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Liu J, Dong Y, Chen J, Jin Y, Qiu Y, Huang L. Corticosteroid in non-COVID-19 induced community-acquired pneumonia, a meta-analysis. Heart Lung 2024; 65:59-71. [PMID: 38432039 DOI: 10.1016/j.hrtlng.2024.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 02/07/2024] [Accepted: 02/24/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND Corticosteroid treatment in non-COVID-19 induced Community-acquired pneumonia (CAP) remains inconclusive. OBJECTIVES We aimed to assess the role of corticosteroid treatment in CAP. METHODS We conducted a comprehensive search of online databases, including PubMed, Embase, and Cochrane, to identify articles published from January 1, 2000, to May 5, 2023. Double-blind RCTs were selected. Two authors screened studies and extracted data. The evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation approach. RESULTS We analyzed data from 12 RCTs, involving 2446 patients. Corticosteroids therapy may reduce short-term mortality in patients with severe CAP (sCAP) and shorten the hospital length of stay in patients with CAP. Furthermore, corticosteroids treatment can decrease the risk of requiring mechanical ventilation, developing septic shock and multiple organ dysfunction syndrome (MODS). There were no significant differences between the corticosteroid and control groups concerning gastrointestinal bleeding and nosocomial infection. The use of corticosteroids could increase the risk of hyperglycemia. CONCLUSION Corticosteroid treatment for sCAP has the potential to provide benefits in reducing short-term mortality, but this conclusion necessitates more evidence. Besides, we found no evidence that strongly prevents us from using corticosteroids in patients with sCAP or those at risk of progressing to sCAP.
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Affiliation(s)
- Jian Liu
- Department of Critical Care Medicine, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China.
| | - Yongquan Dong
- Department of Respiratory Disease, YinZhou Second Hospital, Ningbo, Zhejiang, China
| | - Jia Chen
- Research Center for Healthcare Data Science, Zhejiang Lab, Hangzhou, Zhejiang, China
| | - Yuqing Jin
- Research Center for Healthcare Data Science, Zhejiang Lab, Hangzhou, Zhejiang, China
| | - Yunqing Qiu
- Zhejiang Provincial Key Laboratory for Drug Clinical Research and Evaluation, Department of Clinical Pharmacy, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Lingtong Huang
- Department of Critical Care Medicine, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China.
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2
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Waterer GW, Metersky M. Corticosteroids and Severe Community-acquired Pneumonia: New Data, New Questions and a Swinging Pendulum. Arch Bronconeumol 2023; 59:793-794. [PMID: 37625907 DOI: 10.1016/j.arbres.2023.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 08/04/2023] [Indexed: 08/27/2023]
Affiliation(s)
- Grant W Waterer
- East Metropolitan Health Service, Royal Perth Hospital, Perth, Australia.
| | - Mark Metersky
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Connecticut School of Medicine, Connecticut, United States
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3
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Pearce AK, Zawaydeh Q, McGuire WC, Husain A, Ayoub C, Sweeney DA, Cotton SA, Malhotra A. Secondary infections in critically ill patients with COVID-19 receiving steroid therapy. Sci Prog 2023; 106:368504231207209. [PMID: 37899703 PMCID: PMC10617276 DOI: 10.1177/00368504231207209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2023]
Abstract
Secondary infections can occur during or after the treatment of an initial infection. Glucocorticoids may decrease mortality in patients with severe COVID-19; however, risk of secondary infection is not well described. Our primary objective was to investigate the risk of secondary infection among critically ill patients with COVID-19 treated with glucocorticoids. We examined patients with COVID-19 being treated in the intensive care unit at two academic medical centers from 1 to 7/2020. One hundred-seven patients were included. Of these, 31 received steroids and 76 patients did not. Analysis of the larger cohort was performed followed by a matched pairs analysis of 22 steroid and 22 non-steroid patients. Secondary infection was seen in 14 patients (45.2%) receiving steroids compared to 35(46.1%) not receiving steroids (p = 0.968). Secondary infections were most frequently encountered in the respiratory tract. Escherichia coli and Staphylococcus aureus were the most frequently identified organisms. Mortality was 16.1% in the steroid-treated group compared to 23.7% in the control group (p = 0.388). After performing matched pairs analysis and multivariable logistic regression there was no significant difference between secondary infection or mortality and steroid receipt. Secondary infections were common among critically ill patients with COVID-19, but the incidence of secondary infection was not significantly impacted by steroid treatment.
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Affiliation(s)
- Alex K Pearce
- Division of Pulmonary, Critical Care, Sleep Medicine and Physiology, University of California, San Diego, La Jolla, CA, USA
| | - Qais Zawaydeh
- Department of Internal Medicine, Eisenhower Health, Palm Springs,
CA, USA
| | - W Cameron McGuire
- Division of Pulmonary, Critical Care, Sleep Medicine and Physiology, University of California, San Diego, La Jolla, CA, USA
| | - Abdurrahman Husain
- Division of Pulmonary Critical Care Medicine, Texas A&M School of Medicine, Baylor University Medical Center, Dallas, TX, USA
| | - Claudia Ayoub
- Department of Internal Medicine and Pediatrics, University of Mississippi Medical Center, Jackson, MS, USA
| | - Daniel A Sweeney
- Division of Pulmonary, Critical Care, Sleep Medicine and Physiology, University of California, San Diego, La Jolla, CA, USA
| | - Shannon A Cotton
- Division of Pulmonary, Critical Care, Sleep Medicine and Physiology, University of California, San Diego, La Jolla, CA, USA
| | - Atul Malhotra
- Division of Pulmonary, Critical Care, Sleep Medicine and Physiology, University of California, San Diego, La Jolla, CA, USA
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4
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Abstract
Coronavirus disease 2019 (COVID-19) pneumonia caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has resulted in significant mortality in pandemic proportions. Inflammation in response to the infection contributes to the pathogenesis of pneumonia. This review will discuss prior studies on the use of glucocorticoids to treat respiratory infections, the rationale for the use glucocorticoids in COVID-19, and review of existing data. We will also highlight outstanding research questions for future studies.
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Affiliation(s)
- Francesco Amati
- Respiratory Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Antonio Tonutti
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - John Huston
- Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Critical Care and Sleep Medicine, Center for Pulmonary Infection Research and Treatment, Yale School of Medicine, New Haven, Connecticut
| | - Charles S. Dela Cruz
- Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Critical Care and Sleep Medicine, Center for Pulmonary Infection Research and Treatment, Yale School of Medicine, New Haven, Connecticut
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5
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Caiazzo E, Rezig AOM, Bruzzese D, Ialenti A, Cicala C, Cleland JGF, Guzik TJ, Maffia P, Pellicori P. Systemic administration of glucocorticoids, cardiovascular complications and mortality in patients hospitalised with COVID-19, SARS, MERS or influenza: A systematic review and meta-analysis of randomised trials. Pharmacol Res 2022; 176:106053. [PMID: 34979235 PMCID: PMC8719379 DOI: 10.1016/j.phrs.2021.106053] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 12/28/2021] [Accepted: 12/29/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Administration of glucocorticoids might reduce mortality in patients with severe COVID-19 but have adverse cardiometabolic effects. OBJECTIVES to investigate the effect of systemic administration of glucocorticoids on cardiovascular complications and all-cause mortality in patients hospitalised with respiratory viral infections, including COVID-19, SARS, MERS and influenza. METHODS We identified randomised trials published prior to July 28th, 2021. The Mantel-Haenszel random effects method and the Hartung and Knapp adjustment were used to obtain pooled estimates of treatment effect with 95% confidence intervals. RESULTS No randomised trials of glucocorticoids for SARS, MERS or influenza reported relevant outcomes. We included eleven COVID-19 randomised trials (8109 patients). Overall, compared to placebo or standard care, glucocorticoids were not associated with a reduction of in-hospital mortality (p = 0.09). In a pre-specified sub-analysis, in-hospital mortality was reduced by 19% when follow-up was restricted to 14 days from randomisation (5/11 trials, 1329 patients, p = 0.02). With longer follow-up (9/11 trials, 7874 patients), administration of glucocorticoids was associated with a trend to benefit for those requiring mechanical ventilation (RR 0.86; 95% CI 0.57-1.27) but possible harm for those not receiving oxygen at randomisation (RR 1.27; 95% CI 1.00 - 1.61), an effect that was significantly different amongst subgroups (p = 0.0359). Glucocorticoids reduced the risk of worsening renal function by 37% (4/11 trials); reported rate of other cardiovascular complications was low. CONCLUSIONS Administration of systemic glucocorticoids to patients hospitalised with COVID-19 does not lower mortality overall but may reduce it in those requiring respiratory support and increase it in those who do not.
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Affiliation(s)
- Elisabetta Caiazzo
- Centre for Immunobiology, Institute of Infection, Immunity and Inflammation, College of Medical, Veterinary and Life Sciences, University of Glasgow, UK; Department of Pharmacy, School of Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Asma O M Rezig
- Centre for Immunobiology, Institute of Infection, Immunity and Inflammation, College of Medical, Veterinary and Life Sciences, University of Glasgow, UK
| | - Dario Bruzzese
- Department of Public health, University of Naples Federico II, Naples, Italy
| | - Armando Ialenti
- Department of Pharmacy, School of Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Carla Cicala
- Department of Pharmacy, School of Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - John G F Cleland
- Robertson Centre for Biostatistics, and Glasgow Clinical Trials Unit, Institute of Health and Wellbeing, University of Glasgow, UK; National Heart & Lung Institute, Imperial College London, UK
| | - Tomasz J Guzik
- Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, UK; Department of Internal and Agricultural Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Pasquale Maffia
- Centre for Immunobiology, Institute of Infection, Immunity and Inflammation, College of Medical, Veterinary and Life Sciences, University of Glasgow, UK; Department of Pharmacy, School of Medicine and Surgery, University of Naples Federico II, Naples, Italy; Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, UK.
| | - Pierpaolo Pellicori
- Robertson Centre for Biostatistics, and Glasgow Clinical Trials Unit, Institute of Health and Wellbeing, University of Glasgow, UK.
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6
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Mendelson's syndrome complicated by bacterial aspiration pneumonia triggered by right putamen bleeding: A case report. Respir Med Case Rep 2021; 33:101466. [PMID: 34401302 PMCID: PMC8349091 DOI: 10.1016/j.rmcr.2021.101466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Revised: 06/21/2021] [Accepted: 06/28/2021] [Indexed: 11/21/2022] Open
Abstract
We present the case of an 80-year-old woman with Mendelson's syndrome complicated by bacterial aspiration pneumonia caused by consciousness loss followed by vomiting resulting from putamen bleeding. Her condition worsened rapidly to develop respiratory failure, within a few hours; thereafter, she was intubated. Streptococcus agalactiae and Klebsiella oxytoca were detected from the aspirated sputum sample culture. She was diagnosed with acute respiratory distress syndrome with Mendelson's syndrome complicated by bacterial aspiration pneumonia. Corticosteroid and antibiotic administration improved her condition and led to successful extubation; therefore, these treatment modalities were invaluable. We suggest the clinical considerations for the corticosteroid and antibiotic use in such cases. We report a case of Mendelson's syndrome complicated by bacterial aspiration pneumonia. Use of steroids and antibiotics in such cases is controversial, however, they were reasonable choice in this case. We discussed this debatable issue in this case report.
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7
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Raess N, Schuetz P, Cesana‐Nigro N, Winzeler B, Urwyler SA, Schaedelin S, Rodondi N, Blum MR, Briel M, Mueller B, Christ‐Crain M, Blum CA. Influence of Prednisone on Inflammatory Biomarkers in Community-Acquired Pneumonia: Secondary Analysis of a Randomized Trial. J Clin Pharmacol 2021; 61:1406-1414. [PMID: 34031890 PMCID: PMC8242868 DOI: 10.1002/jcph.1914] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 05/20/2021] [Indexed: 12/18/2022]
Abstract
Glucocorticoids are frequently prescribed in inflammatory diseases and have recently experienced a boom in the treatment of COVID-19. Small studies have shown an effect of glucocorticoids on inflammatory marker levels, but definitive proof is lacking. We investigated the influence of prednisone on inflammatory biomarkers in a previous multicenter, randomized, placebo-controlled trial that compared a 7-day treatment course of 50-mg prednisone to placebo in patients hospitalized with community-acquired pneumonia. We compared levels of C-reactive protein (CRP), procalcitonin (PCT), leukocyte and neutrophil count between patients with and without glucocorticoid treatment at baseline and on days 3, 5, and 7 and at discharge by Wilcoxon tests and analysis of variance. A total of 356 patient data sets in the prednisone group and 355 in the placebo group were available for analysis. Compared to placebo, use of prednisone was associated with reductions in levels of CRP on days 3, 5, and 7 (mean difference of 46%, P < .001 for each time point). For PCT, no such difference was observed. Leukocyte and neutrophil count were higher in the prednisone group at all time points (mean difference of 27% for leukocytes and 33% for neutrophils, P <.001 for all time points). We conclude that after administration of glucocorticoids in community-acquired pneumonia, patients had lower CRP levels and increased leukocyte and neutrophil count as compared to the placebo group. PCT levels were not different between treatment groups. PCT levels thus may more appropriately mirror the resolution of infection compared to more traditional inflammatory markers.
