Steroids. I always have mixed feelings about them. It’s a Love & Hate relationship inside my head. On one hand I cannot stand those who claim steroids are the critical care’s Holy Grail. Steroids for sepsis, ARDS, trauma, anemia, bleeding, extubation failure, cold, hair loss, seizure, meningitis, stroke, hart failure, stinky farts and so on… We all know at least one of these bastards! On the other hand, I feel a warm feeling in my heart when I give steroids in some selected cases: maybe septic shock, some post extubation stridor, maybe meningitis…and sometimes pneumonia. During my residency training there was a “wing” (let’s call it a wing instead of gang) of doctors (mostly pneumologists) who strongly defended the use of steroids as an adjunctive treatment in severe pneumonia, while the other “wing” (intensivists, and myself included) had more important things to do and didn’t give a damn about their opinions.
Well, here we are today, ready to discuss the role of steroids in severe community acquired pneumonia (SCAP). But let me highlight one thing: SEVERE. Not that pneumonia/COPD/edema, A.K.A dirty water, treated with furosemide, antibiotics and salbutamol the ED guys try to turf on you every shift! I mean nasty severe mouth-full-of-sputum pneumonia. “But how am I suppose to know what seve is?”. Fear do not, young padawan. Just exam the patient, check the labs, you can even use some clinical prediction rule if you want to (CURB-65, PSI, SMART-COP, ATS criteria…). Ok, severe pneumonia! Got it!
So, why steroids? One might say it’s because patients with SCAP have [pretentious voice] “critical illness related corticosteroid insufficiency”! Well, F*@# you! This is bullshit! Now, if we believe, as most of us do, that any disease, specially infectious one, can lead to inflammation and sometimes this inflammation might be inappropriate or even out of control, leading to all kinds of shit, well, there it is! Steroids might be useful due its immunomodulating and anti-inflammatory effects. Who knows.
[First year resident voice] OMG! Sterois for SCAP! What an amazing idea! I bet we have tons of good quality evidence and three ANZICS mega trials. Well, sorry to disappoint you but unfortunately, there is a lack of good clinical trials with patient centered outcomes on this mater. We do have some, let’s say, medium-low quality trials [1,2,3,4,5,6,7], and tons of meta-analysis [8,9,10,11,12,13]! Man! We do have more meta-analysis than “real” studies! Jesus! Although we could discuss all the trials and come out with a conclusion, instead we’ll discuss the meta-analysis and try to come out with a pattern. But remember, meta-analysis with crappy studies = crappy meta-analysis.
I found 4 meta-analysis, two of them evaluating directly the role os steroids in SCAP[8,12], and two other[9,10] in hospitalized patients with CAP. We do have other meta-analysis with all sort of patient with CAP, but we’re an ICU blog and old ladies taking amoxiciin at home for a four alveoli pneumonia don’t concern me.
All four studies share a common background, meaning since you have a small group of trials, these trials are used in every meta-analysis. Most of these studies had low risk of bias according the the meta-analysis’ authors, however, except for one study , all the others were small sample studies (from 30 to 300 patients). Therefore, you have to think about publication bias, since the chance of a small study being published is increased if it shows a positive and stronger effect . Unfortunately it is what it is.
OK, below, you’ll see all forest plots for mortality (only in severe pneumonia). You can see the pattern we were looking for.
First, know that we have here odds ratios, risk ratios, and risk difference, demanding different interpretations of the effect magnitude. But if we pretend to forget the biases and methodological flaws for a while, there is something here. There is a consistent tendency favoring the use of steroids in patients with SCAP. I know, in order to accept this in our hearts as truth we have to let go our evidence based medicine souls, and I don’t think I’m ready for this. However, since we’re still waiting for our Aussie friends to run a mega trial, or even until the ESCAPe study (the VA RCT of steroids in SCAP) is published we’re left with these glimpses of possibilities. Maybe this really works.
But now we face another problem: Am I gonna use methylprednisolone? hydrocortisone? dexamethasone? Which dosage? Every single study used a different drug and dosage, and until further evidence, pick which you want. Personally, I use methylprednisolone 1mg/kg/day for 5 days (the dosage Torres used in his trial ). Despite hyperglycemia the regimens used in the trials were safe.
Let’s not forget this discussion is about SCAP, therefore, forget about patients with nasty nosocomial pneumonia or ventilator associated pneumonia, also this discussion doesn’t apply to the ordinary CAP patient. Remember: SCAP!
Again, this is a rather interesting subject, and I’m hungry and looking forward for new evidences, until there, am I ready to give roids for every patient with SCAP? Let’s say that in a myriad of probabilities it is more probable than not that I will give it! Confusing, isn’t it? What can I do? I don’t have a straight answer.
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2. Meijvis SC, Hardeman H, Remmelts HH et al. Dexamethasone and length of hospital stay in patients with community-acquired pneumonia: a randomised, double-blind, placebo-controlled trial The Lancet. 2011; 377(9782):2023-2030.
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14. Meta-Analysis with R pp 107-141