Use of corticosteroids in pneumonia: The pendulum swings back
Resumen
El documento revisa la evidencia sobre el uso de corticoesteroides (CCs) en la neumonía adquirida en la comunidad (NAC), destacando estudios recientes y metaanálisis. Desde 1940, el uso de CCs en infecciones severas ha sido controversial. La base fisiopatológica se centra en mitigar la “tormenta de citoquinas”. Estudios recientes y metaanálisis sugieren que los CCs, especialmente la hidrocortisona, pueden mejorar la supervivencia en NAC severa. Sin embargo, se necesita más investigación para confirmar estas recomendaciones. El uso de CCs debe ser individualizado y administrado tempranamente.
Abstract
This document reviews the evidence on the use of corticosteroids (CS) in community-acquired pneumonia (CAP), highlighting recent studies and meta-analyses. Since the 1940s, the use of CS in severe infections has been controversial. The pathophysiological rationale focuses on mitigating the “cytokine storm.” Recent studies and meta-analyses suggest that CS, particularly hydrocortisone, may improve survival in severe CAP. However, further research is needed to confirm these recommendations. The use of CS should be individualized and administered early.
Abstract
This document reviews the evidence on the use of corticosteroids (CS) in community-acquired pneumonia (CAP), highlighting recent studies and meta-analyses. Since the 1940s, the use of CS in severe infections has been controversial. The pathophysiological rationale focuses on mitigating the “cytokine storm.” Recent studies and meta-analyses suggest that CS, particularly hydrocortisone, may improve survival in severe CAP. However, further research is needed to confirm these recommendations. The use of CS should be individualized and administered early.
Palabras clave:
corticosteroides, neumonía adquirida en la comunidad, infecciones graves, tormenta de citoquinas, hidrocortisona.Keywords:
corticosteroids, community-acquired pneumonia, severe infections, cytokine storm, hydrocortisoneReferences
1. Perla D, Marmorston J. Suprarenal Cortical Hormone and Salt in the Treatment of Pneumonia and Other Severe Infections. Endocrinology. 1940;27(3):367-74. doi:10.1210/endo-27-3-367
2. Menéndez R, Cavalcanti M, Reyes S, et al. Markers of treatment failure in hospitalised community acquired pneumonia. Thorax. 2008;63(5):447-52. doi:10.1136/thx.2007.086785
3. Shindo Y, Ito R, Kobayashi D, et al. Risk factors for 30-day mortality in patients with pneumonia who receive appropriate initial antibiotics: an observational cohort study. Lancet Infect Dis. 2015;15(9):1055-65. doi:10.1016/S1473-3099(15)00151-6
4. Ferrara JL, Abhyankar S, DG. G. Cytokine storm of graft-versus-host disease: a critical effector role for interleukin-1. Transplant Procedures. 1993;25(1):1216-7.
5. Annane D, Pastores SM, Rochwerg B, et al. Guidelines for the diagnosis and management of critical illness-related corticosteroid insufficiency (CIRCI) in critically ill patients (Part I): Society of Critical Care Medicine (SCCM) and European Society of Intensive Care Medicine (ESICM) 2017. Intens Care Med. 2017;43(12):1751-63. doi:10.1007/s00134-017-4919-5
6. Bennett JE, Dolin R, Blaser MJ. Principles and Practice of Infectious Diseases. 8th ed. vol 1. Acute pneumonia. Churchill Livingstone; 2015, pp. 823-846.
7. Wunderink RG. Corticosteroids for Severe Community-Acquired Pneumonia Not for Everyone. Jama-J Am Med Assoc. 2015;313 (7):673-4. doi:DOI 10.1001/jama.2015.115
8. GBD 2016 Lower Respiratory Infections Collaborators. Estimates of the global, regional, and national morbidity, mortality, and aetiologies of lower respiratory infections in 195 countries, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Infect Dis. 2018;18(11):1191-210. doi:10.1016/S1473-3099(18)30310-4
9. Gattarello S, Borgatta B, Sole´-Violan J, et al. Decrease in mortality in severe community-acquired pneumococcal pneumonia: impact of improving antibiotic strategies (2000-2013). Chest. 2014;146:22-31. doi:10.1378/chest.13-1531
10. Kellum JA, Kong L, Fink MP, et al. Understanding the inflammatory cytokine response in pneumonia and sepsis: results of the Genetic and Inflammatory Markers of Sepsis (GenIMS) Study. Arch Int Med. 2007;167(15):1655-63. doi:10.1001/archinte.167.15.1655
11. Kaplan V AD, Griffin MF, et al. Hospitalized community-acquired pneumonia in the elderly: age- and sex-related patterns of care and outcome in the United States. Am J Resp Crit Care Med. 2002;165:766-72. doi:10.1164/ajrccm.165.6.2103038
12. Meduri GU, Shih MC, Bridges L, et al. ESCAPe Study Group. Low-dose methylprednisolone treatment in critically ill patients with severe community-acquired pneumonia. Intens Care Med. 2022;48(8):1009-23. doi: 10.1007/s00134-022-06684-3.
