Reviews
6 October 2015

Corticosteroid Therapy for Patients Hospitalized With Community-Acquired Pneumonia: A Systematic Review and Meta-analysis

Publication: Annals of Internal Medicine
Volume 163, Number 7

Abstract

Background:

Community-acquired pneumonia (CAP) is common and often severe.

Purpose:

To examine the effect of adjunctive corticosteroid therapy on mortality, morbidity, and duration of hospitalization in patients with CAP.

Data Sources:

MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials through 24 May 2015.

Study Selection:

Randomized trials of systemic corticosteroids in hospitalized adults with CAP.

Data Extraction:

Two reviewers independently extracted study data and assessed risk of bias. Quality of evidence was assessed with the Grading of Recommendations Assessment, Development, and Evaluation system by consensus among the authors.

Data Synthesis:

The median age was typically in the 60s, and approximately 60% of patients were male. Adjunctive corticosteroids were associated with possible reductions in all-cause mortality (12 trials; 1974 patients; risk ratio [RR], 0.67 [95% CI, 0.45 to 1.01]; risk difference [RD], 2.8%; moderate certainty), need for mechanical ventilation (5 trials; 1060 patients; RR, 0.45 [CI, 0.26 to 0.79]; RD, 5.0%; moderate certainty), and the acute respiratory distress syndrome (4 trials; 945 patients; RR, 0.24 [CI, 0.10 to 0.56]; RD, 6.2%; moderate certainty). They also decreased time to clinical stability (5 trials; 1180 patients; mean difference, −1.22 days [CI, −2.08 to −0.35 days]; high certainty) and duration of hospitalization (6 trials; 1499 patients; mean difference, −1.00 day [CI, −1.79 to −0.21 days]; high certainty). Adjunctive corticosteroids increased frequency of hyperglycemia requiring treatment (6 trials; 1534 patients; RR, 1.49 [CI, 1.01 to 2.19]; RD, 3.5%; high certainty) but did not increase frequency of gastrointestinal hemorrhage.

Limitations:

There were few events and trials for many outcomes. Trials often excluded patients at high risk for adverse events.

Conclusion:

For hospitalized adults with CAP, systemic corticosteroid therapy may reduce mortality by approximately 3%, need for mechanical ventilation by approximately 5%, and hospital stay by approximately 1 day.

Primary Funding Source:

None.

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Information & Authors

Information

Published In

cover image Annals of Internal Medicine
Annals of Internal Medicine
Volume 163Number 76 October 2015
Pages: 519 - 528