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Affiliation(s)
- Natalie Raess
- Department of General Internal and Emergency Medicine and Department of EndocrinologyDiabetology and MetabolismMedical University ClinicAarauSwitzerland
| | - Philipp Schuetz
- Department of General Internal and Emergency Medicine and Department of EndocrinologyDiabetology and MetabolismMedical University ClinicAarauSwitzerland
| | - Nicole Cesana‐Nigro
- Endocrinology, Diabetology and MetabolismDepartment of Internal Medicine and Department of Clinical ResearchUniversity Hospital BaselBaselSwitzerland
- StoffwechselzentrumSolothurnSwitzerland
| | - Bettina Winzeler
- Endocrinology, Diabetology and MetabolismDepartment of Internal Medicine and Department of Clinical ResearchUniversity Hospital BaselBaselSwitzerland
| | - Sandrine A. Urwyler
- Endocrinology, Diabetology and MetabolismDepartment of Internal Medicine and Department of Clinical ResearchUniversity Hospital BaselBaselSwitzerland
| | - Sabine Schaedelin
- Clinical Trial UnitDepartment of Clinical ResearchUniversity Hospital Basel and University of BaselBaselSwitzerland
| | - Nicolas Rodondi
- Institute of Primary Health Care (BIHAM)University of BernSwitzerland
- Department of General Internal MedicineInselspitalBern University HospitalUniversity of BernBernSwitzerland
| | - Manuel R. Blum
- Institute of Primary Health Care (BIHAM)University of BernSwitzerland
- Department of General Internal MedicineInselspitalBern University HospitalUniversity of BernBernSwitzerland
| | - Matthias Briel
- Basel Institute for Clinical Epidemiology and BiostatisticsDepartment of Clinical ResearchUniversity Hospital Basel and University of BaselBaselSwitzerland
- Department of Health Research MethodsEvidence, and ImpactMcMaster UniversityHamiltonOntarioCanada
| | - Beat Mueller
- Department of General Internal and Emergency Medicine and Department of EndocrinologyDiabetology and MetabolismMedical University ClinicAarauSwitzerland
| | - Mirjam Christ‐Crain
- Endocrinology, Diabetology and MetabolismDepartment of Internal Medicine and Department of Clinical ResearchUniversity Hospital BaselBaselSwitzerland
| | - Claudine A. Blum
- Department of General Internal and Emergency Medicine and Department of EndocrinologyDiabetology and MetabolismMedical University ClinicAarauSwitzerland
- Endocrinology, Diabetology and MetabolismDepartment of Internal Medicine and Department of Clinical ResearchUniversity Hospital BaselBaselSwitzerland
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8
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Waterer GW. Applying the lessons learned from coronavirus disease 2019 to improve pneumonia management. Curr Opin Infect Dis 2021; 34:175-179. [PMID: 33492003 DOI: 10.1097/qco.0000000000000710] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE OF REVIEW Coronavirus disease 2019 (COVID-19) has produced an extraordinary amount of literature in a short time period. This review focuses on what the new literature has provided in terms of more general information about the management of community-acquired pneumonia (CAP). RECENT FINDINGS Measures taken to reduce the spread of COVID-19 have caused a significant drop in influenza worldwide. Improvements in imaging, especially ultrasound, and especially in the application of rapid molecular diagnosis are likely to have significant impact on the management of CAP. Therapeutic advances are so far limited. SUMMARY COVID-19 has taught us that we can do far more to prevent seasonal influenza and its associated mortality, morbidity and economic cost. Improvements in imaging and pathogen diagnosis are welcome, as is the potential for secondary benefits of anti-COVID-19 therapies that may have reach effect on respiratory viruses other than severe acute respiratory syndrome coronavirus 2. As community-transmission is likely to persist for many years, recognition and treatment of severe acute respiratory syndrome coronavirus 2 will need to be incorporated into CAP guidelines moving forward.
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Affiliation(s)
- Grant W Waterer
- Department of Medicine, University of Western Australia, Perth, Western Australia, Australia.,Northwestern University, Chicago, Illinois, USA
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9
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Carmo TA, Ferreira IB, Menezes RC, Telles GP, Otero ML, Arriaga MB, Fukutani KF, Neto LP, Agareno S, Filgueiras Filho NM, Andrade BB, Akrami KM. Derivation and Validation of a Novel Severity Scoring System for Pneumonia at Intensive Care Unit Admission. Clin Infect Dis 2021; 72:942-949. [PMID: 32146482 PMCID: PMC7958772 DOI: 10.1093/cid/ciaa183] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2019] [Accepted: 03/05/2020] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Severity stratification scores developed in intensive care units (ICUs) are used in interventional studies to identify the most critically ill. Studies that evaluate accuracy of these scores in ICU patients admitted with pneumonia are lacking. This study aims to determine performance of severity scores as predictors of mortality in critically ill patients admitted with pneumonia. METHODS Prospective cohort study in a general ICU in Brazil. ICU severity scores (Simplified Acute Physiology Score 3 [SAPS 3] and Sepsis-Related Organ Failure Assessment [qSOFA]), prognostic scores of pneumonia (CURB-65 [confusion, urea, respiratory rate, blood pressure, age] and CRB-65 [confusion, respiratory rate, blood pressure, age]), and clinical and epidemiological variables in the first 6 hours of hospitalization were analyzed. RESULTS Two hundred patients were included between 2015 and 2018, with a median age of 81 years (interquartile range, 67-90 years) and female predominance (52%), primarily admitted from the emergency department (65%) with community-acquired pneumonia (CAP, 80.5%). SAPS 3, CURB-65, CRB-65,and qSOFA all exhibited poor performance in predicting mortality. Multivariate regression identified variables independently associated with mortality that were used to develop a novel pneumonia-specific ICU severity score (Pneumonia Shock score) that outperformed SAPS 3, CURB-65, and CRB-65. The Shock score was validated in an external multicenter cohort of critically ill patients admitted with CAP. CONCLUSIONS We created a parsimonious score that accurately identifies patients with pneumonia at highest risk of ICU death. These findings are critical to accurately stratify patients with severe pneumonia in therapeutic trials that aim to reduce mortality.
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Affiliation(s)
- Thomas A Carmo
- Universidade Salvador, Salvador, Bahia, Brazil
- Multinational Organization Network Sponsoring Translational and Epidemiological Research Initiative, Fundação José Silveira, Salvador, Brazil
| | | | - Rodrigo C Menezes
- União Metropolitana para o Desenvolvimento da Educação e Cultura, Salvador, Bahia, Brazil
| | - Gabriel P Telles
- Escola Bahiana de Medicina e Saúde Pública, Salvador, Bahia, Brazil
| | | | - Maria B Arriaga
- Multinational Organization Network Sponsoring Translational and Epidemiological Research Initiative, Fundação José Silveira, Salvador, Brazil
- Instituto Gonçalo Moniz, Fiocruz, Salvador, Bahia, Brazil
- Faculdade de Medicina da Bahia, Universidade Federal da Bahia, Salvador, Brazil
| | - Kiyoshi F Fukutani
- Multinational Organization Network Sponsoring Translational and Epidemiological Research Initiative, Fundação José Silveira, Salvador, Brazil
- Instituto Gonçalo Moniz, Fiocruz, Salvador, Bahia, Brazil
| | - Licurgo P Neto
- Hospital de Cidade, Intensive Care Unit, Salvador, Bahia, Brazil
| | - Sydney Agareno
- Hospital de Cidade, Intensive Care Unit, Salvador, Bahia, Brazil
| | - Nivaldo M Filgueiras Filho
- Universidade Salvador, Salvador, Bahia, Brazil
- Universidade do Estado da Bahia, Salvador, Bahia, Brazil
- Hospital de Cidade, Núcleo de Ensino e Pesquisa e Comunicação, Salvador, Bahia, Brazil
| | - Bruno B Andrade
- Universidade Salvador, Salvador, Bahia, Brazil
- Multinational Organization Network Sponsoring Translational and Epidemiological Research Initiative, Fundação José Silveira, Salvador, Brazil
- Escola Bahiana de Medicina e Saúde Pública, Salvador, Bahia, Brazil
- Instituto Gonçalo Moniz, Fiocruz, Salvador, Bahia, Brazil
- Faculdade de Medicina da Bahia, Universidade Federal da Bahia, Salvador, Brazil
| | - Kevan M Akrami
- Instituto Gonçalo Moniz, Fiocruz, Salvador, Bahia, Brazil
- Faculdade de Medicina da Bahia, Universidade Federal da Bahia, Salvador, Brazil
- Divisions of Infectious Diseases and Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of California, San Diego, La Jolla, California, USA
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10
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Rombauts A, Abelenda-Alonso G, Cuervo G, Gudiol C, Carratalà J. Role of the inflammatory response in community-acquired pneumonia: clinical implications. Expert Rev Anti Infect Ther 2021; 20:1261-1274. [PMID: 33034228 DOI: 10.1080/14787210.2021.1834848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Despite adequate antibiotic coverage, community-acquired pneumonia (CAP) remains a leading cause of hospitalization and mortality worldwide. It induces both a local pulmonary and a systemic inflammatory response, particularly significant in severe cases. The intensity of the dysregulated host response varies from patient to patient and has a negative impact on survival and other outcomes. AREAS COVERED This comprehensive review summarizes the pathophysiological aspects of the inflammatory response in CAP, briefly discusses the usefulness of biomarkers, and assesses the clinical evidence for modulating the inflammatory pathways. We searched PubMed for the most relevant studies, reviews, and meta-analysis until August 2020. EXPERT OPINION Notable efforts have been made to identify biomarkers that can accurately differentiate between viral and bacterial etiology, and indeed, to enhance risk stratification in CAP. However, none has proven ideal and no recommended biomarker-guided algorithms exist. Biomarker signatures from proteomic and metabolomic studies could be more useful for such assessments. To date, most studies have produced contradictory results concerning the role of immunomodulatory agents (e.g. corticosteroids, macrolides, and statins) in CAP. Adequately identifying the population who may benefit most from effective modulation of the inflammatory response remains a challenge.
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Affiliation(s)
- Alexander Rombauts
- Department of Infectious Diseases, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain.,Bellvitge Biomedical Research Institute (IDIBELL), Hospitalet de Llobregat, Spain
| | - Gabriela Abelenda-Alonso
- Department of Infectious Diseases, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain.,Bellvitge Biomedical Research Institute (IDIBELL), Hospitalet de Llobregat, Spain
| | - Guillermo Cuervo
- Department of Infectious Diseases, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain
| | - Carlota Gudiol
- Department of Infectious Diseases, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain.,Bellvitge Biomedical Research Institute (IDIBELL), Hospitalet de Llobregat, Spain.,Spanish Network for Research in Infectious Disease (REIPI), Instituto de Salud Carlos III, Madrid, Spain.,University of Barcelona, Barcelona, Spain.,Institut Català d'Oncologia (ICO), Hospitalet de Llobregat, Barcelona, Spain
| | - Jordi Carratalà
- Department of Infectious Diseases, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain.,Bellvitge Biomedical Research Institute (IDIBELL), Hospitalet de Llobregat, Spain.,Spanish Network for Research in Infectious Disease (REIPI), Instituto de Salud Carlos III, Madrid, Spain.,University of Barcelona, Barcelona, Spain
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11
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Ye Z, Wang Y, Colunga-Lozano LE, Prasad M, Tangamornsuksan W, Rochwerg B, Yao L, Motaghi S, Couban RJ, Ghadimi M, Bala MM, Gomaa H, Fang F, Xiao Y, Guyatt GH. Efficacité et innocuité des corticostéroïdes dans le traitement de la COVID-19 selon des données pour la COVID-19, d’autres infections aux coronavirus, l’influenza, la pneumonie extrahospitalière et le syndrome de détresse respiratoire aiguë : revue systématique et méta-analyse. CMAJ 2020; 192:E1571-E1584. [PMID: 33229355 DOI: 10.1503/cmaj.200645-f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/01/2020] [Indexed: 02/05/2023] Open
Affiliation(s)
- Zhikang Ye