13. Dequin PF MF, Quenot JP, et al. Hydrocortisone in Severe Community-Acquired Pneumonia. New Engl J Med. 2023;388(21):1931-41. doi:10.1056/NEJMoa2215145.
14. Stern A, Skalsky K, Avni T, et al. Corticoste-roids for pneumonia. Cochrane Db Syst Rev. 2017;12(12):1-88. doi:10.1002/14651858.CD007720
15. Pastores SM, Annane D, Rochwerg B, Sccm, Esicm. Guidelines for the diagnosis and management of critical illness-related corticosteroid insufficiency (CIRCI) in critically ill patients (Part II): Society of Critical Care Medicine (SCCM) and European Society of Intensive Care Medicine (ESICM) 2017. Intens Care Med. 2018;44(4):474-77. doi:10.1007/s00134-017-4951-5
16. Metlay JP WG, Long AC, et al. Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019;200(7):e45-e67. doi:10.1164/rccm.201908-1581ST
17. Chaudhuri D, Sasaki K, Karkar A, et al. Corticosteroids in COVID-19 and non-COVID-19 ARDS: a systematic review and meta-analysis. Intens Care Med. 2021;47(5):521-37. doi:10.1007/s00134-021-06394-2
18. Sterne JAC, Murthy S, Diaz JV, et al. Association Between Administration of Systemic Corticosteroids and Mortality Among Critically Ill Patients With COVID-19 A Meta-analysis. Jama-J Am Med Assoc. 2020;324(13):1330-41. doi:10.1001/jama.2020.17023
19. Mandell LA WR, Anzueto A, et al. Infectious Diseases Society of America; American Thoracic Society. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis. 2007;44 Suppl 2(2):S27-72. doi:10.1086/511159
20. Cain DW, Cidlowski JA. Immune regulation by glucocorticoids. Nat Rev Immunol. 2017;17:233-47. doi:10.1038/nri.2017.1
21. Roquilly A BA, Jacqueline C, et al. Hydrocortisone prevents immunosuppression by interleukin-10+ natural killer cells after trauma-hemorrhage. Crit Care Med. 2014;42:e752–761. doi:10.1097/CCM.0000000000000658
22. Saleem N, Kulkarni A, Snow TAC, et al. Effect of Corticosteroids on Mortality and Clinical Cure in Community-Acquired Pneumonia A Systematic Review, Meta-analysis, and Meta-regression of Randomized Control Trials. Chest. 2023;163:484-97. doi:10.1016/j.chest.2022.08.2229
23. Torres A, Sibila O, Ferrer M, et al. Effect of Corticosteroids on Treatment Failure Among Hospitalized Patients With Severe Community-Acquired Pneumonia and High Inflammatory Response A Randomized Clinical Trial. JAMA. 2015;313:677-86. doi: 10.1001/jama.2015.88
24. Pitre T, Rochwerg B, Zeraatkar D. Corticosteroids in Community-Acquired Pneumonia In or Out? Chest. Jan 2023;163(1): E47-E48. doi:10.1016/j.chest.2022.09.036
25. Fine MJ, Auble TE, Yealy DM, et al. A prediction rule to identify low-risk patients with community-acquired pneumonia. New Engl J Med. 1997;36(4):243-50. doi:10.1056/NEJM199701233360402
26. Metlay JP WG. Time to Treat Severe Community-Acquired Pneumonia with Steroids? N Engl J Med. 2023;388:2001-2. doi:10.1056/NEJMe2302544
27. Rodrigo C, Leonardi-Bee J, Nguyen-Van-Tam J, Lim WS. Corticosteroids as adjunctive therapy in the treatment of influenza. Cochrane Db Syst Rev. 2016;(3). doi:10.10 02/14651858.CD010406
28. Dequin PF, Meziani F, Quenot JP, Kamel T, Ricard JD, Badie J, Reignier J, Heming N, Plantefève G, Souweine B, Voiriot G, Colin G, Frat JP, Mira JP, Barbarot N, François B, Louis G, Gibot S, Guitton C, Giacardi C, Hraiech S, Vimeux S, L’Her E, Faure H, Herbrecht JE, Bouisse C, Joret A, Terzi N, Gacouin A, Quentin C, Jourdain M, Leclerc M, Coffre C, Bourgoin H, Lengellé C, Caille-Fénérol C, Giraudeau B, Le Gouge A; CRICS-TriGGERSep Network. Hydrocortisone in Severe Community-Acquired Pneumonia. N Engl J Med. 2023 May 25;388(21):1931-41. doi: 10.1056/NEJMoa2215145.
