Community–acquired pneumonia (CAP) results in severe systemic and pulmonary inflammation and is often associated with high morbidity and mortality despite the advances in antibiotic therapies and the use of preventive measures such as vaccinations. Treatment with a low dose of corticosteroids might accelerate the resolution of the inflammatory response in the early phase of the disease.1,2 Corticosteroids have shown some benefit in clinical trials when used in patients with severe sepsis and septic shock. However, there are few controlled trials of corticosteroids as adjunctive treatment to antibiotics in the management of pneumonia.3-6
In a recent study published in Lancet7, the investigators hypothesized that the use of intravenous dexamethasone might change the immune response in patients with CAP and therefore might reduce length of hospital stay. Adult patients (n=304) with confirmed CAP, who presented to emergency departments of two teaching hospitals in the Netherlands from November 2007 and September 2010, were randomized to receive either dexamethasone 5mg once daily (n=151) or placebo (n=153) for 4 days. Patients were excluded if they were immunocompromised, needed immediate transfer to the intensive care unit (ICU), or were already receiving corticosteroids or immunosuppressive drugs. Out of 304 patients, 143 (47%) patients had pneumonia with a severity index class 4-5 (79/151 (52%) patients in the dexamethasone group and 64/153 (42%) patients in the placebo group). The median length of stay was 6.5 (IQR 5.0-9.0) days in the dexamethasone group compared with 7.5 (5.3-11·5) days in the placebo group (95% CI 0-2 days; p=0·048). In-hospital mortality and severe adverse events were infrequent and did not differ between groups, although 67/151 (44%) patients in the dexamethasone group had hyperglycemia compared with 35/153 (23%) patients in the placebo group (p<0·0001). Declines in C-reactive protein and interleukin-6 levels in the first 4 days of treatment were greater in patients who received dexamethasone than in those who received placebo. Although not statistically significant, the rates of empyema and the length of stay in the ICU were greater in the dexamethasone group.
In conclusion, although corticosteroids may have modest benefits when added to antibiotic treatment in non-immunocompromized patients with CAP, further studies are still needed to confirm these findings.
1. Monton C, Ewig S, Torres A, et al. Role of glucocorticoids on inflammatory response in nonimmunosuppressed patients with pneumonia: a pilot study. Eur Respir J
2. Rosewicz S, McDonald AR, Maddux BA, et al. Mechanism of glucocorticoid receptor down-regulation by glucocorticoids. J Biol Chem
3. Annane D, Sebille V, Charpentier C, et al. Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. JAMA
4. Mikami K, Suzuki M, Kitagawa H, et al. Efficacy of corticosteroids in the treatment of community-acquired pneumonia requiring hospitalization. Lung
5. Confalonieri M, Urbino R, Potena A, et al. Hydrocortisone infusion for severe community-acquired pneumonia: a preliminary randomized study. Am J Respir Crit Care Med
6. Marik P, Kraus P, Sribante J, et al. Hydrocortisone and tumor necrosis factor in severe community-acquired pneumonia. A randomized controlled study. Chest