- Département de Health Research Methods, Evidence and Impact (Ye, Tangamornsuksan, Rochwerg, Guyatt, Colunga-Lozano, Yao, Motaghi, Fang, Xiao), Université McMaster, Hamilton, Ont.; département de pharmacie (Wang), hôpital de Chaoyang à Beijing, Capital Medical University, Beijing (Chine); département de médecine clinique (Colunga-Lozano), centre des sciences de la santé, université de Guadalajara, Guadalajara (Mexique); département de médecine Communautaire (Prasad), North DMC Medical College, New Delhi (Inde); Faculté de médecine et de santé publique (Tangamornsuksan), HRH Princess Chulabhorn College of Medical Science, Chulabhorn Royal Academy, Bangkok (Thaïlande); département de médecine (Rochwerg); DeGroote Institute for Pain Research and Care (Couban), Université McMaster, Hamilton, Ont.; département de pharmacie clinique (Ghadimi), Faculté de pharmacie, Tehran University of Medical Sciences, Téhéran (Iran); chaire d'épidémiologie et de médecine préventive (Bala), École de médecine de l'Université Jagellonne, Cracovie (Pologne); département de biostatistique (Gomaa), High institute of Public Health, Alexandria University, Alexandrie (Égypte); Centre d'information sur les médicaments (Gomaa), Tanta Chest Hospital, ministère de la Santé et des Populations, Égypte; Clinical Medicine College of Acupuncture, Moxibustion and Rehabilitation (Fang), Guangzhou University of Chinese Medicine, Guangdong (Chine); West China School of Nursing (Xiao), West China Hospital, Sichuan University (Chine)
| | - Ying Wang
- Département de Health Research Methods, Evidence and Impact (Ye, Tangamornsuksan, Rochwerg, Guyatt, Colunga-Lozano, Yao, Motaghi, Fang, Xiao), Université McMaster, Hamilton, Ont.; département de pharmacie (Wang), hôpital de Chaoyang à Beijing, Capital Medical University, Beijing (Chine); département de médecine clinique (Colunga-Lozano), centre des sciences de la santé, université de Guadalajara, Guadalajara (Mexique); département de médecine Communautaire (Prasad), North DMC Medical College, New Delhi (Inde); Faculté de médecine et de santé publique (Tangamornsuksan), HRH Princess Chulabhorn College of Medical Science, Chulabhorn Royal Academy, Bangkok (Thaïlande); département de médecine (Rochwerg); DeGroote Institute for Pain Research and Care (Couban), Université McMaster, Hamilton, Ont.; département de pharmacie clinique (Ghadimi), Faculté de pharmacie, Tehran University of Medical Sciences, Téhéran (Iran); chaire d'épidémiologie et de médecine préventive (Bala), École de médecine de l'Université Jagellonne, Cracovie (Pologne); département de biostatistique (Gomaa), High institute of Public Health, Alexandria University, Alexandrie (Égypte); Centre d'information sur les médicaments (Gomaa), Tanta Chest Hospital, ministère de la Santé et des Populations, Égypte; Clinical Medicine College of Acupuncture, Moxibustion and Rehabilitation (Fang), Guangzhou University of Chinese Medicine, Guangdong (Chine); West China School of Nursing (Xiao), West China Hospital, Sichuan University (Chine)
| | - Luis Enrique Colunga-Lozano
- Département de Health Research Methods, Evidence and Impact (Ye, Tangamornsuksan, Rochwerg, Guyatt, Colunga-Lozano, Yao, Motaghi, Fang, Xiao), Université McMaster, Hamilton, Ont.; département de pharmacie (Wang), hôpital de Chaoyang à Beijing, Capital Medical University, Beijing (Chine); département de médecine clinique (Colunga-Lozano), centre des sciences de la santé, université de Guadalajara, Guadalajara (Mexique); département de médecine Communautaire (Prasad), North DMC Medical College, New Delhi (Inde); Faculté de médecine et de santé publique (Tangamornsuksan), HRH Princess Chulabhorn College of Medical Science, Chulabhorn Royal Academy, Bangkok (Thaïlande); département de médecine (Rochwerg); DeGroote Institute for Pain Research and Care (Couban), Université McMaster, Hamilton, Ont.; département de pharmacie clinique (Ghadimi), Faculté de pharmacie, Tehran University of Medical Sciences, Téhéran (Iran); chaire d'épidémiologie et de médecine préventive (Bala), École de médecine de l'Université Jagellonne, Cracovie (Pologne); département de biostatistique (Gomaa), High institute of Public Health, Alexandria University, Alexandrie (Égypte); Centre d'information sur les médicaments (Gomaa), Tanta Chest Hospital, ministère de la Santé et des Populations, Égypte; Clinical Medicine College of Acupuncture, Moxibustion and Rehabilitation (Fang), Guangzhou University of Chinese Medicine, Guangdong (Chine); West China School of Nursing (Xiao), West China Hospital, Sichuan University (Chine)
| | - Manya Prasad
- Département de Health Research Methods, Evidence and Impact (Ye, Tangamornsuksan, Rochwerg, Guyatt, Colunga-Lozano, Yao, Motaghi, Fang, Xiao), Université McMaster, Hamilton, Ont.; département de pharmacie (Wang), hôpital de Chaoyang à Beijing, Capital Medical University, Beijing (Chine); département de médecine clinique (Colunga-Lozano), centre des sciences de la santé, université de Guadalajara, Guadalajara (Mexique); département de médecine Communautaire (Prasad), North DMC Medical College, New Delhi (Inde); Faculté de médecine et de santé publique (Tangamornsuksan), HRH Princess Chulabhorn College of Medical Science, Chulabhorn Royal Academy, Bangkok (Thaïlande); département de médecine (Rochwerg); DeGroote Institute for Pain Research and Care (Couban), Université McMaster, Hamilton, Ont.; département de pharmacie clinique (Ghadimi), Faculté de pharmacie, Tehran University of Medical Sciences, Téhéran (Iran); chaire d'épidémiologie et de médecine préventive (Bala), École de médecine de l'Université Jagellonne, Cracovie (Pologne); département de biostatistique (Gomaa), High institute of Public Health, Alexandria University, Alexandrie (Égypte); Centre d'information sur les médicaments (Gomaa), Tanta Chest Hospital, ministère de la Santé et des Populations, Égypte; Clinical Medicine College of Acupuncture, Moxibustion and Rehabilitation (Fang), Guangzhou University of Chinese Medicine, Guangdong (Chine); West China School of Nursing (Xiao), West China Hospital, Sichuan University (Chine)
| | - Wimonchat Tangamornsuksan
- Département de Health Research Methods, Evidence and Impact (Ye, Tangamornsuksan, Rochwerg, Guyatt, Colunga-Lozano, Yao, Motaghi, Fang, Xiao), Université McMaster, Hamilton, Ont.; département de pharmacie (Wang), hôpital de Chaoyang à Beijing, Capital Medical University, Beijing (Chine); département de médecine clinique (Colunga-Lozano), centre des sciences de la santé, université de Guadalajara, Guadalajara (Mexique); département de médecine Communautaire (Prasad), North DMC Medical College, New Delhi (Inde); Faculté de médecine et de santé publique (Tangamornsuksan), HRH Princess Chulabhorn College of Medical Science, Chulabhorn Royal Academy, Bangkok (Thaïlande); département de médecine (Rochwerg); DeGroote Institute for Pain Research and Care (Couban), Université McMaster, Hamilton, Ont.; département de pharmacie clinique (Ghadimi), Faculté de pharmacie, Tehran University of Medical Sciences, Téhéran (Iran); chaire d'épidémiologie et de médecine préventive (Bala), École de médecine de l'Université Jagellonne, Cracovie (Pologne); département de biostatistique (Gomaa), High institute of Public Health, Alexandria University, Alexandrie (Égypte); Centre d'information sur les médicaments (Gomaa), Tanta Chest Hospital, ministère de la Santé et des Populations, Égypte; Clinical Medicine College of Acupuncture, Moxibustion and Rehabilitation (Fang), Guangzhou University of Chinese Medicine, Guangdong (Chine); West China School of Nursing (Xiao), West China Hospital, Sichuan University (Chine)
| | - Bram Rochwerg
- Département de Health Research Methods, Evidence and Impact (Ye, Tangamornsuksan, Rochwerg, Guyatt, Colunga-Lozano, Yao, Motaghi, Fang, Xiao), Université McMaster, Hamilton, Ont.; département de pharmacie (Wang), hôpital de Chaoyang à Beijing, Capital Medical University, Beijing (Chine); département de médecine clinique (Colunga-Lozano), centre des sciences de la santé, université de Guadalajara, Guadalajara (Mexique); département de médecine Communautaire (Prasad), North DMC Medical College, New Delhi (Inde); Faculté de médecine et de santé publique (Tangamornsuksan), HRH Princess Chulabhorn College of Medical Science, Chulabhorn Royal Academy, Bangkok (Thaïlande); département de médecine (Rochwerg); DeGroote Institute for Pain Research and Care (Couban), Université McMaster, Hamilton, Ont.; département de pharmacie clinique (Ghadimi), Faculté de pharmacie, Tehran University of Medical Sciences, Téhéran (Iran); chaire d'épidémiologie et de médecine préventive (Bala), École de médecine de l'Université Jagellonne, Cracovie (Pologne); département de biostatistique (Gomaa), High institute of Public Health, Alexandria University, Alexandrie (Égypte); Centre d'information sur les médicaments (Gomaa), Tanta Chest Hospital, ministère de la Santé et des Populations, Égypte; Clinical Medicine College of Acupuncture, Moxibustion and Rehabilitation (Fang), Guangzhou University of Chinese Medicine, Guangdong (Chine); West China School of Nursing (Xiao), West China Hospital, Sichuan University (Chine)
| | - Liang Yao
- Département de Health Research Methods, Evidence and Impact (Ye, Tangamornsuksan, Rochwerg, Guyatt, Colunga-Lozano, Yao, Motaghi, Fang, Xiao), Université McMaster, Hamilton, Ont.; département de pharmacie (Wang), hôpital de Chaoyang à Beijing, Capital Medical University, Beijing (Chine); département de médecine clinique (Colunga-Lozano), centre des sciences de la santé, université de Guadalajara, Guadalajara (Mexique); département de médecine Communautaire (Prasad), North DMC Medical College, New Delhi (Inde); Faculté de médecine et de santé publique (Tangamornsuksan), HRH Princess Chulabhorn College of Medical Science, Chulabhorn Royal Academy, Bangkok (Thaïlande); département de médecine (Rochwerg); DeGroote Institute for Pain Research and Care (Couban), Université McMaster, Hamilton, Ont.; département de pharmacie clinique (Ghadimi), Faculté de pharmacie, Tehran University of Medical Sciences, Téhéran (Iran); chaire d'épidémiologie et de médecine préventive (Bala), École de médecine de l'Université Jagellonne, Cracovie (Pologne); département de biostatistique (Gomaa), High institute of Public Health, Alexandria University, Alexandrie (Égypte); Centre d'information sur les médicaments (Gomaa), Tanta Chest Hospital, ministère de la Santé et des Populations, Égypte; Clinical Medicine College of Acupuncture, Moxibustion and Rehabilitation (Fang), Guangzhou University of Chinese Medicine, Guangdong (Chine); West China School of Nursing (Xiao), West China Hospital, Sichuan University (Chine)
| | - Shahrzad Motaghi
- Département de Health Research Methods, Evidence and Impact (Ye, Tangamornsuksan, Rochwerg, Guyatt, Colunga-Lozano, Yao, Motaghi, Fang, Xiao), Université McMaster, Hamilton, Ont.; département de pharmacie (Wang), hôpital de Chaoyang à Beijing, Capital Medical University, Beijing (Chine); département de médecine clinique (Colunga-Lozano), centre des sciences de la santé, université de Guadalajara, Guadalajara (Mexique); département de médecine Communautaire (Prasad), North DMC Medical College, New Delhi (Inde); Faculté de médecine et de santé publique (Tangamornsuksan), HRH Princess Chulabhorn College of Medical Science, Chulabhorn Royal Academy, Bangkok (Thaïlande); département de médecine (Rochwerg); DeGroote Institute for Pain Research and Care (Couban), Université McMaster, Hamilton, Ont.; département de pharmacie clinique (Ghadimi), Faculté de pharmacie, Tehran University of Medical Sciences, Téhéran (Iran); chaire d'épidémiologie et de médecine préventive (Bala), École de médecine de l'Université Jagellonne, Cracovie (Pologne); département de biostatistique (Gomaa), High institute of Public Health, Alexandria University, Alexandrie (Égypte); Centre d'information sur les médicaments (Gomaa), Tanta Chest Hospital, ministère de la Santé et des Populations, Égypte; Clinical Medicine College of Acupuncture, Moxibustion and Rehabilitation (Fang), Guangzhou University of Chinese Medicine, Guangdong (Chine); West China School of Nursing (Xiao), West China Hospital, Sichuan University (Chine)
| | - Rachel J Couban