History

Published online: 6 October 2015
Published in issue: 6 October 2015

Keywords

Authors

Affiliations

Reed A.C. Siemieniuk, MD
From McMaster University, Hamilton, Ontario, Canada; Instituto de Investigación Biomédica Sant Pau, Barcelona, Spain; University Hospital of Basel, Basel, Switzerland; and University of Oslo, Oslo, Norway.
Maureen O. Meade, MD
From McMaster University, Hamilton, Ontario, Canada; Instituto de Investigación Biomédica Sant Pau, Barcelona, Spain; University Hospital of Basel, Basel, Switzerland; and University of Oslo, Oslo, Norway.
Pablo Alonso-Coello, MD, PhD
From McMaster University, Hamilton, Ontario, Canada; Instituto de Investigación Biomédica Sant Pau, Barcelona, Spain; University Hospital of Basel, Basel, Switzerland; and University of Oslo, Oslo, Norway.
Matthias Briel, MD, MSc
From McMaster University, Hamilton, Ontario, Canada; Instituto de Investigación Biomédica Sant Pau, Barcelona, Spain; University Hospital of Basel, Basel, Switzerland; and University of Oslo, Oslo, Norway.
Nathan Evaniew, MD
From McMaster University, Hamilton, Ontario, Canada; Instituto de Investigación Biomédica Sant Pau, Barcelona, Spain; University Hospital of Basel, Basel, Switzerland; and University of Oslo, Oslo, Norway.
Manya Prasad, MBBS
From McMaster University, Hamilton, Ontario, Canada; Instituto de Investigación Biomédica Sant Pau, Barcelona, Spain; University Hospital of Basel, Basel, Switzerland; and University of Oslo, Oslo, Norway.
Paul E. Alexander, MSc, PhD
From McMaster University, Hamilton, Ontario, Canada; Instituto de Investigación Biomédica Sant Pau, Barcelona, Spain; University Hospital of Basel, Basel, Switzerland; and University of Oslo, Oslo, Norway.
Yutong Fei, MD, PhD
From McMaster University, Hamilton, Ontario, Canada; Instituto de Investigación Biomédica Sant Pau, Barcelona, Spain; University Hospital of Basel, Basel, Switzerland; and University of Oslo, Oslo, Norway.
Per O. Vandvik, MD, PhD
From McMaster University, Hamilton, Ontario, Canada; Instituto de Investigación Biomédica Sant Pau, Barcelona, Spain; University Hospital of Basel, Basel, Switzerland; and University of Oslo, Oslo, Norway.
Mark Loeb, MD, MSc
From McMaster University, Hamilton, Ontario, Canada; Instituto de Investigación Biomédica Sant Pau, Barcelona, Spain; University Hospital of Basel, Basel, Switzerland; and University of Oslo, Oslo, Norway.
Gordon H. Guyatt, MD, MSc
From McMaster University, Hamilton, Ontario, Canada; Instituto de Investigación Biomédica Sant Pau, Barcelona, Spain; University Hospital of Basel, Basel, Switzerland; and University of Oslo, Oslo, Norway.
Acknowledgment: The authors thank Aravin Duraikannan, who wrote the program used to create the forest plots.
Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M15-0715.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that she has no financial relationships or interests to disclose. Darren B. Taichman, MD, PhD, Executive Deputy Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer.
Corresponding Author: Reed A.C. Siemieniuk, MD, Department of Clinical Epidemiology & Biostatistics, McMaster University, 1280 Main Street West, Hamilton, Ontario L8S 4K1, Canada; e-mail, [email protected].
Current Author Addresses: Drs. Siemieniuk, Meade, Evaniew, Alexander, Fei, Loeb, and Guyatt: Department of Clinical Epidemiology & Biostatistics, McMaster University, 1280 Main Street West, Hamilton, Ontario L8S 4K1, Canada.
Dr. Alonso-Coello: Centro Cochrane Iberoamericano, Instituto de Investigación Biomédica Sant Pau-CIBER de Epidemiología y Salud Pública (CIBERESP-IIB-Sant Pau), Sant Antoni Maria Claret 171, 08041 Barcelona, Spain.
Dr. Briel: Institute for Clinical Epidemiology and Biostatistics, Universitätsspital Basel, Hebelstrasse 10, 4056 Basel, Switzerland.
Dr. Prasad: Department of Community Medicine, Pt. B.D. Sharma Postgraduate Institute of Medical Sciences, Rohtak, Haryana, India.
Dr. Vandvik: Department of Health Management and Health Economics, University of Oslo, Postboks 1089 Blindern, 0318 Oslo, Norway.
Author Contributions: Conception and design: R.A.C. Siemieniuk, P. Alonso-Coello, N. Evaniew, M. Prasad, P.O. Vandvik, M. Loeb, G.H. Guyatt.
Analysis and interpretation of the data: R.A.C. Siemieniuk, M.O. Meade, P. Alonso-Coello, M. Briel, N. Evaniew, P.E. Alexander, P.O. Vandvik, G.H. Guyatt.
Drafting of the article: R.A.C. Siemieniuk, P. Alonso-Coello.
Critical revision of the article for important intellectual content: R.A.C. Siemieniuk, M.O. Meade, P. Alonso-Coello, M. Briel, N. Evaniew, M. Prasad, Y. Fei, P.O. Vandvik, M. Loeb, G.H. Guyatt.
Final approval of the article: R.A.C. Siemieniuk, M.O. Meade, P. Alonso-Coello, M. Briel, N. Evaniew, M. Prasad, P.E. Alexander, Y. Fei, P.O. Vandvik, M. Loeb, G.H. Guyatt.
Provision of study materials or patients: M. Briel.
Statistical expertise: R.A.C. Siemieniuk.
Administrative, technical, or logistic support: G.H. Guyatt.
Collection and assembly of data: R.A.C. Siemieniuk, N. Evaniew, M. Prasad, P.E. Alexander, Y. Fei.
This article was published online first at www.annals.org on 11 August 2015.

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Reed A.C. Siemieniuk, Maureen O. Meade, Pablo Alonso-Coello, et al. Corticosteroid Therapy for Patients Hospitalized With Community-Acquired Pneumonia: A Systematic Review and Meta-analysis. Ann Intern Med.2015;163:519-528. [Epub 6 October 2015]. doi:10.7326/M15-0715

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