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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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Ceccato A, Russo A, Barbeta E, Oscanoa P, Tiseo G, Gabarrus A, Di Giannatale P, Nogas S, Cilloniz C, Menichetti F, Ferrer M, Niederman M, Falcone M, Torres A. Real-world corticosteroid use in severe pneumonia: a propensity-score-matched study. Crit Care 2021; 25:432. [PMID: 34915895 PMCID: PMC8674860 DOI: 10.1186/s13054-021-03840-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 11/24/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Community-acquired pneumonia (CAP) is a leading cause of morbidity and mortality worldwide despite correct antibiotic use. Corticosteroids have long been evaluated as a treatment option, but heterogeneous effects on survival have precluded their widespread implementation. We aimed to evaluate whether corticosteroids might improve clinical outcomes in patients with severe CAP and high inflammatory responses. STUDY DESIGN AND METHODS We analyzed two prospective observational cohorts of patients with CAP in Barcelona and Rome who were admitted to intensive care with a high inflammatory response. Propensity score (PS) matching was used to obtain balance among the baseline variables in both groups, and we excluded patients with viral pneumonia or who received hydrocortisone. RESULTS Of the 610 patients admitted with severe CAP, 198 (32%) received corticosteroids and 387 had major criteria for severe CAP. All patients had a baseline serum C-reactive protein above 15 mg/dL. Patients who received corticosteroids were more commonly male, had more comorbidities (e.g., cancer or chronic obstructive pulmonary disease), and presented with significantly higher sequential organ failure assessment scores. Eighty-nine patients met major severity criteria (invasive mechanical ventilation and/or septic shock) and were matched per group. Twenty-eight-day mortality was lower among patients receiving corticosteroids (16 patients, 18%) than among those not receiving them (28 patients, 31%; p = 0.037). After PS matching, corticosteroid therapy reduced the 28-day mortality risk in patients who met major severity criteria (hazard ratio (HR) 0.53, 95% confidence interval (CI) 0.29-0.98) (p = 0.043). In patients who did not meet major severity criteria, no benefits were observed with corticosteroid use (HR 0.88 (95%CI 0.32-2.36). CONCLUSIONS Corticosteroid treatment may be of benefit for patients with CAP who have septic shock and/or a high inflammatory response and requirement for invasive mechanical ventilation. Corticosteroids appear to have no impact on mortality when these features are not present.
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Affiliation(s)
- A Ceccato
- Ciber de Enfermedades Respiratorias (Ciberes, CB06/06/0028), Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), University of Barcelona (UB), Barcelona, Spain
| | - A Russo
- Department of Public Health and Infectious Diseases, Policlinico Umberto I, "Sapienza" University of Rome, Rome, Italy
| | - E Barbeta
- Ciber de Enfermedades Respiratorias (Ciberes, CB06/06/0028), Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), University of Barcelona (UB), Barcelona, Spain
- Department of Pneumology, Institut Clinic de Respiratori, Hospital Clinic of Barcelona, Villarroel 170, 08036, Barcelona, Spain
| | - P Oscanoa
- Ciber de Enfermedades Respiratorias (Ciberes, CB06/06/0028), Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), University of Barcelona (UB), Barcelona, Spain
- Department of Pneumology, Institut Clinic de Respiratori, Hospital Clinic of Barcelona, Villarroel 170, 08036, Barcelona, Spain
| | - G Tiseo
- Infectious Diseases Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - A Gabarrus
- Ciber de Enfermedades Respiratorias (Ciberes, CB06/06/0028), Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), University of Barcelona (UB), Barcelona, Spain
- Department of Pneumology, Institut Clinic de Respiratori, Hospital Clinic of Barcelona, Villarroel 170, 08036, Barcelona, Spain
| | - P Di Giannatale
- Department of Medical, Oral and Biotechnological Sciences, School of Medicine and Health Sciences, Section of Anesthesia Analgesia, Perioperative and Intensive Care, SS. Annunziata Hospital, Gabriele d'Annunzio University of Chieti-Pescara, Chieti, Italy
| | - S Nogas
- Dipartimento Scienze Chirurgiche E Diagnostiche Integrate (DISC), Università Degli Studi Di Genova, Genova, Italy
| | - C Cilloniz
- Ciber de Enfermedades Respiratorias (Ciberes, CB06/06/0028), Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), University of Barcelona (UB), Barcelona, Spain
- Department of Pneumology, Institut Clinic de Respiratori, Hospital Clinic of Barcelona, Villarroel 170, 08036, Barcelona, Spain
| | - F Menichetti
- Infectious Diseases Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - M Ferrer
- Ciber de Enfermedades Respiratorias (Ciberes, CB06/06/0028), Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), University of Barcelona (UB), Barcelona, Spain
- Department of Pneumology, Institut Clinic de Respiratori, Hospital Clinic of Barcelona, Villarroel 170, 08036, Barcelona, Spain
| | - M Niederman
- Division of Pulmonary and Critical Care Medicine, Weill Cornell Medical College, New York Presbyterian/Weill Cornell Medical Center, New York, NY, USA
| | - M Falcone
- Infectious Diseases Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - A Torres
- Ciber de Enfermedades Respiratorias (Ciberes, CB06/06/0028), Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), University of Barcelona (UB), Barcelona, Spain.