- Département de Health Research Methods, Evidence and Impact (Ye, Tangamornsuksan, Rochwerg, Guyatt, Colunga-Lozano, Yao, Motaghi, Fang, Xiao), Université McMaster, Hamilton, Ont.; département de pharmacie (Wang), hôpital de Chaoyang à Beijing, Capital Medical University, Beijing (Chine); département de médecine clinique (Colunga-Lozano), centre des sciences de la santé, université de Guadalajara, Guadalajara (Mexique); département de médecine Communautaire (Prasad), North DMC Medical College, New Delhi (Inde); Faculté de médecine et de santé publique (Tangamornsuksan), HRH Princess Chulabhorn College of Medical Science, Chulabhorn Royal Academy, Bangkok (Thaïlande); département de médecine (Rochwerg); DeGroote Institute for Pain Research and Care (Couban), Université McMaster, Hamilton, Ont.; département de pharmacie clinique (Ghadimi), Faculté de pharmacie, Tehran University of Medical Sciences, Téhéran (Iran); chaire d'épidémiologie et de médecine préventive (Bala), École de médecine de l'Université Jagellonne, Cracovie (Pologne); département de biostatistique (Gomaa), High institute of Public Health, Alexandria University, Alexandrie (Égypte); Centre d'information sur les médicaments (Gomaa), Tanta Chest Hospital, ministère de la Santé et des Populations, Égypte; Clinical Medicine College of Acupuncture, Moxibustion and Rehabilitation (Fang), Guangzhou University of Chinese Medicine, Guangdong (Chine); West China School of Nursing (Xiao), West China Hospital, Sichuan University (Chine)
| | - Maryam Ghadimi
- Département de Health Research Methods, Evidence and Impact (Ye, Tangamornsuksan, Rochwerg, Guyatt, Colunga-Lozano, Yao, Motaghi, Fang, Xiao), Université McMaster, Hamilton, Ont.; département de pharmacie (Wang), hôpital de Chaoyang à Beijing, Capital Medical University, Beijing (Chine); département de médecine clinique (Colunga-Lozano), centre des sciences de la santé, université de Guadalajara, Guadalajara (Mexique); département de médecine Communautaire (Prasad), North DMC Medical College, New Delhi (Inde); Faculté de médecine et de santé publique (Tangamornsuksan), HRH Princess Chulabhorn College of Medical Science, Chulabhorn Royal Academy, Bangkok (Thaïlande); département de médecine (Rochwerg); DeGroote Institute for Pain Research and Care (Couban), Université McMaster, Hamilton, Ont.; département de pharmacie clinique (Ghadimi), Faculté de pharmacie, Tehran University of Medical Sciences, Téhéran (Iran); chaire d'épidémiologie et de médecine préventive (Bala), École de médecine de l'Université Jagellonne, Cracovie (Pologne); département de biostatistique (Gomaa), High institute of Public Health, Alexandria University, Alexandrie (Égypte); Centre d'information sur les médicaments (Gomaa), Tanta Chest Hospital, ministère de la Santé et des Populations, Égypte; Clinical Medicine College of Acupuncture, Moxibustion and Rehabilitation (Fang), Guangzhou University of Chinese Medicine, Guangdong (Chine); West China School of Nursing (Xiao), West China Hospital, Sichuan University (Chine)
| | - Malgorzata M Bala
- Département de Health Research Methods, Evidence and Impact (Ye, Tangamornsuksan, Rochwerg, Guyatt, Colunga-Lozano, Yao, Motaghi, Fang, Xiao), Université McMaster, Hamilton, Ont.; département de pharmacie (Wang), hôpital de Chaoyang à Beijing, Capital Medical University, Beijing (Chine); département de médecine clinique (Colunga-Lozano), centre des sciences de la santé, université de Guadalajara, Guadalajara (Mexique); département de médecine Communautaire (Prasad), North DMC Medical College, New Delhi (Inde); Faculté de médecine et de santé publique (Tangamornsuksan), HRH Princess Chulabhorn College of Medical Science, Chulabhorn Royal Academy, Bangkok (Thaïlande); département de médecine (Rochwerg); DeGroote Institute for Pain Research and Care (Couban), Université McMaster, Hamilton, Ont.; département de pharmacie clinique (Ghadimi), Faculté de pharmacie, Tehran University of Medical Sciences, Téhéran (Iran); chaire d'épidémiologie et de médecine préventive (Bala), École de médecine de l'Université Jagellonne, Cracovie (Pologne); département de biostatistique (Gomaa), High institute of Public Health, Alexandria University, Alexandrie (Égypte); Centre d'information sur les médicaments (Gomaa), Tanta Chest Hospital, ministère de la Santé et des Populations, Égypte; Clinical Medicine College of Acupuncture, Moxibustion and Rehabilitation (Fang), Guangzhou University of Chinese Medicine, Guangdong (Chine); West China School of Nursing (Xiao), West China Hospital, Sichuan University (Chine)
| | - Huda Gomaa
- Département de Health Research Methods, Evidence and Impact (Ye, Tangamornsuksan, Rochwerg, Guyatt, Colunga-Lozano, Yao, Motaghi, Fang, Xiao), Université McMaster, Hamilton, Ont.; département de pharmacie (Wang), hôpital de Chaoyang à Beijing, Capital Medical University, Beijing (Chine); département de médecine clinique (Colunga-Lozano), centre des sciences de la santé, université de Guadalajara, Guadalajara (Mexique); département de médecine Communautaire (Prasad), North DMC Medical College, New Delhi (Inde); Faculté de médecine et de santé publique (Tangamornsuksan), HRH Princess Chulabhorn College of Medical Science, Chulabhorn Royal Academy, Bangkok (Thaïlande); département de médecine (Rochwerg); DeGroote Institute for Pain Research and Care (Couban), Université McMaster, Hamilton, Ont.; département de pharmacie clinique (Ghadimi), Faculté de pharmacie, Tehran University of Medical Sciences, Téhéran (Iran); chaire d'épidémiologie et de médecine préventive (Bala), École de médecine de l'Université Jagellonne, Cracovie (Pologne); département de biostatistique (Gomaa), High institute of Public Health, Alexandria University, Alexandrie (Égypte); Centre d'information sur les médicaments (Gomaa), Tanta Chest Hospital, ministère de la Santé et des Populations, Égypte; Clinical Medicine College of Acupuncture, Moxibustion and Rehabilitation (Fang), Guangzhou University of Chinese Medicine, Guangdong (Chine); West China School of Nursing (Xiao), West China Hospital, Sichuan University (Chine)
| | - Fang Fang
- Département de Health Research Methods, Evidence and Impact (Ye, Tangamornsuksan, Rochwerg, Guyatt, Colunga-Lozano, Yao, Motaghi, Fang, Xiao), Université McMaster, Hamilton, Ont.; département de pharmacie (Wang), hôpital de Chaoyang à Beijing, Capital Medical University, Beijing (Chine); département de médecine clinique (Colunga-Lozano), centre des sciences de la santé, université de Guadalajara, Guadalajara (Mexique); département de médecine Communautaire (Prasad), North DMC Medical College, New Delhi (Inde); Faculté de médecine et de santé publique (Tangamornsuksan), HRH Princess Chulabhorn College of Medical Science, Chulabhorn Royal Academy, Bangkok (Thaïlande); département de médecine (Rochwerg); DeGroote Institute for Pain Research and Care (Couban), Université McMaster, Hamilton, Ont.; département de pharmacie clinique (Ghadimi), Faculté de pharmacie, Tehran University of Medical Sciences, Téhéran (Iran); chaire d'épidémiologie et de médecine préventive (Bala), École de médecine de l'Université Jagellonne, Cracovie (Pologne); département de biostatistique (Gomaa), High institute of Public Health, Alexandria University, Alexandrie (Égypte); Centre d'information sur les médicaments (Gomaa), Tanta Chest Hospital, ministère de la Santé et des Populations, Égypte; Clinical Medicine College of Acupuncture, Moxibustion and Rehabilitation (Fang), Guangzhou University of Chinese Medicine, Guangdong (Chine); West China School of Nursing (Xiao), West China Hospital, Sichuan University (Chine)
| | - Yingqi Xiao
- Département de Health Research Methods, Evidence and Impact (Ye, Tangamornsuksan, Rochwerg, Guyatt, Colunga-Lozano, Yao, Motaghi, Fang, Xiao), Université McMaster, Hamilton, Ont.; département de pharmacie (Wang), hôpital de Chaoyang à Beijing, Capital Medical University, Beijing (Chine); département de médecine clinique (Colunga-Lozano), centre des sciences de la santé, université de Guadalajara, Guadalajara (Mexique); département de médecine Communautaire (Prasad), North DMC Medical College, New Delhi (Inde); Faculté de médecine et de santé publique (Tangamornsuksan), HRH Princess Chulabhorn College of Medical Science, Chulabhorn Royal Academy, Bangkok (Thaïlande); département de médecine (Rochwerg); DeGroote Institute for Pain Research and Care (Couban), Université McMaster, Hamilton, Ont.; département de pharmacie clinique (Ghadimi), Faculté de pharmacie, Tehran University of Medical Sciences, Téhéran (Iran); chaire d'épidémiologie et de médecine préventive (Bala), École de médecine de l'Université Jagellonne, Cracovie (Pologne); département de biostatistique (Gomaa), High institute of Public Health, Alexandria University, Alexandrie (Égypte); Centre d'information sur les médicaments (Gomaa), Tanta Chest Hospital, ministère de la Santé et des Populations, Égypte; Clinical Medicine College of Acupuncture, Moxibustion and Rehabilitation (Fang), Guangzhou University of Chinese Medicine, Guangdong (Chine); West China School of Nursing (Xiao), West China Hospital, Sichuan University (Chine)
| | - Gordon H Guyatt
- Département de Health Research Methods, Evidence and Impact (Ye, Tangamornsuksan, Rochwerg, Guyatt, Colunga-Lozano, Yao, Motaghi, Fang, Xiao), Université McMaster, Hamilton, Ont.; département de pharmacie (Wang), hôpital de Chaoyang à Beijing, Capital Medical University, Beijing (Chine); département de médecine clinique (Colunga-Lozano), centre des sciences de la santé, université de Guadalajara, Guadalajara (Mexique); département de médecine Communautaire (Prasad), North DMC Medical College, New Delhi (Inde); Faculté de médecine et de santé publique (Tangamornsuksan), HRH Princess Chulabhorn College of Medical Science, Chulabhorn Royal Academy, Bangkok (Thaïlande); département de médecine (Rochwerg); DeGroote Institute for Pain Research and Care (Couban), Université McMaster, Hamilton, Ont.; département de pharmacie clinique (Ghadimi), Faculté de pharmacie, Tehran University of Medical Sciences, Téhéran (Iran); chaire d'épidémiologie et de médecine préventive (Bala), École de médecine de l'Université Jagellonne, Cracovie (Pologne); département de biostatistique (Gomaa), High institute of Public Health, Alexandria University, Alexandrie (Égypte); Centre d'information sur les médicaments (Gomaa), Tanta Chest Hospital, ministère de la Santé et des Populations, Égypte; Clinical Medicine College of Acupuncture, Moxibustion and Rehabilitation (Fang), Guangzhou University of Chinese Medicine, Guangdong (Chine); West China School of Nursing (Xiao), West China Hospital, Sichuan University (Chine)
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Ye Z, Wang Y, Colunga-Lozano LE, Prasad M, Tangamornsuksan W, Rochwerg B, Yao L, Motaghi S, Couban RJ, Ghadimi M, Bala MM, Gomaa H, Fang F, Xiao Y, Guyatt GH. Efficacy and safety of corticosteroids in COVID-19 based on evidence for COVID-19, other coronavirus infections, influenza, community-acquired pneumonia and acute respiratory distress syndrome: a systematic review and meta-analysis. CMAJ 2020; 192:E756-E767. [PMID: 32409522 DOI: 10.1503/cmaj.200645] [Citation(s) in RCA: 140] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/01/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Very little direct evidence exists on use of corticosteroids in patients with coronavirus disease 2019 (COVID-19). Indirect evidence from related conditions must therefore inform inferences regarding benefits and harms. To support a guideline for managing COVID-19, we conducted systematic reviews examining the impact of corticosteroids in COVID-19 and related severe acute respiratory illnesses. METHODS We searched standard international and Chinese biomedical literature databases and prepublication sources for randomized controlled trials (RCTs) and observational studies comparing corticosteroids versus no corticosteroids in patients with COVID-19, severe acute respiratory syndrome (SARS) or Middle East respiratory syndrome (MERS). For acute respiratory distress syndrome (ARDS), influenza and community-acquired pneumonia (CAP), we updated the most recent rigorous systematic review. We conducted random-effects meta-analyses to pool relative risks and then used baseline risk in patients with COVID-19 to generate absolute effects. RESULTS In ARDS, according to 1 small cohort study in patients with COVID-19 and 7 RCTs in non-COVID-19 populations (risk ratio [RR] 0.72, 95% confidence interval [CI] 0.55 to 0.93, mean difference 17.3% fewer; low-quality evidence), corticosteroids may reduce mortality. In patients with severe COVID-19 but without ARDS, direct evidence from 2 observational studies provided very low-quality evidence of an increase in mortality with corticosteroids (hazard ratio [HR] 2.30, 95% CI 1.00 to 5.29, mean difference 11.9% more), as did observational data from influenza studies. Observational data from SARS and MERS studies provided very low-quality evidence of a small or no reduction in mortality. Randomized controlled trials in CAP suggest that corticosteroids may reduce mortality (RR 0.70, 95% CI 0.50 to 0.98, 3.1% lower; very low-quality evidence), and may increase hyperglycemia. INTERPRETATION Corticosteroids may reduce mortality for patients with COVID-19 and ARDS. For patients with severe COVID-19 but without ARDS, evidence regarding benefit from different bodies of evidence is inconsistent and of very low quality.
