 2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
Figure 3
Figure 3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
Figure 4
Figure 4
Funnel plot of comparison: 1 Corticosteroids versus no treatment or placebo, outcome: 1.1 Mortality ‐ adults.
Figure 5
Figure 5
Meta‐regression of the log risk ratios for the effect of steroids on mortality against the mortality rate (%) in the control group.
Figure 6
Figure 6
Meta‐regression of the log risk ratios for the effect of steroids on mortality against the mean age in the study population.
Analysis 1.1
Analysis 1.1
Comparison 1 Corticosteroids versus no treatment or placebo, Outcome 1 Mortality ‐ adults.
Analysis 1.2
Analysis 1.2
Comparison 1 Corticosteroids versus no treatment or placebo, Outcome 2 Mortality ‐ adults, severe pneumonia, by allocation concealment.
Analysis 1.3
Analysis 1.3
Comparison 1 Corticosteroids versus no treatment or placebo, Outcome 3 Mortality ‐ adults, non‐severe pneumonia, by allocation concealment.
Analysis 1.4
Analysis 1.4
Comparison 1 Corticosteroids versus no treatment or placebo, Outcome 4 Mortality ‐ children.
Analysis 1.5
Analysis 1.5
Comparison 1 Corticosteroids versus no treatment or placebo, Outcome 5 Early clinical failure ‐ adults.
Analysis 1.6
Analysis 1.6
Comparison 1 Corticosteroids versus no treatment or placebo, Outcome 6 Early clinical failure ‐ children.
Analysis 1.7
Analysis 1.7
Comparison 1 Corticosteroids versus no treatment or placebo, Outcome 7 Early clinical failure ‐ adults + children by allocation concealment.
Analysis 1.8
Analysis 1.8
Comparison 1 Corticosteroids versus no treatment or placebo, Outcome 8 Time to clinical cure ‐ adults.
Analysis 1.9
Analysis 1.9
Comparison 1 Corticosteroids versus no treatment or placebo, Outcome 9 Time to clinical cure ‐ children.
Analysis 1.10
Analysis 1.10
Comparison 1 Corticosteroids versus no treatment or placebo, Outcome 10 Need for mechanical ventilation ‐ adults.
Analysis 1.11
Analysis 1.11
Comparison 1 Corticosteroids versus no treatment or placebo, Outcome 11 Development of shock ‐ adults.
Analysis 1.12
Analysis 1.12
Comparison 1 Corticosteroids versus no treatment or placebo, Outcome 12 Need for ICU transfer ‐ adults.
Analysis 1.13
Analysis 1.13
Comparison 1 Corticosteroids versus no treatment or placebo, Outcome 13 Length of hospitalisation ‐ adults.
Analysis 1.14
Analysis 1.14
Comparison 1 Corticosteroids versus no treatment or placebo, Outcome 14 Length of ICU stay ‐ adults.
Analysis 1.15
Analysis 1.15
Comparison 1 Corticosteroids versus no treatment or placebo, Outcome 15 Length of hospitalisation ‐ children.
Analysis 1.16
Analysis 1.16
Comparison 1 Corticosteroids versus no treatment or placebo, Outcome 16 Pneumonia complications ‐ adults + children.
Analysis 1.17
Analysis 1.17
Comparison 1 Corticosteroids versus no treatment or placebo, Outcome 17 Secondary infections ‐ adults.
Analysis 1.18
Analysis 1.18
Comparison 1 Corticosteroids versus no treatment or placebo, Outcome 18 Secondary infections ‐ children.
Analysis 1.19
Analysis 1.19
Comparison 1 Corticosteroids versus no treatment or placebo, Outcome 19 Any adverse events ‐ adults.
Analysis 1.20
Analysis 1.20
Comparison 1 Corticosteroids versus no treatment or placebo, Outcome 20 Hyperglycaemia ‐ adults.
Analysis 1.21
Analysis 1.21
Comparison 1 Corticosteroids versus no treatment or placebo, Outcome 21 Gastrointestinal bleeding ‐ adults.
Analysis 1.22
Analysis 1.22
Comparison 1 Corticosteroids versus no treatment or placebo, Outcome 22 Neuropsychiatric side effects ‐ adults.
Analysis 1.23
Analysis 1.23
Comparison 1 Corticosteroids versus no treatment or placebo, Outcome 23 Adverse cardiac events ‐ adults.
Analysis 1.24
Analysis 1.24
Comparison 1 Corticosteroids versus no treatment or placebo, Outcome 24 Any adverse events ‐ children.

Update of

  • Corticosteroids for Pneumonia
    Y Chen et al. Cochrane Database Syst Rev (3), CD007720. PMID 21412908. - Review
    In most patients with pneumonia, corticosteroids are generally beneficial for accelerating the time to resolution of symptoms. However, evidence from the included studies …

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