Real-world corticosteroid use in severe pneumonia: a propensity-score-matched study
A. Ceccato,
A. Russo,
E. Barbeta,
P. Oscanoa,
G. Tiseo,
A. Gabarrus,
P. Di Giannatale,
S. Nogas,
C. Cilloniz,
F. Menichetti,
M. Ferrer,
M. Niederman,
M. Falcone,
A. Torres
Affiliations
A. Ceccato
Ciber de Enfermedades Respiratorias (Ciberes, CB06/06/0028), Institut d’Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), University of Barcelona (UB)
A. Russo
Department of Public Health and Infectious Diseases, Policlinico Umberto I, “Sapienza” University of Rome
E. Barbeta
Ciber de Enfermedades Respiratorias (Ciberes, CB06/06/0028), Institut d’Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), University of Barcelona (UB)
P. Oscanoa
Ciber de Enfermedades Respiratorias (Ciberes, CB06/06/0028), Institut d’Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), University of Barcelona (UB)
G. Tiseo
Infectious Diseases Unit, Department of Clinical and Experimental Medicine, University of Pisa
A. Gabarrus
Ciber de Enfermedades Respiratorias (Ciberes, CB06/06/0028), Institut d’Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), University of Barcelona (UB)
P. Di Giannatale
Department of Medical, Oral and Biotechnological Sciences, School of Medicine and Health Sciences, Section of Anesthesia Analgesia, Perioperative and Intensive Care, SS. Annunziata Hospital, Gabriele d’Annunzio University of Chieti-Pescara
S. Nogas
Dipartimento Scienze Chirurgiche E Diagnostiche Integrate (DISC), Università Degli Studi Di Genova
C. Cilloniz
Ciber de Enfermedades Respiratorias (Ciberes, CB06/06/0028), Institut d’Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), University of Barcelona (UB)
F. Menichetti
Infectious Diseases Unit, Department of Clinical and Experimental Medicine, University of Pisa
M. Ferrer
Ciber de Enfermedades Respiratorias (Ciberes, CB06/06/0028), Institut d’Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), University of Barcelona (UB)
M. Niederman
Division of Pulmonary and Critical Care Medicine, Weill Cornell Medical College, New York Presbyterian/Weill Cornell Medical Center
M. Falcone
Infectious Diseases Unit, Department of Clinical and Experimental Medicine, University of Pisa
A. Torres
Ciber de Enfermedades Respiratorias (Ciberes, CB06/06/0028), Institut d’Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), University of Barcelona (UB)
Abstract Background Community-acquired pneumonia (CAP) is a leading cause of morbidity and mortality worldwide despite correct antibiotic use. Corticosteroids have long been evaluated as a treatment option, but heterogeneous effects on survival have precluded their widespread implementation. We aimed to evaluate whether corticosteroids might improve clinical outcomes in patients with severe CAP and high inflammatory responses. Study design and methods We analyzed two prospective observational cohorts of patients with CAP in Barcelona and Rome who were admitted to intensive care with a high inflammatory response. Propensity score (PS) matching was used to obtain balance among the baseline variables in both groups, and we excluded patients with viral pneumonia or who received hydrocortisone. Results Of the 610 patients admitted with severe CAP, 198 (32%) received corticosteroids and 387 had major criteria for severe CAP. All patients had a baseline serum C-reactive protein above 15 mg/dL. Patients who received corticosteroids were more commonly male, had more comorbidities (e.g., cancer or chronic obstructive pulmonary disease), and presented with significantly higher sequential organ failure assessment scores. Eighty-nine patients met major severity criteria (invasive mechanical ventilation and/or septic shock) and were matched per group. Twenty-eight-day mortality was lower among patients receiving corticosteroids (16 patients, 18%) than among those not receiving them (28 patients, 31%; p = 0.037). After PS matching, corticosteroid therapy reduced the 28-day mortality risk in patients who met major severity criteria (hazard ratio (HR) 0.53, 95% confidence interval (CI) 0.29–0.98) (p = 0.043). In patients who did not meet major severity criteria, no benefits were observed with corticosteroid use (HR 0.88 (95%CI 0.32–2.36). Conclusions Corticosteroid treatment may be of benefit for patients with CAP who have septic shock and/or a high inflammatory response and requirement for invasive mechanical ventilation. Corticosteroids appear to have no impact on mortality when these features are not present.
