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FACP. Colegio de médicos de Tarragona Nº 4305520 / fgcapriles@gmail.com




Sunday, April 24, 2016

Corticosteroids for CAP

Resultado de imagen de PulmCCM
PulmCCM - April 23, 2016 
"Earlier this year, Wan et al. published a systematic review and meta-analysis on the efficacy and safety of corticosteroids for community-acquired pneumonia [CAP]. Reports of corticosteroids for the treatment of pneumonia date back at least 6 decades; as in a plethora of other pathologies, the pendulum for corticosteroids in community-acquired pneumonia continues to swing...
The benefit of corticosteroids in CAP – including severe CAP – are reminiscent of their known benefits in COPD exacerbations [AECOPD]. The landmark VA-Cooperative trial in 1999 demonstrated that, compared to placebo, corticosteroids got patients with AECOPD out of the hospital earlier by about 1 day. Additionally, there was a small improvement in FEV1 and patients receiving steroids were less likely to have ‘treatment failure’ [interestingly, mostly driven by the need for open-label steroids].
As Wan et al. note, a fairly large trial would be required to confidently detect a mortality benefit for corticosteroids in CAP. Until then [if ever], we will likely squabble and make use of post-hoc subgroup analyses to justify or condemn their use. What is, perhaps, most important is that a short course of steroids is unlikely to cause clinical deterioration in patients with community-acquired pneumonia. Also of note is keen recognition of inclusion and exclusion criteria. Many studies utilized by Wan et al. in their meta-analysis specifically excluded patients with nosocomial pneumonia, immunosuppression, uncontrolled hyperglycemia, pregnancy, adrenal insufficiency, recent gastrointestinal hemorrhage, etc. One even excluded patients en route to the ICU.
Regardless, the calls to add corticosteroids to the general management of community-acquired pneumonia have begun; I do not foresee them getting softer, especially with exquisite emphasis placed on length of stay and cost-containment."