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DRUG INFORMATION ROUNDS

Corticosteroid Treatment of Severe Community-Acquired Pneumonia

Clinical Pharmacotherapeutic Specialist—Critical Care, CSU Pharmaceutical Sciences, Vancouver General Hospital; Clinical Assistant Professor, Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada

Richard S Slavik, PharmD FCSHP

Clinical Pharmacotherapeutic Specialist—Critical Care, CSU Pharmaceutical Sciences, Vancouver General Hospital; Clinical Assistant Professor, Faculty of Pharmaceutical Sciences, University of British Columbia

Judith Marin, PharmD

Clinical Pharmacist—Renal Program, Fraser Health Authority, Surrey, British Columbia

Reprints: Dr. Gorman, Faculty of Pharmaceutical Sciences, University of British Columbia, 855 W. 12th Ave., Vancouver, BC, Canada V5Z 1M9, fax 604/875-5267, sean.gorman{at}vch.ca

OBJECTIVE: To assess the evidence for adjunctive corticosteroids for severe community-acquired pneumonia (CAP).

DATA SOURCES: MEDLINE (1966-February 2007) and EMBASE (1980-February 2007) were searched to identify English- and French-language publications that evaluated the use of corticosteroids for CAP in adults. Major search terms included community-acquired pneumonia, intensive care unit, steroids, glucocorticoids, and adrenal cortex hormones.

STUDY SELECTION AND DATA EXTRACTION: Clinical studies that evaluated the use of corticosteroids for CAP in adults were included. Clinical and surrogate markers of pneumonia were evaluated.

DATA SYNTHESIS: Severe CAP is associated with an increase in pulmonary and circulatory cytokines such as interleukin-6 and tumor necrosis factor- that may be associated with higher mortality. Corticosteroids suppress inflammatory reactions and prevent migration of inflammatory cells from the circulation to tissues by suppressing the synthesis of chemokines and cytokines. One observational comparative study and 2 randomized, controlled studies examined the effects of corticosteroid therapy at various doses on endpoints of pulmonary and systemic inflammation and clinical outcomes. One small observational pilot study revealed that methylprednisolone blunted some of the pulmonary and systemic markers of inflammation. One small, randomized, placebo-controlled study revealed that hydrocortisone had no significant effects on markers of pulmonary and systemic inflammation or clinical outcomes. Another small, randomized, placebo-controlled preliminary study with methodological limitations revealed improvements in oxygenation, organ dysfunction score, and markers of inflammation favoring hydrocortisone over placebo.

CONCLUSIONS: Given the lack of proven benefit on clinically meaningful endpoints and adverse events, corticosteroids cannot be recommended for adjunctive treatment of severe CAP.

Key Words: glucocorticoids, mechanical ventilation, pneumonia

Published Online, May 22, 2007. www.theannals.com, DOI 10.1345/aph.1H660