29. Confalonieri M UR, Potena A, et al. Hydrocortisone infusion for severe community-acquired pneumonia: a preliminary randomized study. Am J Respir Crit Care Med. 2005;171:242-8. doi:10.1164/rccm.200406-808OC
30. See XY, Wang TH, Chang YC, et al. Impact of different corticosteroids on severe community-acquired pneumonia: a systematic review and meta-analysis. Bmj Open Respir Res. 2024;11(1). doi:10.1136/bmjresp-2023-002141
31. Cheema HA, Musheer A, Ejaz A, et al. Efficacy and safety of corticosteroids for the treatment of community-acquired pneumonia: A systematic review and meta-analysis of randomized controlled trials. J Crit Care. 2024;80:154507. doi:10.1016/j.jcrc.2023.154507
32. Díaz Caballero LA AA, Saleem Paryani N, et al. Comparing the efficacy of corticosteroids among patients with community-acquired pneumonia in the ICU versus non-ICU settings: A systematic review and meta-analysis. Steroids. 2024;205:205:109389:1-10. doi:10.1016/j.steroids.2024.109389
33. Wu JY, Tsai YW, Hsu WH, et al. Efficacy and safety of adjunctive corticosteroids therapy for patients with severe community-acquired pneumonia A systematic review and meta-analysis. Crit Care. 2023;27(1). doi:10.1186/s13054-023-04561-z
34. Bergmann F, Pracher L, Sawodny R, et al. Efficacy and Safety of Corticosteroid Therapy for Community-Acquired Pneumonia: A Meta-Analysis and Meta-Regression of Randomized, Controlled Trials. Clin Infect Dis. 2023;77:1704-13. doi:10.1093/cid/ciad496
35. Wu WF, Fang Q, He GJ. Efficacy of corticosteroid treatment for severe community-acquired pneumonia: A meta-analysis. Am J Emerg Med. 2018;36(2):179-84. doi:10.1016/j.ajem.2017.07.050
36. Huang J, Guo JQ, Li HT, Huang WB, Zhang TT. Efficacy and safety of adjunctive corticosteroids therapy for patients with severe community-acquired pneumonia A systematic review and meta-analysis. Medicine. 2019;98(13). doi:10.1097/MD.0000000000014636
37. Briel M, Spoorenberg SMC, Snijders D, et al. Corticosteroids in Patients Hospitalized With Community-Acquired Pneumonia: Systematic Review and Individual Patient Data Meta-analysis. Clin Infect Dis. 2018;66(3):346-54. doi:10.1093/cid/cix801
38. Siemieniuk RAC, Meade MO, Alonso-Coello P, et al. Corticosteroid Therapy for Patients Hospitalized With Community Acquired Pneumonia A Systematic Review and Meta-analysis. Ann Intern Med. 2015;163(7): 519-28. doi:10.7326/M15-0715
39. Chaudhuri D, Nei AM, Rochwerg B, et al. 2024 Focused Update: Guidelines on Use of Corticosteroids in Sepsis, Acute Respiratory Distress Syndrome, and Community-Acquired Pneumonia. Crit Care Med. 2024;52:e219-e233. doi:10.1097/Ccm.0000000000006172
40. Confalonieri M UR, Potena A, et al. Hydrocortisone infusion for severe community-acquired pneumonia: a preliminary randomized study. Am J Respir Crit Care Med. 2005;171:242-8. doi:10.1164/rccm.200406-808OC
41. Nafae RM RM, Amany FM, et al. Adjuvant role of corticosteroids in the treatment of community-acquired pneumonia. Egypt J Chest Dis Tuberc. 2013;62:439-45. doi:10.1016/j.ejcdt.2013.03.009
42. Alipanah N CC. Phenotyping in acute respiratory distress syndrome: state of the art and clinical implications. Curr Opin Crit Care. 2022;28:1-8. doi:10.1097/MCC.0000000000000903
43. Wittermans E, van der Zee PA, Qi H, et al. Latent class analysis-based subgroups and response to corticosteroids in hospitalised community-acquired pneumonia patients: a validation study. Erj Open Res. 2023;9(2):00577-2022. doi:10.1183/23120541.00577-2022
44. Wittermans E, van der Zee PA, Qi HC, et al. Community-acquired pneumonia subgroups and differential response to corticosteroids: a secondary analysis of controlled studies. Erj Open Res. 2022;8(1):Artn 00489-2021. doi:10.1183/23120541.00489-2021
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