Question 18

Critically evaluate the role of corticosteroids in patients with severe community-acquired pneumonia
NOT caused by SARS-CoV-2 infection under the following headings:

a) Rationale.    (2 marks)
b) Potential risks.    (3 marks)
c) Evidence supporting or refuting corticosteroid use in community-acquired pneumonia.     (5 marks)
 

[Click here to toggle visibility of the answers]

College Answer

Syllabus topic/section: 2.1.5 Respiratory Intensive Care – L1.

Aim: To explore the evidence and use of corticosteroids in respiratory infections.

Discussion: Community Acquired Pneumonia (CAP) is one of the leading causes of death in Australia and most developed countries. Candidates who scored well answered specifically about the rationale and evidence for steroids in non-COVID CAP. Depth into the effects of steroid anti-inflammatory, immune modulating properties or link to how this could improve outcomes in respiratory function or other outcomes were rewarded. Candidates who explained their understanding of results of trials or meta-analysis (Blum et al, Torres et al, Meduri et al, CAPE-COD, Cochrane review) and explained reason for use in severe CAP vs non-severe CAP scored more marks. Candidates are advised to take a moment to read the question carefully and respond accurately (e.g. the question was very specific, but answers mostly related to the general use of steroids in critical illness). Specific mention of trial names or mentioning all the trials is not required to pass, however the candidate was rewarded if this information was given. Candidates about to sit their fellowship exam should have a fair understanding of the literature to justify their clinical practice

Marking rubric

Rationale

2 marks

Does not iterate rationale.

OR

Very limited detail, key elements missing.

<1 mark

Limited detail.

Main elements present but unstructured.

1 mark

Broad detail for rationale included.

May still have some unstructured elements.

1.5 marks

Detailed and complete explanation of rationale.

Structured.

1.5 -2 marks

Potential risks

3 marks

Nil or fewer than 2 potential risks.

<1 mark

Reasonable list outlines major risks

e.g. hyperglycaemia, GIT bleeding

1 mark

Comprehensive list.

1-1.5 marks

Complete list. Ranging across all systems

1.5-3 marks

Evidence

5 marks

Poor details mentioned, with some interpretation and major positive and negative findings. May comment on limitations.

OR

trials mentioned but very limited or inaccurate interpretation and detail.

<1.5 marks

Accurate interpretation and accurate major positive and negative findings. Some findings or details missing, or minor inaccuracies.

Does not have to mention trials explicitly to pass.

May comment on limitations.

1.5-2.5 marks

Accurate interpretation and major positive and negative findings accurately described.

Includes some comment on limitations.

2.5-3.5 marks

Trials mentioned explicitly. E.g. Cape COD, Meduri

Accurate interpretation and significant positive and negative findings.

Limitations clearly and accurately described.

Indications clearly and accurately described with clinical application.

3.5-5 marks

Discussion

This has appeared before, as Question 5 from the first paper of 2016, and the candidates with knowledge of deep CICM lore would have been able to identify the level of depth expected. 

Rationale:

  • Much of the organ system effects of pneumonia may be related to the inflammatory reaction
  • Anti-inflammatory drugs like steroids may reduce the release of cytokines, thereby dampening the SIRS response
  • Modulation of the pro-inflammatory response should lead to a more rapid resolution of clinical features
  • Similar rationale in specific infections, where the evidence is strong:
    • dexamethasone for pneumococcal meningitis
    • PJP
    • COVID 
  • Collateral benefit for any underlying COPD, asthma, organising pneumonia, and hidden adrenal suppression

Potential risks:  this appears to have been a section expecting generic steroid side effects. In the following list some effort was made to relate the risks to the pneumonia in question.

  • Immunosuppression could give rise to worsening infection
  • Metabolic side effects (eg. hyperglycaemia, hypernatremia, fluid retention) increase the burden and complexity of care and have known mortality disadvantages
  • Adrenal suppression could delay discharge from the ICU because of persitsten haemodynamic instability
  • CNS side effects (eg. delirium, psychosis) and musculoskeletal side effects (eg. myopathy) could delay weaning from ventilation
  • There is an increased risk of GI bleeding
  • Some forms of pneumonia are known to get worse with steroids, eg. Influenza where mortality is doubled (Rodrigo et al, 2015 ) and Aspergillus (Parody et al, 2009)


Evidence:

  • Torres et al : compared methylprednisolone (n = 61) or placebo (n = 59) for 5 days.
    • Less treatment failure with steroids (13% vs 31%)
    • No difference in mortality
  • 785 patients randomised to 50mg prednisolone or placebo
    • "Median time to clinical stability was shorter in the prednisone group" - 3.0 days vs. 4.4
    • Not specifically ICU patients - all CAP admissions were enrolled
  • A 2015 meta-analysis including the above data suggested that the use of corticosteroids may reduce
    • mortality by 3%
    • need for mechanical ventilation by 5%
    • hospital stay by 1 day
  • CAPE-COD trial (Dequin et al, 2023) gave the treatment group 200mg/day of hydrocortisone tapered over 8-14 days and found:
    • Reduced mortality (6.2% vs 11.9%)
    • Reduced intubation rate (18.0% vs 29.5%)
    • Reduced used of vasopressors (15.3% vs 25%)
    • The effect was most pronounced in the group of patients with the highest CRP (over 150 mg/L)

References

Pareja, Jaime G., Robert Garland, and Henry Koziel. "Use of adjunctive corticosteroids in severe adult non-HIV Pneumocystis carinii pneumonia." CHEST Journal 113.5 (1998): 1215-1224.

Rodrigo, Chamira, et al. "Effect of corticosteroid therapy on influenza-related mortality: a systematic review and meta-analysis." Journal of Infectious Diseases 212.2 (2015): 183-194.

Parody, Rocio, et al. "Predicting survival in adults with invasive aspergillosis during therapy for hematological malignancies or after hematopoietic stem cell transplantation: single‐center analysis and validation of the seattle, french, and strasbourg prognostic indexes." American journal of hematology 84.9 (2009): 571-578.

Wunderink, Richard G., and Grant W. Waterer. "Community-acquired pneumonia." New England Journal of Medicine 370.6 (2014): 543-551.

Annane, Djillali. "Corticosteroids and pneumonia: time to change practice." The Lancet 385.9977 (2015): 1484-1485.

Siemieniuk, Reed AC, et al. "Corticosteroid Therapy for Patients Hospitalized With Community-Acquired Pneumonia: A Systematic Review and Meta-analysis." Annals of internal medicine (2015).

Torres, Antoni, et al. "Effect of corticosteroids on treatment failure among hospitalized patients with severe community-acquired pneumonia and high inflammatory response: a randomized clinical trial." JAMA 313.7 (2015): 677-686.

Blum, Claudine Angela, et al. The Lancet 385.9977 (2015): 1511-1518.

Wunderink, Richard G. "Corticosteroids for Severe Community-Acquired Pneumonia: Not for Everyone." JAMA 313.7 (2015): 673-674.