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Affiliation(s)
- Zhikang Ye
- Department of Health Research Methods, Evidence and Impact (Ye, Tangamornsuksan, Rochwerg, Guyatt, Colunga-Lozano, Yao, Motaghi, Fang, Xiao), McMaster University, Hamilton, Ont.; Department of Pharmacy (Wang), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; Department of Clinical Medicine (Colunga-Lozano), Health Science Center, Universidad de Guadalajara, Guadalajara, Mexico; Department of Community Medicine (Prasad), North DMC Medical College, New Delhi, India; Faculty of Medicine and Public Health (Tangamornsuksan), HRH Princess Chulabhorn College of Medical Science, Chulabhorn Royal Academy, Bangkok, Thailand; Department of Medicine (Rochwerg); DeGroote Institute for Pain Research and Care (Couban), McMaster University, Hamilton, Ont.; Department of Clinical Pharmacy (Ghadimi), Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran; Chair of Epidemiology and Preventive Medicine Jagiellonian (Bala), University Medical College, Krakow, Poland; Biostatistics Department (Gomaa), High institute of Public Health, Alexandria University, Alexandria, Egypt; Drug Information Center (Gomaa), Tanta Chest Hospital, Ministry of Health and Population, Egypt; Clinical Medicine College of Acupuncture, Moxibustion and Rehabilitation (Fang), Guangzhou University of Chinese Medicine, Guangdong, China; West China School of Nursing (Xiao), West China Hospital, Sichuan University, China
| | - Ying Wang
- Department of Health Research Methods, Evidence and Impact (Ye, Tangamornsuksan, Rochwerg, Guyatt, Colunga-Lozano, Yao, Motaghi, Fang, Xiao), McMaster University, Hamilton, Ont.; Department of Pharmacy (Wang), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; Department of Clinical Medicine (Colunga-Lozano), Health Science Center, Universidad de Guadalajara, Guadalajara, Mexico; Department of Community Medicine (Prasad), North DMC Medical College, New Delhi, India; Faculty of Medicine and Public Health (Tangamornsuksan), HRH Princess Chulabhorn College of Medical Science, Chulabhorn Royal Academy, Bangkok, Thailand; Department of Medicine (Rochwerg); DeGroote Institute for Pain Research and Care (Couban), McMaster University, Hamilton, Ont.; Department of Clinical Pharmacy (Ghadimi), Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran; Chair of Epidemiology and Preventive Medicine Jagiellonian (Bala), University Medical College, Krakow, Poland; Biostatistics Department (Gomaa), High institute of Public Health, Alexandria University, Alexandria, Egypt; Drug Information Center (Gomaa), Tanta Chest Hospital, Ministry of Health and Population, Egypt; Clinical Medicine College of Acupuncture, Moxibustion and Rehabilitation (Fang), Guangzhou University of Chinese Medicine, Guangdong, China; West China School of Nursing (Xiao), West China Hospital, Sichuan University, China
| | - Luis Enrique Colunga-Lozano
- Department of Health Research Methods, Evidence and Impact (Ye, Tangamornsuksan, Rochwerg, Guyatt, Colunga-Lozano, Yao, Motaghi, Fang, Xiao), McMaster University, Hamilton, Ont.; Department of Pharmacy (Wang), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; Department of Clinical Medicine (Colunga-Lozano), Health Science Center, Universidad de Guadalajara, Guadalajara, Mexico; Department of Community Medicine (Prasad), North DMC Medical College, New Delhi, India; Faculty of Medicine and Public Health (Tangamornsuksan), HRH Princess Chulabhorn College of Medical Science, Chulabhorn Royal Academy, Bangkok, Thailand; Department of Medicine (Rochwerg); DeGroote Institute for Pain Research and Care (Couban), McMaster University, Hamilton, Ont.; Department of Clinical Pharmacy (Ghadimi), Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran; Chair of Epidemiology and Preventive Medicine Jagiellonian (Bala), University Medical College, Krakow, Poland; Biostatistics Department (Gomaa), High institute of Public Health, Alexandria University, Alexandria, Egypt; Drug Information Center (Gomaa), Tanta Chest Hospital, Ministry of Health and Population, Egypt; Clinical Medicine College of Acupuncture, Moxibustion and Rehabilitation (Fang), Guangzhou University of Chinese Medicine, Guangdong, China; West China School of Nursing (Xiao), West China Hospital, Sichuan University, China
| | - Manya Prasad
- Department of Health Research Methods, Evidence and Impact (Ye, Tangamornsuksan, Rochwerg, Guyatt, Colunga-Lozano, Yao, Motaghi, Fang, Xiao), McMaster University, Hamilton, Ont.; Department of Pharmacy (Wang), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; Department of Clinical Medicine (Colunga-Lozano), Health Science Center, Universidad de Guadalajara, Guadalajara, Mexico; Department of Community Medicine (Prasad), North DMC Medical College, New Delhi, India; Faculty of Medicine and Public Health (Tangamornsuksan), HRH Princess Chulabhorn College of Medical Science, Chulabhorn Royal Academy, Bangkok, Thailand; Department of Medicine (Rochwerg); DeGroote Institute for Pain Research and Care (Couban), McMaster University, Hamilton, Ont.; Department of Clinical Pharmacy (Ghadimi), Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran; Chair of Epidemiology and Preventive Medicine Jagiellonian (Bala), University Medical College, Krakow, Poland; Biostatistics Department (Gomaa), High institute of Public Health, Alexandria University, Alexandria, Egypt; Drug Information Center (Gomaa), Tanta Chest Hospital, Ministry of Health and Population, Egypt; Clinical Medicine College of Acupuncture, Moxibustion and Rehabilitation (Fang), Guangzhou University of Chinese Medicine, Guangdong, China; West China School of Nursing (Xiao), West China Hospital, Sichuan University, China
| | - Wimonchat Tangamornsuksan
- Department of Health Research Methods, Evidence and Impact (Ye, Tangamornsuksan, Rochwerg, Guyatt, Colunga-Lozano, Yao, Motaghi, Fang, Xiao), McMaster University, Hamilton, Ont.; Department of Pharmacy (Wang), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; Department of Clinical Medicine (Colunga-Lozano), Health Science Center, Universidad de Guadalajara, Guadalajara, Mexico; Department of Community Medicine (Prasad), North DMC Medical College, New Delhi, India; Faculty of Medicine and Public Health (Tangamornsuksan), HRH Princess Chulabhorn College of Medical Science, Chulabhorn Royal Academy, Bangkok, Thailand; Department of Medicine (Rochwerg); DeGroote Institute for Pain Research and Care (Couban), McMaster University, Hamilton, Ont.; Department of Clinical Pharmacy (Ghadimi), Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran; Chair of Epidemiology and Preventive Medicine Jagiellonian (Bala), University Medical College, Krakow, Poland; Biostatistics Department (Gomaa), High institute of Public Health, Alexandria University, Alexandria, Egypt; Drug Information Center (Gomaa), Tanta Chest Hospital, Ministry of Health and Population, Egypt; Clinical Medicine College of Acupuncture, Moxibustion and Rehabilitation (Fang), Guangzhou University of Chinese Medicine, Guangdong, China; West China School of Nursing (Xiao), West China Hospital, Sichuan University, China
| | - Bram Rochwerg
- Department of Health Research Methods, Evidence and Impact (Ye, Tangamornsuksan, Rochwerg, Guyatt, Colunga-Lozano, Yao, Motaghi, Fang, Xiao), McMaster University, Hamilton, Ont.; Department of Pharmacy (Wang), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; Department of Clinical Medicine (Colunga-Lozano), Health Science Center, Universidad de Guadalajara, Guadalajara, Mexico; Department of Community Medicine (Prasad), North DMC Medical College, New Delhi, India; Faculty of Medicine and Public Health (Tangamornsuksan), HRH Princess Chulabhorn College of Medical Science, Chulabhorn Royal Academy, Bangkok, Thailand; Department of Medicine (Rochwerg); DeGroote Institute for Pain Research and Care (Couban), McMaster University, Hamilton, Ont.; Department of Clinical Pharmacy (Ghadimi), Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran; Chair of Epidemiology and Preventive Medicine Jagiellonian (Bala), University Medical College, Krakow, Poland; Biostatistics Department (Gomaa), High institute of Public Health, Alexandria University, Alexandria, Egypt; Drug Information Center (Gomaa), Tanta Chest Hospital, Ministry of Health and Population, Egypt; Clinical Medicine College of Acupuncture, Moxibustion and Rehabilitation (Fang), Guangzhou University of Chinese Medicine, Guangdong, China; West China School of Nursing (Xiao), West China Hospital, Sichuan University, China
| | - Liang Yao
- Department of Health Research Methods, Evidence and Impact (Ye, Tangamornsuksan, Rochwerg, Guyatt, Colunga-Lozano, Yao, Motaghi, Fang, Xiao), McMaster University, Hamilton, Ont.; Department of Pharmacy (Wang), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; Department of Clinical Medicine (Colunga-Lozano), Health Science Center, Universidad de Guadalajara, Guadalajara, Mexico; Department of Community Medicine (Prasad), North DMC Medical College, New Delhi, India; Faculty of Medicine and Public Health (Tangamornsuksan), HRH Princess Chulabhorn College of Medical Science, Chulabhorn Royal Academy, Bangkok, Thailand; Department of Medicine (Rochwerg); DeGroote Institute for Pain Research and Care (Couban), McMaster University, Hamilton, Ont.; Department of Clinical Pharmacy (Ghadimi), Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran; Chair of Epidemiology and Preventive Medicine Jagiellonian (Bala), University Medical College, Krakow, Poland; Biostatistics Department (Gomaa), High institute of Public Health, Alexandria University, Alexandria, Egypt; Drug Information Center (Gomaa), Tanta Chest Hospital, Ministry of Health and Population, Egypt; Clinical Medicine College of Acupuncture, Moxibustion and Rehabilitation (Fang), Guangzhou University of Chinese Medicine, Guangdong, China; West China School of Nursing (Xiao), West China Hospital, Sichuan University, China
| | - Shahrzad Motaghi
- Department of Health Research Methods, Evidence and Impact (Ye, Tangamornsuksan, Rochwerg, Guyatt, Colunga-Lozano, Yao, Motaghi, Fang, Xiao), McMaster University, Hamilton, Ont.; Department of Pharmacy (Wang), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; Department of Clinical Medicine (Colunga-Lozano), Health Science Center, Universidad de Guadalajara, Guadalajara, Mexico; Department of Community Medicine (Prasad), North DMC Medical College, New Delhi, India; Faculty of Medicine and Public Health (Tangamornsuksan), HRH Princess Chulabhorn College of Medical Science, Chulabhorn Royal Academy, Bangkok, Thailand; Department of Medicine (Rochwerg); DeGroote Institute for Pain Research and Care (Couban), McMaster University, Hamilton, Ont.; Department of Clinical Pharmacy (Ghadimi), Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran; Chair of Epidemiology and Preventive Medicine Jagiellonian (Bala), University Medical College, Krakow, Poland; Biostatistics Department (Gomaa), High institute of Public Health, Alexandria University, Alexandria, Egypt; Drug Information Center (Gomaa), Tanta Chest Hospital, Ministry of Health and Population, Egypt; Clinical Medicine College of Acupuncture, Moxibustion and Rehabilitation (Fang), Guangzhou University of Chinese Medicine, Guangdong, China; West China School of Nursing (Xiao), West China Hospital, Sichuan University, China
| | - Rachel J Couban
- Department of Health Research Methods, Evidence and Impact (Ye, Tangamornsuksan, Rochwerg, Guyatt, Colunga-Lozano, Yao, Motaghi, Fang, Xiao), McMaster University, Hamilton, Ont.; Department of Pharmacy (Wang), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; Department of Clinical Medicine (Colunga-Lozano), Health Science Center, Universidad de Guadalajara, Guadalajara, Mexico; Department of Community Medicine (Prasad), North DMC Medical College, New Delhi, India; Faculty of Medicine and Public Health (Tangamornsuksan), HRH Princess Chulabhorn College of Medical Science, Chulabhorn Royal Academy, Bangkok, Thailand; Department of Medicine (Rochwerg); DeGroote Institute for Pain Research and Care (Couban), McMaster University, Hamilton, Ont.; Department of Clinical Pharmacy (Ghadimi), Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran; Chair of Epidemiology and Preventive Medicine Jagiellonian (Bala), University Medical College, Krakow, Poland; Biostatistics Department (Gomaa), High institute of Public Health, Alexandria University, Alexandria, Egypt; Drug Information Center (Gomaa), Tanta Chest Hospital, Ministry of Health and Population, Egypt; Clinical Medicine College of Acupuncture, Moxibustion and Rehabilitation (Fang), Guangzhou University of Chinese Medicine, Guangdong, China; West China School of Nursing (Xiao), West China Hospital, Sichuan University, China
| | - Maryam Ghadimi
- Department of Health Research Methods, Evidence and Impact (Ye, Tangamornsuksan, Rochwerg, Guyatt, Colunga-Lozano, Yao, Motaghi, Fang, Xiao), McMaster University, Hamilton, Ont.; Department of Pharmacy (Wang), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; Department of Clinical Medicine (Colunga-Lozano), Health Science Center, Universidad de Guadalajara, Guadalajara, Mexico; Department of Community Medicine (Prasad), North DMC Medical College, New Delhi, India; Faculty of Medicine and Public Health (Tangamornsuksan), HRH Princess Chulabhorn College of Medical Science, Chulabhorn Royal Academy, Bangkok, Thailand; Department of Medicine (Rochwerg); DeGroote Institute for Pain Research and Care (Couban), McMaster University, Hamilton, Ont.; Department of Clinical Pharmacy (Ghadimi), Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran; Chair of Epidemiology and Preventive Medicine Jagiellonian (Bala), University Medical College, Krakow, Poland; Biostatistics Department (Gomaa), High institute of Public Health, Alexandria University, Alexandria, Egypt; Drug Information Center (Gomaa), Tanta Chest Hospital, Ministry of Health and Population, Egypt; Clinical Medicine College of Acupuncture, Moxibustion and Rehabilitation (Fang), Guangzhou University of Chinese Medicine, Guangdong, China; West China School of Nursing (Xiao), West China Hospital, Sichuan University, China
| | - Malgorzata M Bala
- Department of Health Research Methods, Evidence and Impact (Ye, Tangamornsuksan, Rochwerg, Guyatt, Colunga-Lozano, Yao, Motaghi, Fang, Xiao), McMaster University, Hamilton, Ont.; Department of Pharmacy (Wang), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; Department of Clinical Medicine (Colunga-Lozano), Health Science Center, Universidad de Guadalajara, Guadalajara, Mexico; Department of Community Medicine (Prasad), North DMC Medical College, New Delhi, India; Faculty of Medicine and Public Health (Tangamornsuksan), HRH Princess Chulabhorn College of Medical Science, Chulabhorn Royal Academy, Bangkok, Thailand; Department of Medicine (Rochwerg); DeGroote Institute for Pain Research and Care (Couban), McMaster University, Hamilton, Ont.; Department of Clinical Pharmacy (Ghadimi), Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran; Chair of Epidemiology and Preventive Medicine Jagiellonian (Bala), University Medical College, Krakow, Poland; Biostatistics Department (Gomaa), High institute of Public Health, Alexandria University, Alexandria, Egypt; Drug Information Center (Gomaa), Tanta Chest Hospital, Ministry of Health and Population, Egypt; Clinical Medicine College of Acupuncture, Moxibustion and Rehabilitation (Fang), Guangzhou University of Chinese Medicine, Guangdong, China; West China School of Nursing (Xiao), West China Hospital, Sichuan University, China
| | - Huda Gomaa
