March 4, 2015
Should Steroids Be Used to Lower Treatment Failure in Pneumonia Patients?

Barcelona, Spain—The corticosteroid methylprednisolone shows success in decreasing treatment failure in patients with severe community-acquired pneumonia and high initial inflammatory response, according to a new study.

The report, published recently in the Journal of the American Medical Association, notes that community-acquired pneumonia is the leading infectious cause of death in developed countries. Despite advances in antibiotic treatment, mortality among hospitalized patients remains high, especially in those with severe pneumonia and in the 10% to 20% for whom treatment fails.

Even though corticosteroids are known to decrease the expression and action of many cytokines involved in the inflammatory response associated with pneumonia, the benefit of using the drug in those patients was unclear, according to background in the article.

To determine the effectiveness of corticosteroids in pneumonia patients, Antoni Torres, MD, PhD, of the Hospital Clinic, Barcelona, Spain, and colleagues randomly assigned 120 patients at three Spanish teaching hospitals with severe community-acquired pneumonia and a high inflammatory response—defined as blood test for C-reactive protein of greater than 150 mg/L at admission—to receive intravenously the corticosteroid methylprednisolone or placebo for 5 days, started within 36 hours of hospital admission.

Results indicate that there was less treatment failure, such as the development of shock, need for invasive mechanical ventilation, and death within 72 hours of treatment among the 61 patients in the methylprednisolone group—13% versus 31% for the 59 patients in the placebo group. Overall, patients who received corticosteroid treatment had 66% lower odds of treatment failure, the authors report.

In-hospital deaths did not statistically differ, however, between the two groups—10% in the methylprednisolone group compared to 15% in the placebo group. Hyperglycemia also was more common in the methylprednisolone group, 18%, than in the placebo group, 12%.

“Among patients with severe community-acquired pneumonia and high initial inflammatory response, the acute use of methylprednisolone compared with placebo decreased treatment failure,” the authors write. “If replicated, these findings would support the use of corticosteroids as adjunctive treatment in this clinical population.”

In an accompanying editorial, Richard G. Wunderink, MD, of the Northwestern University Feinberg School of Medicine, Chicago, suggests the key question is what “exactly are steroids preventing?”

“Because radiographic progression during the period between 72 hours and five days was the primary driver of treatment differences, understanding what this clinical finding represents is key to acceptance of the findings,” Wunderink writes. “The two logical explanations for radiographic progression are uncontrolled pneumonia and development of acute respiratory distress syndrome. Although the latter is supported by a body of literature, a beneficial effect on uncontrolled pneumonia is less logical. A more intriguing possibility is that corticosteroids block a Jarisch-Herxheimer-like reaction to initiation of antibiotics in patients with high genomic bacterial load.”

U.S. Pharmacist Social Connect