- Department of Pneumology, Institut Clinic de Respiratori, Hospital Clinic of Barcelona, Villarroel 170, 08036, Barcelona, Spain.
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Laterre PF, Sánchez-García M, van der Poll T, de la Rosa O, Cadogan KA, Lombardo E, François B. A phase Ib/IIa, randomised, double-blind, multicentre trial to assess the safety and efficacy of expanded Cx611 allogeneic adipose-derived stem cells (eASCs) for the treatment of patients with community-acquired bacterial pneumonia admitted to the intensive care unit. BMC Pulm Med 2020; 20:309. [PMID: 33238991 PMCID: PMC7686829 DOI: 10.1186/s12890-020-01324-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 10/22/2020] [Indexed: 12/12/2022] Open
Abstract
Background Community-acquired bacterial pneumonia (CABP) can lead to sepsis and is associated with high mortality rates in patients presenting with shock and/or respiratory failure and who require mechanical ventilation and admission to intensive care units, thus reflecting the limited effectiveness of current therapy. Preclinical studies support the efficacy of expanded allogeneic adipose-derived mesenchymal stem cells (eASCs) in the treatment of sepsis. In this study, we aim to test the safety, tolerability and efficacy of eASCs as adjunctive therapy in patients with severe CABP (sCABP). Methods In addition to standard of care according to local guidelines, we will administer eASCs (Cx611) or placebo intravenously as adjunctive therapy to patients with sCABP. Enrolment is planned for approximately 180 patients who will be randomised to treatment groups in a 1:1 ratio according to a pre-defined randomization list. An equal number of patients is planned for allocation to each group. Cx611 will be administered on Day 1 and on Day 3 at a dose of 160 million cells (2 million cells / mL, total volume 80 mL) through a 20–30 min (240 mL/hr) intravenous (IV) central line infusion after dilution with Ringer Lactate solution. Placebo (Ringer Lactate) will also be administered through a 20–30 min (240 mL/hr) IV central line infusion at the same quantity (total volume of 80 mL) and following the same schedule as the active treatment. The study was initiated in January 2017 and approved by competent authorities and ethics committees in Belgium, Spain, Lithuania, Italy, Norway and France; monitoring will be performed at regular intervals. Funding is from the European Union’s Horizon 2020 Research and Innovation Program. Discussion SEPCELL is the first trial to assess the effects of eASCs in sCABP. The data generated will advance understanding of the mode of action of Cx611 and will provide evidence on the safety, tolerability and efficacy of Cx611 in patients with sCABP. These data will be critical for the design of future confirmatory clinical investigations and will assist in defining endpoints, key biomarkers of interest and sample size determination. Trial registration NCT03158727, retrospectively registered on 9 May 2017. Supplementary Information The online version contains supplementary material available at 10.1186/s12890-020-01324-2.
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Affiliation(s)
- Pierre-François Laterre
- Intensive Care Unit, St Luc University Hospital, Université Catholique de Louvain, 10 avenue, 1200, Brussels, Belgium.
| | | | - Tom van der Poll
- The Center of Experimental and Molecular Medicine, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Olga de la Rosa
- Takeda Madrid, Cell Therapy Technology Center, Tres Cantos, Spain
| | | | | | - Bruno François
- Intensive Care Unit, and Inserm CIC1435 & UMR1092, Dupuytren University Hospital, Limoges, France
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4
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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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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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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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Gavrilovic S, Andrijevic A, Mujakovic A, Odeyemi Y, Paralija B, Gajic O. Adjunct corticosteroid treatment in patients with pneumonia: A precision medicine approach. Bosn J Basic Med Sci 2019; 19:315-320. [PMID: 30640592 PMCID: PMC6868487 DOI: 10.17305/bjbms.2019.3977] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 12/18/2018] [Indexed: 01/29/2023] Open
Abstract
Pneumonia is the leading infectious cause of death worldwide. While inflammation is critically important in host response to microbial invasion, exaggerated inflammation can damage the lungs, contributing to respiratory failure and mortality. Corticosteroids are effective in reducing inflammation and can also cause immune suppression. Presently, clinicians are unable to reliably distinguish between exaggerated and appropriate immune response and thus cannot rapidly identify patients most likely to benefit from adjunctive corticosteroids. In this review, we propose a biomarker-guided, precision medicine approach to corticosteroid treatment, aimed to give these medications at appropriate dose and time and only to patients who have exaggerated inflammation.