- Department of Health Research Methods, Evidence and Impact (Ye, Tangamornsuksan, Rochwerg, Guyatt, Colunga-Lozano, Yao, Motaghi, Fang, Xiao), McMaster University, Hamilton, Ont.; Department of Pharmacy (Wang), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; Department of Clinical Medicine (Colunga-Lozano), Health Science Center, Universidad de Guadalajara, Guadalajara, Mexico; Department of Community Medicine (Prasad), North DMC Medical College, New Delhi, India; Faculty of Medicine and Public Health (Tangamornsuksan), HRH Princess Chulabhorn College of Medical Science, Chulabhorn Royal Academy, Bangkok, Thailand; Department of Medicine (Rochwerg); DeGroote Institute for Pain Research and Care (Couban), McMaster University, Hamilton, Ont.; Department of Clinical Pharmacy (Ghadimi), Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran; Chair of Epidemiology and Preventive Medicine Jagiellonian (Bala), University Medical College, Krakow, Poland; Biostatistics Department (Gomaa), High institute of Public Health, Alexandria University, Alexandria, Egypt; Drug Information Center (Gomaa), Tanta Chest Hospital, Ministry of Health and Population, Egypt; Clinical Medicine College of Acupuncture, Moxibustion and Rehabilitation (Fang), Guangzhou University of Chinese Medicine, Guangdong, China; West China School of Nursing (Xiao), West China Hospital, Sichuan University, China
| | - Fang Fang
- Department of Health Research Methods, Evidence and Impact (Ye, Tangamornsuksan, Rochwerg, Guyatt, Colunga-Lozano, Yao, Motaghi, Fang, Xiao), McMaster University, Hamilton, Ont.; Department of Pharmacy (Wang), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; Department of Clinical Medicine (Colunga-Lozano), Health Science Center, Universidad de Guadalajara, Guadalajara, Mexico; Department of Community Medicine (Prasad), North DMC Medical College, New Delhi, India; Faculty of Medicine and Public Health (Tangamornsuksan), HRH Princess Chulabhorn College of Medical Science, Chulabhorn Royal Academy, Bangkok, Thailand; Department of Medicine (Rochwerg); DeGroote Institute for Pain Research and Care (Couban), McMaster University, Hamilton, Ont.; Department of Clinical Pharmacy (Ghadimi), Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran; Chair of Epidemiology and Preventive Medicine Jagiellonian (Bala), University Medical College, Krakow, Poland; Biostatistics Department (Gomaa), High institute of Public Health, Alexandria University, Alexandria, Egypt; Drug Information Center (Gomaa), Tanta Chest Hospital, Ministry of Health and Population, Egypt; Clinical Medicine College of Acupuncture, Moxibustion and Rehabilitation (Fang), Guangzhou University of Chinese Medicine, Guangdong, China; West China School of Nursing (Xiao), West China Hospital, Sichuan University, China
| | - Yingqi Xiao
- Department of Health Research Methods, Evidence and Impact (Ye, Tangamornsuksan, Rochwerg, Guyatt, Colunga-Lozano, Yao, Motaghi, Fang, Xiao), McMaster University, Hamilton, Ont.; Department of Pharmacy (Wang), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; Department of Clinical Medicine (Colunga-Lozano), Health Science Center, Universidad de Guadalajara, Guadalajara, Mexico; Department of Community Medicine (Prasad), North DMC Medical College, New Delhi, India; Faculty of Medicine and Public Health (Tangamornsuksan), HRH Princess Chulabhorn College of Medical Science, Chulabhorn Royal Academy, Bangkok, Thailand; Department of Medicine (Rochwerg); DeGroote Institute for Pain Research and Care (Couban), McMaster University, Hamilton, Ont.; Department of Clinical Pharmacy (Ghadimi), Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran; Chair of Epidemiology and Preventive Medicine Jagiellonian (Bala), University Medical College, Krakow, Poland; Biostatistics Department (Gomaa), High institute of Public Health, Alexandria University, Alexandria, Egypt; Drug Information Center (Gomaa), Tanta Chest Hospital, Ministry of Health and Population, Egypt; Clinical Medicine College of Acupuncture, Moxibustion and Rehabilitation (Fang), Guangzhou University of Chinese Medicine, Guangdong, China; West China School of Nursing (Xiao), West China Hospital, Sichuan University, China
| | - Gordon H Guyatt
- Department of Health Research Methods, Evidence and Impact (Ye, Tangamornsuksan, Rochwerg, Guyatt, Colunga-Lozano, Yao, Motaghi, Fang, Xiao), McMaster University, Hamilton, Ont.; Department of Pharmacy (Wang), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; Department of Clinical Medicine (Colunga-Lozano), Health Science Center, Universidad de Guadalajara, Guadalajara, Mexico; Department of Community Medicine (Prasad), North DMC Medical College, New Delhi, India; Faculty of Medicine and Public Health (Tangamornsuksan), HRH Princess Chulabhorn College of Medical Science, Chulabhorn Royal Academy, Bangkok, Thailand; Department of Medicine (Rochwerg); DeGroote Institute for Pain Research and Care (Couban), McMaster University, Hamilton, Ont.; Department of Clinical Pharmacy (Ghadimi), Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran; Chair of Epidemiology and Preventive Medicine Jagiellonian (Bala), University Medical College, Krakow, Poland; Biostatistics Department (Gomaa), High institute of Public Health, Alexandria University, Alexandria, Egypt; Drug Information Center (Gomaa), Tanta Chest Hospital, Ministry of Health and Population, Egypt; Clinical Medicine College of Acupuncture, Moxibustion and Rehabilitation (Fang), Guangzhou University of Chinese Medicine, Guangdong, China; West China School of Nursing (Xiao), West China Hospital, Sichuan University, China
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Use of corticosteroids in influenza-associated acute respiratory distress syndrome and severe pneumonia: a systemic review and meta-analysis. Sci Rep 2020; 10:3044. [PMID: 32080223 PMCID: PMC7033254 DOI: 10.1038/s41598-020-59732-7] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 02/03/2020] [Indexed: 12/29/2022] Open
Abstract
Influenza-related severe pneumonia and acute respiratory distress syndrome (ARDS) are severe threats to human health. The objective of this study was to assess the effects of systematic corticosteroid therapy in patients with pneumonia or ARDS. The PubMed, EMBASE, Web of Science and SCOPUS databases were searched up to July, 2019. Nineteen studies including 6637 individuals were identified, and fifteen studies (6427 patients) were included in the meta-analysis of mortality. Eighteen were observational studies and one was a randomized controlled trial (RCT). The meta-analysis results showed that corticosteroid therapy was associated with significantly higher mortality (OR 1.53, 95% CI [1.16, 2.01]) and incidence of nosocomial infection (OR 3.15, 95% CI [1.54, 6.45]). Subgroup analysis showed that among patients with unadjusted estimates, the odds of mortality were higher in patients receiving corticosteroid treatment (OR 1.98, 95% CI [1.23, 3.17]), however, among patients with adjusted estimates, the result showed no statistically significant difference between corticosteroid group and control group (OR 1.31, 95% CI [0.95, 1.80]). Current data do not support the routine use of corticosteroids in patients with influenza severe pneumonia or ARDS. RCTs are needed to provide more robust evidence.
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14
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Use of glucocorticoids in the critical care setting: Science and clinical evidence. Pharmacol Ther 2020; 206:107428. [DOI: 10.1016/j.pharmthera.2019.107428] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 10/02/2019] [Indexed: 02/07/2023]
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15
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Lansbury LE, Rodrigo C, Leonardi-Bee J, Nguyen-Van-Tam J, Shen Lim W. Corticosteroids as Adjunctive Therapy in the Treatment of Influenza: An Updated Cochrane Systematic Review and Meta-analysis. Crit Care Med 2020; 48:e98-e106. [PMID: 31939808 DOI: 10.1097/ccm.0000000000004093] [Citation(s) in RCA: 122] [Impact Index Per Article: 30.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVES Corticosteroids may be beneficial in sepsis, but uncertainty remains over their effects in severe influenza. This systematic review updates the current evidence regarding corticosteroids in the treatment of influenza and examines the effect of dose on outcome. DATA SOURCES Electronic databases (MEDLINE, EMBASE, CINAHL, LILACS, CENTRAL, and Web of Science) and trial registries were searched to October 2018 for randomized controlled trials, quasi-experimental designs, and observational cohort studies reporting corticosteroid versus no corticosteroid treatment in individuals with influenza. STUDY SELECTION AND DATA EXTRACTION Two researchers independently assessed studies for inclusion. Risk of bias was assessed using the Cochrane Risk of Bias tool (randomized controlled trials) or Newcastle-Ottawa Scale (observational studies). Where appropriate, we estimated the effect of corticosteroids by random-effects meta-analyses using the generic inverse variance method. Meta-regression analysis was used to assess the association of corticosteroid dose and mortality. DATA SYNTHESIS We identified 30 eligible studies, all observational apart from one randomized controlled trial. Twenty-one observational studies were included in the meta-analysis of mortality, which suggested an adverse association with corticosteroid therapy (odds ratio, 3.90; 95% CI, 2.31-6.60; 15 studies; adjusted hazard ratio, 1.49; 95% CI, 1.09-2.02; six studies). Risk of bias assessment was consistent with potential confounding by indication. Pooled analysis of seven studies showed increased odds of hospital-acquired infection in people treated with corticosteroids (unadjusted odds ratio, 2.74; 95% CI, 1.51-4.95). Meta-regression of the effect of dose on mortality did not reveal an association, but reported doses of corticosteroids in included studies were high (mostly > 40 mg methylprednisolone [or equivalent] per day). CONCLUSIONS Corticosteroid treatment in influenza is associated with increased mortality and hospital-acquired infection, but the evidence relates mainly to high corticosteroid doses and is of low quality with potential confounding by indication a major concern.
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Affiliation(s)
- Louise E Lansbury
- Division of Epidemiology and Public Health, University of Nottingham, Nottingham, United Kingdom
- Nottingham Biomedical Research Centre NIHR, United Kingdom
| | - Chamira Rodrigo
- Department of Respiratory Medicine, Nottingham University Hospitals Trust, Nottingham, United Kingdom
| | - Jo Leonardi-Bee
- Division of Epidemiology and Public Health, University of Nottingham, Nottingham, United Kingdom
| | - Jonathan Nguyen-Van-Tam
- Division of Epidemiology and Public Health, University of Nottingham, Nottingham, United Kingdom
| | - Wei Shen Lim
- Nottingham Biomedical Research Centre NIHR, United Kingdom
- Department of Respiratory Medicine, Nottingham University Hospitals Trust, Nottingham, United Kingdom
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16
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Abstract
Community-acquired pneumonia (CAP) is a leading cause of morbidity and mortality despite adequate antibiotic therapy. It is the single most common cause of infection-related mortality in the United States. An exaggerated host inflammatory response can potentially be harmful to both the lung and host, and has been associated with treatment failure and mortality. Modulation of inflammatory response may, therefore, be theoretically beneficial. The anti-inflammatory and immunosuppressive effects of steroids seem an attractive therapeutic option in severe CAP patients. Available datapoint to overall shorter time to clinical stability and decreased length-of-stay in CAP patients, with a potential mortality benefit in severe CAP. The level of evidence is, however, low to moderate regarding mortality due to high heterogeneity and insufficient power of data. Furthermore, steroids were deleterious in influenza pneumonia and in patients with pneumococcal pneumonia data suggest a lack of efficacy and potential harm. Both European and American guidelines recommend not using corticosteroids in CAP. Patients who might benefit and those that can be harmed from steroids remain to be clearly identified, as does the ideal steroid for CAP patients, based on pharmacokinetic and pharmacodynamic properties. It is essential for future studies to avoid the same methodological bias present in the available data so that high-quality evidence on the true role of steroids in CAP can be provided.
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Affiliation(s)
- David Nora
- Polyvalent Intensive Care Unit, São Francisco Xavier Hospital, Centro Hospitalar De Lisboa Ocidental, Lisbon, Portugal.,NOVA Medical School, CHRC, New University of Lisbon, Lisbon, Portugal
| | - Wagner Nedel
- Intensive Care Unit, Hospital Nossa Senhora Da Conceição, Porto Alegre, Brazil
| | - Thiago Lisboa
- Critical Care Department, Hospital De Clínicas De Porto Alegre, Post-Graduation Program (PPG) Pneumology,Universidade Federal Do Rio Grande Do Sul, Porto Alegre, Brazil
| | - Jorge Salluh
- D'or Institute for Research and Education, Rio De Janeiro, Brazil
| | - Pedro Póvoa
- Polyvalent Intensive Care Unit, São Francisco Xavier Hospital, Centro Hospitalar De Lisboa Ocidental, Lisbon, Portugal.,NOVA Medical School, CHRC, New University of Lisbon, Lisbon, Portugal.,Center for Clinical Epidemiology and Research Unit of Clinical Epidemiology, OUH Odense University Hospital, Denmark
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17
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Corticosteroids for Community-Acquired Pneumonia: Overstated Benefits and Understated Risks. Chest 2019; 156:1049-1053. [PMID: 31287999 DOI: 10.1016/j.chest.2019.06.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 06/24/2019] [Accepted: 06/26/2019] [Indexed: 01/13/2023] Open
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18
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Urwyler SA, Blum CA, Coslovsky M, Mueller B, Schuetz P, Christ-Crain M. Cytokines and Cortisol - predictors of treatment response to corticosteroids in community-acquired pneumonia? J Intern Med 2019; 286:75-87. [PMID: 30873676 DOI: 10.1111/joim.12891] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND A previous study found community-acquired pneumonia (CAP) patients with imbalance of high inflammation and discordantly low cortisol levels to benefit most from adjunctive corticosteroid treatment. Our aim was to validate this hypothesis in a preplanned secondary analysis of the randomized controlled STEP trial. METHODS Patients included in the STEP trial receiving 50 mg prednisone or placebo for 5 days were categorized based on pro-inflammatory cytokines (Interleukin-6/8/MCP-1), CRP and cortisol levels on admission into four groups (high/low inflammation and high/low cortisol). The primary combined end-point was mortality or ICU admission within 30 days. RESULTS In total, 632 patients (315 prednisone, 317 placebo) were included in this analysis. Prednisone did not significantly reduce the risk for the primary end-point in patients with high cytokines/low cortisol and in any other subgroups. However, we noted some differences in the strength of corticosteroid effect in the different subgroups with stronger effects in patients with high cytokines [OR 0.44 (0.10,1.72)] compared to patients with low cytokines [OR 0.68 (0.30,1.5)] (P-interaction = 0.600). The effects did not differ according to cortisol levels. CONCLUSION The imbalance of high inflammation state and low cortisol levels did not predict treatment response to corticosteroids in patients with CAP. However, in line to previous research, inflammation as measured by cytokine levels irrespective of cortisol tended to predict treatment response to corticosteroids in CAP. Whether this concept may help to personalize corticosteroids to patients most likely benefitting from this treatment needs to be tested in future intervention trials.
