Efficacy and safety of glucocorticoids in the treatment of severe community-acquired pneumonia A meta-analysis

Background: Recent clinical trials have shown that adjunctive glucocorticoids is associated with inhibiting excessive inflammatory response and modulating cytokines release offering several advantages over conventional therapy on relieving clinical symptoms, reducing mortality, and improving prognosis. However, given the severe complications triggered by glucocorticosteroid, whether similar benefits may be achieved by patients undergoing glucocorticosteroid intervention remains controversial. Our meta-analysis aimed to investigate the efficacy and safety of adjunctive glucocorticoids in the treatment of severe community acquired pneumonia. Methods: A search of PubMed, EMBASE, Cochrane Library, EBASO, Medline, Google Scholar, Science Dicet, CBM, and CNKI databases was performed to analyze all relevant randomized controlled trials (RCTs) of corticosteroids in patients with severe community acquired pneumonia (CAP) up to January 2018. All-cause mortality, C-reactive protein (CRP) level, incidence of septic shock, and requirement of mechanical ventilation were selected as efficacy outcomes. Major adverse events involving super infection, upper gastrointestinal bleeding, and hyperglycemia were safety outcomes. Meta-analysis was conducted with RevMan 5.3 software. Results: A total of 10 RCTs comprising 665 patients were included for analysis. Regarding efficacy outcomes, adjunctive corticosteroid seemed to be superior compared with conventional treatment in terms of all-cause mortality (relative risk [RR]: 0.47, 95% confidence interval [CI], 0.3-0.74, P=.001), CRP level on day 8 after administration (standard mean difference [SMD]: -0.8, 95% CI, -1.11 to -0.5, P<.001), incidence of septic shock (odds ratio [OR] 0.15, 95% CI, 0.07-0.29, P<.001) and requirement for mechanical ventilation (OR: 0.32,95% CI, 0.20-0.52, P<.001). Meanwhile, we found that lowdose (<= 86mg) (RR: 0.41,95% CI, 0.21-0.82, P=.01) and prolonged (>5 days) (RR: 0.35, 95% CI, 0.15-0.81, P=.01) use of corticosteroids in dosage modus of a maintenance dose after a bolus (RR: 0.28, 95% CI, 0.14-0.55, P=.002) obtained better results in death through subgroup analysis. Regarding safety outcomes, no difference was observed between 2 groups in terms of upper gastrointestinal bleeding (OR: 0.83, 95% CI, 0.27-2.52, P=.74), hyperglycemia (OR: 1.3, 95% CI, 0.68-2.49, P=.42), and super infection (OR: 1.11, 95% CI, 0.14-9.13, P=.92). Conclusion: Adjunctive corticosteroid yielded favorable outcomes in the treatment of severe community acquired pneumonia (SCAP) as evidenced by decreased all-cause mortality, incidence of septic shock, and requirement for mechanical ventilation without increasing risk of adverse events. Low dose (<= 86mg/d), prolonged use (>5 days) of corticosteroid in dosage modus of a maintenance dose after a bolus can be recommended as preferred regimen to guard against SCAP.