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Affiliation(s)
- Srdjan Gavrilovic
- Intensive Care Unit, Institute for Pulmonary Diseases of Vojvodina, Sremska Kamenica, Serbia Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia.
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Chalmers S, Khawaja A, Wieruszewski PM, Gajic O, Odeyemi Y. Diagnosis and treatment of acute pulmonary inflammation in critically ill patients: The role of inflammatory biomarkers. World J Crit Care Med 2019. [DOI: 10.5492/wjccm.v8.i5.74] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Chalmers S, Khawaja A, Wieruszewski PM, Gajic O, Odeyemi Y. Diagnosis and treatment of acute pulmonary inflammation in critically ill patients: The role of inflammatory biomarkers. World J Crit Care Med 2019; 8:59-71. [PMID: 31559145 PMCID: PMC6753396 DOI: 10.5492/wjccm.v8.i5.59] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 07/02/2019] [Accepted: 08/06/2019] [Indexed: 02/06/2023] Open
Abstract
Pneumonia and acute respiratory distress syndrome are common and important causes of respiratory failure in the intensive care unit with a significant impact on morbidity, mortality and health care utilization despite early antimicrobial therapy and lung protective mechanical ventilation. Both clinical entities are characterized by acute pulmonary inflammation in response to direct or indirect lung injury. Adjunct anti-inflammatory treatment with corticosteroids is increasingly used, although the evidence for benefit is limited. The treatment decisions are based on radiographic, clinical and physiological variables without regards to inflammatory state. Current evidence suggests a role of biomarkers for the assessment of severity, and distinguishing sub-phenotypes (hyper-inflammatory versus hypo-inflammatory) with important prognostic and therapeutic implications. Although many inflammatory biomarkers have been studied the most common and of interest are C-reactive protein, procalcitonin, and pro-inflammatory cytokines including interleukin 6. While extensively studied as prognostic tools (prognostic enrichment), limited data are available for the role of biomarkers in determining appropriate initiation, timing and dosing of adjunct anti-inflammatory treatment (predictive enrichment).
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Affiliation(s)
- Sarah Chalmers
- Multidisciplinary Epidemiology and Translational Research in Intensive Care Group, Mayo Clinic, Rochester, MN 55905, United States
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN 55905, United States
| | - Ali Khawaja
- Multidisciplinary Epidemiology and Translational Research in Intensive Care Group, Mayo Clinic, Rochester, MN 55905, United States
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN 55905, United States
| | - Patrick M Wieruszewski
- Multidisciplinary Epidemiology and Translational Research in Intensive Care Group, Mayo Clinic, Rochester, MN 55905, United States
- Department of Pharmacy, Mayo Clinic, Rochester, MN 55905, United States
| | - Ognjen Gajic
- Multidisciplinary Epidemiology and Translational Research in Intensive Care Group, Mayo Clinic, Rochester, MN 55905, United States
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN 55905, United States
| | - Yewande Odeyemi
- Multidisciplinary Epidemiology and Translational Research in Intensive Care Group, Mayo Clinic, Rochester, MN 55905, United States
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN 55905, United States
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Lloyd M, Karahalios A, Janus E, Skinner EH, Haines T, De Silva A, Lowe S, Shackell M, Ko S, Desmond L, Karunajeewa H. Effectiveness of a Bundled Intervention Including Adjunctive Corticosteroids on Outcomes of Hospitalized Patients With Community-Acquired Pneumonia: A Stepped-Wedge Randomized Clinical Trial. JAMA Intern Med 2019; 179:1052-1060. [PMID: 31282921 PMCID: PMC6618815 DOI: 10.1001/jamainternmed.2019.1438] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
IMPORTANCE Community-acquired pneumonia remains a leading cause of hospitalization, mortality, and health care costs worldwide. Randomized clinical trials support the use of adjunctive corticosteroids, early progressive mobilization, antibiotic switching rules, and dietary interventions in improving outcomes. However, it is uncertain whether implementing these interventions will translate into effectiveness under routine health care conditions. OBJECTIVE To evaluate the effectiveness of a bundle of evidence-supported treatments under conditions of routine care in a representative population hospitalized for community-acquired pneumonia. DESIGN, SETTING, AND PARTICIPANTS A double-blind, stepped-wedge, cluster-randomized clinical trial with 90-day follow-up was conducted between August 1, 2016, and October 29, 2017, in the general internal medicine service at 2 tertiary hospitals in Melbourne, Australia, among a consecutive sample of patients with community-acquired