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Affiliation(s)
- S A Urwyler
- Department of Endocrinology, Diabetology and Metabolism, University Hospital Basel, Basel, Switzerland.,Department of Clinical Research, University Hospital Basel, Basel, Switzerland
| | - C A Blum
- Department of Clinical Research, University Hospital Basel, Basel, Switzerland.,Department of Endocrinology, Medical University Clinic, Kantonsspital Aarau, Aarau, Switzerland
| | - M Coslovsky
- Department of Clinical Research, Clinical trial unit, University of Basel, Basel, Switzerland
| | - B Mueller
- Department of Clinical Research, University Hospital Basel, Basel, Switzerland.,Department of Endocrinology, Medical University Clinic, Kantonsspital Aarau, Aarau, Switzerland
| | - P Schuetz
- Department of Clinical Research, University Hospital Basel, Basel, Switzerland.,Department of Endocrinology, Medical University Clinic, Kantonsspital Aarau, Aarau, Switzerland
| | - M Christ-Crain
- Department of Endocrinology, Diabetology and Metabolism, University Hospital Basel, Basel, Switzerland.,Department of Clinical Research, University Hospital Basel, Basel, Switzerland
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Lansbury L, Rodrigo C, Leonardi‐Bee J, Nguyen‐Van‐Tam J, Lim WS. Corticosteroids as adjunctive therapy in the treatment of influenza. Cochrane Database Syst Rev 2019; 2:CD010406. [PMID: 30798570 PMCID: PMC6387789 DOI: 10.1002/14651858.cd010406.pub3] [Citation(s) in RCA: 86] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Specific treatments for influenza are limited to neuraminidase inhibitors and adamantanes. Corticosteroids show evidence of benefit in sepsis and related conditions, most likely due to their anti-inflammatory and immunomodulatory properties. Although commonly prescribed for severe influenza, there is uncertainty over their potential benefits or harms. This is an update of a review first published in 2016. OBJECTIVES To systematically assess the effectiveness and potential adverse effects of corticosteroids as adjunctive therapy in the treatment of influenza, taking into account differences in timing and doses of corticosteroids. SEARCH METHODS We searched CENTRAL (2018, Issue 9), which includes the Cochrane Acute Respiratory infections Group's Specialised Register, MEDLINE (1946 to October week 1, 2018), Embase (1980 to 3 October 2018), CINAHL (1981 to 3 October 2018), LILACS (1982 to 3 October 2018), Web of Science (1985 to 3 October 2018), abstracts from the last three years of major infectious disease and microbiology conferences, and references of included articles. We also searched the World Health Organization International Clinical Trials Registry Platform, ClinicalTrials.gov, and the ISRCTN registry on 3 October 2018. SELECTION CRITERIA We included randomised controlled trials (RCTs), quasi-RCTs, and observational studies that compared corticosteroid treatment with no corticosteroid treatment for influenza or influenza-like illness. We did not restrict studies by language of publication, influenza subtypes, clinical setting, or age of participants. We selected eligible studies in two stages: sequential examination of title and abstract, followed by full text. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed risk of bias. We pooled estimates of effect using a random-effects model, where appropriate. We assessed heterogeneity using the I2 statistic and assessed the certainty of the evidence using the GRADE framework. MAIN RESULTS This updated review includes 30 studies (one RCT with two arms and 29 observational studies) with a total of 99,224 participants. We included 19 studies in the original review (n = 3459), all of which were observational, with 13 studies included in the meta-analysis for mortality. We included 12 new studies in this update (one RCT and 11 observational studies), and excluded one study in the original review as it has been superceded by a more recent analysis. Twenty-one studies were included in the meta-analysis (9536 individuals), of which 15 studied people infected with 2009 influenza A H1N1 virus (H1N1pdm09). Data specific to mortality were of very low quality, based predominantly on observational studies, with inconsistent reporting of variables potentially associated with the outcomes of interest, differences between studies in the way in which they were conducted, and with the likelihood of potential confounding by indication. Reported doses of corticosteroids used were high, and indications for their use were not well reported. On meta-analysis, corticosteroid therapy was associated with increased mortality (odds ratio (OR) 3.90, 95% confidence interval (CI) 2.31 to 6.60; I2 = 68%; 15 studies). A similar increase in risk of mortality was seen in a stratified analysis of studies reporting adjusted estimates (OR 2.23, 95% CI 1.54 to 3.24; I2 = 0%; 5 studies). An association between corticosteroid therapy and increased mortality was also seen on pooled analysis of six studies which reported adjusted hazard ratios (HRs) (HR 1.49, 95% CI 1.09 to 2.02; I2 = 69%). Increased odds of hospital-acquired infection related to corticosteroid therapy were found on pooled analysis of seven studies (pooled OR 2.74, 95% CI 1.51 to 4.95; I2 = 90%); all were unadjusted estimates, and we graded the data as of very low certainty. AUTHORS' CONCLUSIONS We found one RCT of adjunctive corticosteroid therapy for treating people with community-acquired pneumonia, but the number of people with laboratory-confirmed influenza in the treatment and placebo arms was too small to draw conclusions regarding the effect of corticosteroids in this group, and we did not include it in our meta-analyses of observational studies. The certainty of the available evidence from observational studies was very low, with confounding by indication a major potential concern. Although we found that adjunctive corticosteroid therapy is associated with increased mortality, this result should be interpreted with caution. In the context of clinical trials of adjunctive corticosteroid therapy in sepsis and pneumonia that report improved outcomes, including decreased mortality, more high-quality research is needed (both RCTs and observational studies that adjust for confounding by indication). The currently available evidence is insufficient to determine the effectiveness of corticosteroids for people with influenza.
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Affiliation(s)
- Louise Lansbury
- The University of NottinghamDepartment of Epidemiology and Public HealthCity Hospital CampusHucknall RoadNottinghamUKNG5 1PB
| | - Chamira Rodrigo
- Nottingham University Hospitals TrustDepartment of Respiratory MedicineCity CampusHucknall RoadNottinghamNottinghamshireUKNG5 1PB
| | - Jo Leonardi‐Bee
- The University of NottinghamDivision of Epidemiology and Public HealthClinical Sciences BuildingNottingham City Hospital NHS Trust Campus, Hucknall RoadNottinghamUKNG5 1PB
| | - Jonathan Nguyen‐Van‐Tam
- The University of NottinghamFaculty of Medicine and Health SciencesRoom A40DClinical Sciences Building City Hospital Campus, Hucknall RoadNottinghamNottinghamshireUKNG5 1PB
| | - Wei Shen Lim
- Nottingham University Hospitals TrustDepartment of Respiratory MedicineCity CampusHucknall RoadNottinghamNottinghamshireUKNG5 1PB
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Ceccato A, Ferrer M, Barbeta E, Torres A. Adjunctive Therapies for Community-Acquired Pneumonia. Clin Chest Med 2018; 39:753-764. [DOI: 10.1016/j.ccm.2018.07.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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21
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Soumagne T, Rabbat A. [Corticosteroids in community acquired pneumonia: Where are we in 2018?]. Rev Mal Respir 2018; 35:813-827. [PMID: 30217573 DOI: 10.1016/j.rmr.2018.01.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Accepted: 01/23/2018] [Indexed: 12/15/2022]
Abstract
Community-acquired pneumonia (CAP) is a common infectious disease and one of the main causes of mortality worldwide. Despite an improvement in management globally, mortality remains high especially in severe forms of CAP. Adequate early antibiotics remain the cornerstone of the treatment but adjuvant corticosteroid administration is being considered to counterbalance the systemic inflammatory reaction and modulate the immune response. In the last ten years, several clinical trials and meta-analyses have been conducted in severe and non-severe CAP to assess the efficacy of corticosteroids. The benefits on the duration of hospitalization and the time to clinical stability are quite small and early mortality does not seem to be improved. Corticosteroids should not, therefore, be used routinely in patients with CAP, even in severe cases. However, new therapeutic trials are currently underway.
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Key Words
- Community acquired pneumonia, Severe, Corticosteroids, Mortality, Duration of hospitalization, Side effects
- Pneumopathie aiguë communautaire, Sévère, Corticostéroïdes, Mortalité, Durée d’hospitalisation, Effets secondaires
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Affiliation(s)
- T Soumagne
- Service de pneumologie et soins intensifs respiratoires, hôpital Cochin, hôpitaux universitaires, Paris centre, AP-HP, 75679 Paris cedex 14, France; Service de pneumologie, hôpital Jean-Minjoz, CHU de Besançon, 25030 Besançon cedex, France; Service de physiologie-explorations fonctionnelles, hôpital Jean-Minjoz, CHU de Besançon, 25030 Besançon cedex, France.
| | - A Rabbat
- Service de pneumologie et soins intensifs respiratoires, hôpital Cochin, hôpitaux universitaires, Paris centre, AP-HP, 75679 Paris cedex 14, France
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Menéndez R, Amara-Elori I, Méndez R. Corticosteroids and pneumonia - targeting the ideal candidate. Expert Rev Respir Med 2018; 12:721-724. [PMID: 30016132 DOI: 10.1080/17476348.2018.1502085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Rosario Menéndez
- a Pneumology Department , University and Polytechnic Hospital La Fe , Valencia , Spain
| | - Isabel Amara-Elori
- a Pneumology Department , University and Polytechnic Hospital La Fe , Valencia , Spain
| | - Raul Méndez
- a Pneumology Department , University and Polytechnic Hospital La Fe , Valencia , Spain
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Felix KM, Jaimez IA, Nguyen TVV, Ma H, Raslan WA, Klinger CN, Doyle KP, Wu HJJ. Gut Microbiota Contributes to Resistance Against Pneumococcal Pneumonia in Immunodeficient Rag -/- Mice. Front Cell Infect Microbiol 2018; 8:118. [PMID: 29755958 PMCID: PMC5932343 DOI: 10.3389/fcimb.2018.00118] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2017] [Accepted: 03/27/2018] [Indexed: 12/20/2022] Open
Abstract
Streptococcus pneumoniae causes infection-related mortality worldwide. Immunocompromised individuals, including young children, the elderly, and those with immunodeficiency, are especially vulnerable, yet little is known regarding S. pneumoniae-related pathogenesis and protection in immunocompromised hosts. Recently, strong interest has emerged in the gut microbiota's impact on lung diseases, or the "gut-lung axis." However, the mechanisms of gut microbiota protection against gut-distal lung diseases like pneumonia remain unclear. We investigated the role of the gut commensal, segmented filamentous bacteria (SFB), against pneumococcal pneumonia in immunocompetent and immunocompromised mouse models. For the latter, we chose the Rag-/- model, with adaptive immune deficiency. Immunocompetent adaptive protection against S. pneumoniae infection is based on antibodies against pneumococcal capsular polysaccharides, prototypical T cell independent-II (TI-II) antigens. Although SFB colonization enhanced TI-II antibodies in C57BL/6 mice, our data suggest that SFB did not further protect these immunocompetent animals. Indeed, basal B cell activity in hosts without SFB is sufficient for essential protection against S. pneumoniae. However, in immunocompromised Rag-/- mice, we demonstrate a gut-lung axis of communication, as SFB influenced lung protection by regulating innate immunity. Neutrophil resolution is crucial to recovery, since an unchecked neutrophil response causes severe tissue damage. We found no early neutrophil recruitment differences between hosts with or without SFB; however, we observed a significant drop in lung neutrophils in the resolution phase of S. pneumoniae infection, which corresponded with lower CD47 expression, a molecule that inhibits phagocytosis of apoptotic cells, in SFB-colonized Rag-/- mice. SFB promoted a shift in lung neutrophil phenotype from inflammatory neutrophils expressing high levels of CD18 and low levels of CD62L, to pro-resolution neutrophils with low CD18 and high CD62L. Blocking CD47 in SFB(-) mice increased pro-resolution neutrophils, suggesting CD47 down-regulation may be one neutrophil-modulating mechanism SFB utilizes. The SFB-induced lung neutrophil phenotype remained similar with heat-inactivated S. pneumoniae treatment, indicating these SFB-induced changes in neutrophil phenotype during the resolution phase are not simply secondary to better bacterial clearance in SFB(+) than SFB(-) mice. Together, these data demonstrate that the gut commensal SFB may provide much-needed protection in immunocompromised hosts in part by promoting neutrophil resolution post lung infection.
