Lower Mortality in Patients Treated with Hydrocortisone for Severe Community-Acquired Pneumonia

Are corticosteroids beneficial for patients with community-acquired pneumonia (CAP)? Earlier this year, a randomized, controlled trial of patients with severe CAP showed no benefit for steroids (Intensive Care Med 2022; 48:1009). Just last month, a meta-analysis of 16 randomized trials also showed no effect on mortality (NEJM JW Gen Med Apr 15 2023 and Chest 2023; 163:484). Interestingly though, the meta-analysis showed that patients treated with corticosteroids were less likely to need intubation.

French investigators randomized 800 patients who were admitted to the intensive care unit with severe CAP to receive hydrocortisone (intravenous 200 mg daily) or placebo. Patients began treatment within 24 hours of developing severe CAP and were treated for 4 days and then tapered over 4 or 10 days depending on clinical improvement. About one quarter of patients were intubated at enrollment, and 40% were receiving high-flow nasal cannula oxygen. No standardized microbiologic investigation was done.

This trial began prior to the pandemic, and enrollment was halted in March 2020. Mortality at 28 days was significantly lower with hydrocortisone than with placebo (6% vs. 12%); this benefit persisted at 90 days. The hydrocortisone group was also less likely to require mechanical ventilation and less likely to develop shock. Hyperglycemia was more common in patients treated with hydrocortisone, but other adverse events were similar between groups.