pneumonia. The primary analysis and preparation of results took place between May 14 and November 25, 2018. INTERVENTIONS Treating clinical teams were advised to prescribe prednisolone acetate, 50 mg/d, for 7 days (in the absence of any contraindication) and de-escalate from parenteral to oral antibiotics according to standardized criteria. Algorithm-guided early mobilization and malnutrition screening and treatment were also implemented. MAIN OUTCOMES AND MEASURES Hospital length of stay, mortality, readmission, and intervention-associated adverse events (eg, gastrointestinal bleeding and hyperglycemia). RESULTS A total of 917 patients were screened, and 816 (351 women and 465 men; mean [SD] age, 76 [13] years) were included in the intention-to-treat analysis, with 401 patients receiving the intervention and 415 patients in the control group. An unadjusted geometric mean ratio of 0.95 (95% CI, 0.78-1.16) was observed for the difference in length of stay (days) between the intervention and control groups. Similarly, no significant differences were observed for the secondary outcomes of mortality and readmission, and the results remained unchanged after further adjustment for sex and age. The study reported higher proportions of gastrointestinal bleeding in the intervention group (9 [2.2%]) compared with the controls (3 [0.7%]), with an unadjusted estimated difference in mean proportions of 0.008 (95% CI, 0.005-0.010). CONCLUSIONS AND RELEVANCE This bundled intervention including adjunctive corticosteroids demonstrated no evidence of effectiveness and resulted in a higher incidence of gastrointestinal bleeding. Efficacy of individual interventions demonstrated in clinical trials may not necessarily translate into effectiveness when implemented in combination and may even result in net harm. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT02835040.
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Affiliation(s)
- Melanie Lloyd
- Department of Physiotherapy, Western Health, The University of Melbourne, Melbourne, Australia.,Department of Medicine, Western Health, University of Melbourne, Melbourne, Australia
| | - Amalia Karahalios
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Australia
| | - Edward Janus
- Department of Medicine, Western Health, University of Melbourne, Melbourne, Australia.,General Internal Medicine Unit, Western Health, The University of Melbourne, Melbourne, Australia
| | - Elizabeth H Skinner
- Department of Physiotherapy, Western Health, The University of Melbourne, Melbourne, Australia.,School of Primary and Allied Health Care, Monash University, Melbourne, Australia
| | - Terry Haines
- School of Primary and Allied Health Care, Monash University, Melbourne, Australia
| | - Anurika De Silva
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Australia
| | - Stephanie Lowe
- Department of Physiotherapy, Western Health, The University of Melbourne, Melbourne, Australia
| | - Melina Shackell
- Department of Physiotherapy, Western Health, The University of Melbourne, Melbourne, Australia
| | - Soe Ko
- General Internal Medicine Unit, Western Health, The University of Melbourne, Melbourne, Australia
| | - Lucy Desmond
- General Internal Medicine Unit, Western Health, The University of Melbourne, Melbourne, Australia
| | - Harin Karunajeewa
- Department of Medicine, Western Health, University of Melbourne, Melbourne, Australia.,General Internal Medicine Unit, Western Health, The University of Melbourne, Melbourne, Australia.,Division of Population Health and Immunity, The Walter and Eliza Hall Institute of Medical Research, Parkville, Australia
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11
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Sarkies MN, Skinner EH, Bowles KA, Morris ME, Williams C, O'Brien L, Bardoel A, Martin J, Holland AE, Carey L, White J, Haines TP. A novel counterbalanced implementation study design: methodological description and application to implementation research. Implement Sci 2019; 14:45. [PMID: 31046788 PMCID: PMC6498461 DOI: 10.1186/s13012-019-0896-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 04/15/2019] [Indexed: 12/27/2022] Open
Abstract
Background Implementation research is increasingly being recognised for optimising the outcomes of clinical practice. Frequently, the benefits of new evidence are not implemented due to the difficulties applying traditional research methodologies to implementation settings. Randomised controlled trials are not always practical for the implementation phase of knowledge transfer, as differences between individual and organisational readiness for change combined with small sample sizes can lead to imbalances in factors that impede or facilitate change between intervention and control groups. Within-cluster repeated measure designs could control for variance between intervention and control groups by allowing the same clusters to receive a sequence of conditions. Although in implementation