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Affiliation(s)
- Krysta M. Felix
- Department of Immunobiology, University of Arizona, Tucson, AZ, United States
| | - Ivan A. Jaimez
- Department of Immunobiology, University of Arizona, Tucson, AZ, United States
| | - Thuy-Vi V. Nguyen
- Department of Immunobiology, University of Arizona, Tucson, AZ, United States
- Department of Neurology, College of Medicine, University of Arizona, Tucson, AZ, United States
| | - Heqing Ma
- Department of Immunobiology, University of Arizona, Tucson, AZ, United States
| | - Walid A. Raslan
- Department of Immunobiology, University of Arizona, Tucson, AZ, United States
| | | | - Kristian P. Doyle
- Department of Immunobiology, University of Arizona, Tucson, AZ, United States
- Department of Neurology, College of Medicine, University of Arizona, Tucson, AZ, United States
| | - Hsin-Jung J. Wu
- Department of Immunobiology, University of Arizona, Tucson, AZ, United States
- Arizona Arthritis Center, College of Medicine, University of Arizona, Tucson, AZ, United States
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Mantero M, Tarsia P, Gramegna A, Henchi S, Vanoni N, Di Pasquale M. Antibiotic therapy, supportive treatment and management of immunomodulation-inflammation response in community acquired pneumonia: review of recommendations. Multidiscip Respir Med 2017; 12:26. [PMID: 29034094 PMCID: PMC5628439 DOI: 10.1186/s40248-017-0106-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Accepted: 09/08/2017] [Indexed: 11/29/2022] Open
Abstract
Community-acquired pneumonia is a common and serious disease, with high rates of morbidity and mortality. Management and treatment of community-acquired pneumonia are described in three main documents: the 2007 American Thoracic Society guidelines, the 2011 European Respiratory Society guidelines, and the 2009 British Thoracic Society guidelines, updated by the NICE in 2015. Despite the validity of current guidelines in improving prognosis and management of patients with community-acquired pneumonia, not all recommendations have high levels of evidence and there are still some controversial issues. In particular, there are some areas of low evidence such as the efficacy of an antibiotic molecule or scheme in patients with same risk factors; duration of antibiotic treatment, supportive therapy for acute respiratory failure and immunomodulation molecules. This review will summarize the main recommendations with high level of evidence and discuss the recommendations with lower evidence, analyzing the studies published after the guidelines’ release.
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Affiliation(s)
- Marco Mantero
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Internal Medicine Department, Respiratory Unit and Regional Adult Cystic Fibrosis Center, IRCCS Fondazione Cà Granda Ospedale Maggiore Policlinico, Via Francesco Sforza, 35 Milan, Italy
| | - Paolo Tarsia
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Internal Medicine Department, Respiratory Unit and Regional Adult Cystic Fibrosis Center, IRCCS Fondazione Cà Granda Ospedale Maggiore Policlinico, Via Francesco Sforza, 35 Milan, Italy
| | - Andrea Gramegna
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Internal Medicine Department, Respiratory Unit and Regional Adult Cystic Fibrosis Center, IRCCS Fondazione Cà Granda Ospedale Maggiore Policlinico, Via Francesco Sforza, 35 Milan, Italy
| | - Sonia Henchi
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Internal Medicine Department, Respiratory Unit and Regional Adult Cystic Fibrosis Center, IRCCS Fondazione Cà Granda Ospedale Maggiore Policlinico, Via Francesco Sforza, 35 Milan, Italy
| | - Nicolò Vanoni
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Internal Medicine Department, Respiratory Unit and Regional Adult Cystic Fibrosis Center, IRCCS Fondazione Cà Granda Ospedale Maggiore Policlinico, Via Francesco Sforza, 35 Milan, Italy
| | - Marta Di Pasquale
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Internal Medicine Department, Respiratory Unit and Regional Adult Cystic Fibrosis Center, IRCCS Fondazione Cà Granda Ospedale Maggiore Policlinico, Via Francesco Sforza, 35 Milan, Italy
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25
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Ceccato A, Cilloniz C, Ranzani OT, Menendez R, Agusti C, Gabarrus A, Ferrer M, Sibila O, Niederman MS, Torres A. Treatment with macrolides and glucocorticosteroids in severe community-acquired pneumonia: A post-hoc exploratory analysis of a randomized controlled trial. PLoS One 2017; 12:e0178022. [PMID: 28617807 PMCID: PMC5472276 DOI: 10.1371/journal.pone.0178022] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Accepted: 05/05/2017] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Systemic corticosteroids have anti-inflammatory effects, whereas macrolides also have immunomodulatory activity in addition to their primary antimicrobial actions. We aimed to evaluate the potential interaction effect between corticosteroids and macrolides on the systemic inflammatory response in patients with severe community-acquired pneumonia to determine if combining these two immunomodulating agents was harmful, or possibly beneficial. METHODS We performed a post-hoc exploratory analysis of a randomized clinical trial conducted in three tertiary hospitals in Spain. This trial included patients with severe community-acquired pneumonia with high inflammatory response (C-reactive protein [CRP] >15 mg/dL) who were randomized to receive methylprednisolone 0.5 mg/kg/tpd or placebo. The choice of antibiotic treatment was at the physician's discretion. One hundred and six patients were classified into four groups according to antimicrobial therapy combination (β-lactam plus macrolide or β-lactam plus fluoroquinolone) and corticosteroid arm (placebo or corticosteroids). The primary outcome was treatment failure (composite outcome of early treatment failure, or of late treatment failure, or of both early and late treatment failure). RESULTS The methylprednisolone with β-lactam plus macrolide group had more elderly patients, with comorbidities, and higher pneumonia severity index (PSI) risk class V, but a lower proportion of intensive care unit admission, compared to the other groups. We found non differences in treatment failure between groups (overall p = 0.374); however, a significant difference in late treatment failure was observed (4 patients in the placebo with β-lactam plus macrolide group (31%) vs. 9 patients in the placebo with β-lactam plus fluoroquinolone group (24%) vs. 0 patients in the methylprednisolone with β-lactam plus macrolide group (0%) vs. 2 patients [5%] in the methylprednisolone with β-lactam plus fluoroquinolone group overall p = 0.009). We found a significant difference for In-hospital mortality in the per protocol population (overall p = 0.01). We did not find significant differences in treatment failure, early or late; or In-hospital mortality after adjusting for severity (PSI), year and centre of enrolment. CONCLUSIONS In this exploratory analysis, we observed that the glucocorticosteroids and macrolides combination had no statistically significant association with main clinical outcomes compared with other combinations in patients with severe community acquired pneumonia and a high inflammatory response after taking account potential confounders. TRIAL REGISTRATION Clinicaltrials.gov NCT00908713.
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Affiliation(s)
- Adrian Ceccato
- Department of Pneumology, Institut Clinic de Respiratori, Hospital Clinic of Barcelona—Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona (UB)—SGR 911—Ciber de Enfermedades Respiratorias (Ciberes, CB06/06/0028) Villarroel, Barcelona, Spain
- Seccion Neumologia, Hospital Nacional Prof. Alejandro Posadas, Illia y Marconi s/n Palomar, Argentina
| | - Catia Cilloniz
- Department of Pneumology, Institut Clinic de Respiratori, Hospital Clinic of Barcelona—Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona (UB)—SGR 911—Ciber de Enfermedades Respiratorias (Ciberes, CB06/06/0028) Villarroel, Barcelona, Spain
| | - Otavio T. Ranzani
- Department of Pneumology, Institut Clinic de Respiratori, Hospital Clinic of Barcelona—Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona (UB)—SGR 911—Ciber de Enfermedades Respiratorias (Ciberes, CB06/06/0028) Villarroel, Barcelona, Spain
- Respiratory Intensive Care Unit, Pulmonary Division, Heart Institute, Hospital das Clínicas, University of São Paulo, Av. Dr. Arnaldo, 455-Cerqueira César—CEP: São Paulo, Brazil
| | - Rosario Menendez
- Servicio de Neumología, IIS/Hospital Universitario y Politécnico La Fe, Avinguda de Fernando Abril Martorell, Valencia, CIBERES, Spain
| | - Carles Agusti
- Department of Pneumology, Institut Clinic de Respiratori, Hospital Clinic of Barcelona—Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona (UB)—SGR 911—Ciber de Enfermedades Respiratorias (Ciberes, CB06/06/0028) Villarroel, Barcelona, Spain
| | - Albert Gabarrus
- Department of Pneumology, Institut Clinic de Respiratori, Hospital Clinic of Barcelona—Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona (UB)—SGR 911—Ciber de Enfermedades Respiratorias (Ciberes, CB06/06/0028) Villarroel, Barcelona, Spain
| | - Miquel Ferrer
- Department of Pneumology, Institut Clinic de Respiratori, Hospital Clinic of Barcelona—Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona (UB)—SGR 911—Ciber de Enfermedades Respiratorias (Ciberes, CB06/06/0028) Villarroel, Barcelona, Spain
| | - Oriol Sibila
- Servei de Pneumologia, Hospital de la Santa Creu i Sant Pau, Sant Antoni Maria Claret 167, Barcelona, Spain
| | - Michael S. Niederman
- Division of Pulmonary and Critical Care Medicine, Weill Cornell Medical College, New York Presbyterian/Weill Cornell Medical Center, NY, New York, NY, United States of America
| | - Antoni Torres
- Department of Pneumology, Institut Clinic de Respiratori, Hospital Clinic of Barcelona—Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona (UB)—SGR 911—Ciber de Enfermedades Respiratorias (Ciberes, CB06/06/0028) Villarroel, Barcelona, Spain
- * E-mail:
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Schuetz P. Personalized medicine of patients with respiratory infections through the measurement of specific blood biomarkers: fact or fiction? Expert Rev Respir Med 2017; 11:605-607. [PMID: 28610545 DOI: 10.1080/17476348.2017.1338953] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Philipp Schuetz
- a Medical University Department , Kantonsspital Aarau, Endocrinology/Diabetes/Clinical Nutrition and Internal Medicine , Aarau , Switzerland
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Cazzola M, Rogliani P, Aliberti S, Blasi F, Matera MG. An update on the pharmacotherapeutic management of lower respiratory tract infections. Expert Opin Pharmacother 2017; 18:973-988. [PMID: 28480770 DOI: 10.1080/14656566.2017.1328497] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
INTRODUCTION Our knowledge about lower respiratory tract infections (LRTIs) has improved substantially in the last years, but the management of respiratory infections is still a challenge and we are still far from using precision medicine in their treatment. Areas covered: The approaches developed in recent years to improve the pharmacotherapeutic management of LRTIs, such as novel diagnostic assays to facilitate medical decision-making, attempts for selecting an optimal empiric antibiotic regimen, and the role of new and possibly unproven adjunctive therapies, are described. Expert opinion: Early and appropriate antibiotics remain the cornerstone in the treatment of LRTIs. The updated trend is to apply antimicrobial stewardship principles and initiatives to optimize both the management and the outcomes of LTRIs. Biomarkers, mainly C-reactive protein (CRP) and procalcitonin (PCT), can improve the diagnostic and prognostic assessment of LRTIs and aid to guide antibiotic therapy. The widespread use of antimicrobial agents has greatly contributed to faster development of antibiotic resistance and the emergence of opportunistic pathogens, which substitute the indigenous microbiota. However, very few new antibiotics in development to overcome existing resistance and ensure continued success in the treatment of LRTIs have been approved, likely because antibiotic stewardship programs discourage the use of new agents.
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Affiliation(s)
- Mario Cazzola
- a Department of Systems Medicine , Università degli Studi di Roma "Tor Vergata" , Rome , Italy
| | - Paola Rogliani
- a Department of Systems Medicine , Università degli Studi di Roma "Tor Vergata" , Rome , Italy
| | - Stefano Aliberti
- b Department of Pathophysiology and Transplantation , Università degli Studi di Milano, IRCCS Fondazione Cà Granda Ospedale Maggiore Policlinico , Milan , Italy
| | - Francesco Blasi
- b Department of Pathophysiology and Transplantation , Università degli Studi di Milano, IRCCS Fondazione Cà Granda Ospedale Maggiore Policlinico , Milan , Italy
| | - Maria Gabriella Matera
- c Department of Experimental Medicine , Università degli Studi della Campania "Luigi Vanvitelli" , Naples , Italy
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Anderson R, Feldman C. Pneumolysin as a potential therapeutic target in severe pneumococcal disease. J Infect 2017; 74:527-544. [PMID: 28322888 DOI: 10.1016/j.jinf.2017.03.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Revised: 03/09/2017] [Accepted: 03/11/2017] [Indexed: 12/13/2022]
Abstract
Acute pulmonary and cardiac injury remain significant causes of morbidity and mortality in those afflicted with severe pneumococcal disease, with the risk for early mortality often persisting several years beyond clinical recovery. Although remaining to be firmly established in the clinical setting, a considerable body of evidence, mostly derived from murine models of experimental infection, has implicated the pneumococcal, cholesterol-binding, pore-forming toxin, pneumolysin (Ply), in the pathogenesis of lung and myocardial dysfunction. Topics covered in this review include the burden of pneumococcal disease, risk factors, virulence determinants of the pneumococcus, complications of severe disease, antibiotic and adjuvant therapies, as well as the structure of Ply and the role of the toxin in disease pathogenesis. Given the increasing recognition of the clinical potential of Ply-neutralisation strategies, the remaining sections of the review are focused on updates of the types, benefits and limitations of currently available therapies which may attenuate, directly and/or indirectly, the injurious actions of Ply. These include recently described experimental therapies such as various phytochemicals and lipids, and a second group of more conventional agents the members of which remain the subject of ongoing clinical evaluation. This latter group, which is covered more extensively, encompasses macrolides, statins, corticosteroids, and platelet-targeted therapies, particularly aspirin.
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Affiliation(s)
- Ronald Anderson
- Department of Immunology and Institute of Cellular and Molecular Medicine, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa.
| | - Charles Feldman
- Division of Pulmonology, Department of Internal Medicine, Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Corticothérapie systémique et pneumopathies communautaires : où en est-on ? MEDECINE INTENSIVE REANIMATION 2017. [DOI: 10.1007/s13546-017-1254-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Chalmers JD. Corticosteroids for community-acquired pneumonia: a critical view of the evidence. Eur Respir J 2016; 48:984-986. [DOI: 10.1183/13993003.01329-2016] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Accepted: 07/06/2016] [Indexed: 11/05/2022]
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