This is a plain English summary of an original research article
For adults admitted to hospital with severe pneumonia, this review found that adding corticosteroids to the usual antibiotic treatment may be beneficial. The evidence was less supportive of using corticosteroids in people with less severe pneumonia. Results showed modest benefits in allowing patients to reach a clinically stable recovery and leave hospital an average of one day earlier. Reduced need for artificial breathing support was the main benefit for people with non-severe pneumonia. The review showed that using corticosteroids increased levels of blood sugar. This and other potential adverse events were not well investigated, as people at risk of them were excluded from most studies.
The current 2014 NICE guideline on pneumonia does not recommend routinely offering a corticosteroid to patients with community‑acquired pneumonia unless they have other conditions for which this treatment is indicated. The guideline is due to be reviewed in late 2016.
Before changing practice further trials would be helpful, to see if it is possible to replicate the findings and to clarify which corticosteroid to use, at what dose, and for whom. A more thorough assessment of potential adverse events, in people at higher risk of diabetes for example, would also help to quantify the potential downsides of a change in practice.
Why was this study needed?
Pneumonia is common, particularly in winter, with between 5 and 11 in every 1,000 adults catching pneumonia each year. The illness is much more dangerous for those who smoke, are elderly, have existing lung conditions or an impaired immune system. The impact of pneumonia is large in terms of treatment costs and loss of life: between 22 and 42% of adults with community acquired pneumonia are admitted to hospital and 5 to 14% of people with more severe illness die from the condition.
Antibiotics are the main treatment for pneumonia. A 2011 systematic review of six small trials found that adding corticosteroid treatment increased speed of recovery slightly, but the evidence was not strong. The current review aimed to update the evidence on benefits and potential side effects of add-on corticosteroid treatment for people who had been admitted to hospital with pneumonia.
What did this study do?
This systematic review included 13 randomised controlled trials, with 2,005 participants. It updated and added to a 2011 review with a further nine trials. The majority of trial participants were men in their sixties. All the studies compared add-on treatment with corticosteroid (such as dexamethasone, prednisolone or hydrocortisone) with inactive placebo treatment. All the patients were receiving antibiotics as the main treatment for their pneumonia. The main outcomes were mortality from all causes, time to clinical stability and days to discharge from hospital.
This systematic review was rigorously carried out using the same approach as the Cochrane review it aimed to update. The underlying trials were at moderate or low risk of bias. However, there were few trials for each outcome, and most trials excluded participants who were at risk of adverse events. This limits our confidence in the findings and the relevance of the research to severe pneumonia.
What did it find?
The effects of corticosteroids in the trials were:
- Length of hospital stay was reduced by average of one day in the three studies which had low risk of bias for this outcome (1,288 participants, mean difference 1.00 days, 95%CI, -1.79 to -0.21 days).
- Time to clinical stability – meaning regaining normal values for basic functions such as body temperature and breathing rate – was shorter by just over a day in the five studies which measured this (1,180 participants, mean difference -1.22 days, CI -2.08 to -0.35 days).
- Mortality from all causes was only significantly reduced when the data was pooled from six trials (388 participants) on severe pneumonia (risk ratio [RR] 0.39, 95% confidence interval [CI] 0.20 - 0.77). However, the authors thought that this effect might be spurious.
- The need for mechanical ventilation was reduced in the five studies that measured this outcome (1,060 participants, a range of severity of pneumonia, RR, 0.45 [CI, 0.26 to 0.79]). There was most benefit for people with less severe pneumonia.
- A severe complication of pneumonia called acute respiratory distress syndrome was uncommon overall, but risk was reduced when trial participants received corticosteroids (4 trials, 945 participants, RR 0.24, CI 0.10 – 0.56).
- The main side effect of corticosteroid treatment – risk of raised blood glucose - was increased (6 trials, 1,534 participants, RR 1.49, CI 1.01 to 2.19). However, patients at risk of side effects of corticosteroid treatment were excluded from most trials.
What does current guidance say on this issue?
The current 2014 NICE guideline on pneumonia does not recommend routinely offering a corticosteroid to patients with community‑acquired pneumonia unless they have other conditions which are usually treated with corticosteroid treatment. The guidance is due to be reviewed in late 2016.
What are the implications?
Pneumonia is a common and potentially costly condition to treat, so at first sight implementing the findings of this review could offer significant savings. Reducing hospital stays for pneumonia by one day saves £192 on average. For the 175,000 people admitted to hospital with community-acquired pneumonia in 2013/14 this could have saved over £33 million. The benefits of corticosteroid treatment applied mainly to those with severe pneumonia who are more likely to need more costly intensive care and mechanical breathing support. Approaches to corticosteroid treatment and underlying antibiotic therapy varied widely between studies, therefore the researchers call for more research into the potential impact of any change in practice.
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