Systemic corticosteroids for community-acquired pneumonia: Reasons for use and lack of benefit on outcome

Background and objective Although the benefits of systemic corticosteroids in community-acquired pneumonia (CAP) are not clear, their use is frequent in clinical practice. We described the frequency of this practice, patients' characteristics and its clinical impact. Methods We investigated all adult CAP patients visited between June 1997 and January 2008 (n = 3257). Results Two hundred and sixty patients received systemic corticosteroids (8%) with a mean daily dose of 45 (33) mg (median, 36 mg/day). Patients receiving corticosteroids were older (74 (13) vs 65 (19) years), had more comorbidities (respiratory, 59% vs 38%, cardiac, 29% vs 16%, etc.), higher Pneumonia Severity Index (Fine IV-V, 76% vs 50%) and had received inhaled corticosteroids (36% vs 15%) and previous antibiotics (31% vs 23%) more frequently (P < 0.01, each). Significant predictors of corticosteroid administration were: chronic obstructive pulmonary disease (odds ratio (OR), 1.91), fever (OR, 0.59), expectoration (OR, 1.59), creatinine (+1 mg/dL, OR, 0.92), SaO₂ ≥ 92% (OR, 0.46), C-reactive protein (+5 mg/dL; OR, 0.92) and cardiac failure (OR, 1.76). Mortality (6% vs 7%; P = 0.43) and time to clinical stability (4 (3-6) vs 5 (3-7) days; P = 0.11) did not differ between the two groups, while length of hospital stay was longer for the steroid group (9 (6-14) vs 6 (3-9) days; P < 0.01). Conclusions The main reasons for administering systemic steroids were the presence of chronic respiratory comorbidity or severe clinical presentation, but therapy did not influence mortality or clinical stability; by contrast, steroid administration was associated with prolonged length of stay. Nevertheless the steroid group did not show an increased mortality as it was expected according to the initial Pneumonia Severity Index score. Influence of steroids on outcomes of CAP need to be further investigated through randomized clinical trial. See Editorial, page 199 Despite the lack of a clear benefit, systemic corticosteroids are frequently administered in CAP. We investigated clinical reasons for steroid prescription and the impact on major outcomes, showing no correlation with mortality or clinical stability independent of severity and cumulative steroid dosage, but an increase in length of hospital stay.