settings, they can contaminate the intervention and control groups after the initial exposure to interventions. We propose the novel application of counterbalanced design to implementation research where repeated measures are employed through crossover, but contamination is averted by counterbalancing different health contexts in which to test the implementation strategy. Methods In a counterbalanced implementation study, the implementation strategy (independent variable) has two or more levels evaluated across an equivalent number of health contexts (e.g. community-acquired pneumonia and nutrition for critically ill patients) using the same outcome (dependent variable). This design limits each cluster to one distinct strategy related to one specific context, and therefore does not overburden any cluster to more than one focussed implementation strategy for a particular outcome, and provides a ready-made control comparison, holding fixed. The different levels of the independent variable can be delivered concurrently because each level uses a different health context within each cluster to avoid the effect of treatment contamination from exposure to the intervention or control condition. Results An example application of the counterbalanced implementation design is presented in a hypothetical study to demonstrate the comparison of ‘video-based’ and ‘written-based’ evidence summary research implementation strategies for changing clinical practice in community-acquired pneumonia and nutrition in critically ill patient health contexts. Conclusion A counterbalanced implementation study design provides a promising model for concurrently investigating the success of research implementation strategies across multiple health context areas such as community-acquired pneumonia and nutrition for critically ill patients. Electronic supplementary material The online version of this article (10.1186/s13012-019-0896-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Mitchell N Sarkies
- School of Primary and Allied Health Care, Monash University, Building G Peninsula Campus, McMahons Road, Frankston, Victoria, 3199, Australia. .,Allied Health Research Unit, Monash Health, 400 Warrigal Road, Cheltenham, Victoria, 3092, Australia. .,Department of Physiotherapy, Monash Health, 400 Warrigal Road, Cheltenham, Victoria, 3092, Australia.
| | - Elizabeth H Skinner
- Allied Health Research Unit, Monash Health, 400 Warrigal Road, Cheltenham, Victoria, 3092, Australia
| | - Kelly-Ann Bowles
- Department of Community Emergency Health and Paramedic Practice, Monash University, Building H Peninsula Campus, McMahons Road, Frankston, Victoria, 3199, Australia
| | - Meg E Morris
- La Trobe Centre for Sport and Exercise Medicine Research, La Trobe University, Bundoora, Victoria, 3086, Australia.,North Eastern Rehabilitation Centre, Healthscope, Ivanhoe, Victoria, 3079, Australia
| | - Cylie Williams
- Peninsula Health, 4 Hastings Road, Frankston, Victoria, 3199, Australia
| | - Lisa O'Brien
- Department of Occupational Therapy, Monash University, Building G Peninsula Campus, McMahons Road, Frankston, Victoria, 3199, Australia
| | - Anne Bardoel
- Department of Management and Marketing, Swinburne University, BA Buidling John Street, Hawthorn Campus, Hawthorn, Victoria, 3122, Australia
| | - Jenny Martin
- Swinburne University, John Street, Hawthorn, Victoria, 3122, Australia
| | - Anne E Holland
- Alfred Health and La Trobe University, 99 Commercial Road, Melbourne, Victoria, 3004, Australia
| | - Leeanne Carey
- Occupational Therapy, School of Allied Health, La Trobe University, Bundoora, Victoria, 3086, Australia.,Neurorehabilitation and Recovery, Melbourne Brain Centre, Florey Institute of Neuroscience and Mental Health, 245 Burgundy Street, Heidelberg, Victoria, 3084, Australia
| | - Jennifer White
- School of Primary and Allied Health Care, Monash University, Building G Peninsula Campus, McMahons Road, Frankston, Victoria, 3199, Australia
| | - Terry P Haines
- School of Primary and Allied Health Care, Monash University, Building G Peninsula Campus, McMahons Road, Frankston, Victoria, 3199, Australia
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Esposito MC, Santos ALA, Bonfilio R, de Araújo MB. A Critical Review of Analytical Methods in Pharmaceutical Matrices for Determination of Corticosteroids. Crit Rev Anal Chem 2019; 50:111-124. [PMID: 30869528 DOI: 10.1080/10408347.2019.1581050] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Corticosteroids are a class of hormones released by the adrenal cortex, which includes glucocorticoids and mineralocorticoids. Glucocorticoids have an important role in the metabolism of carbohydrates, proteins and calcium and effective anti-inflammatory and immunosuppressive activity. Due to their intense immunomodulatory and anti-inflammatory activity, glucocorticoids are used in the treatment of various inflammatory, malignant, allergic conditions such as rhinitis, asthma, dermatological, rheumatic, ophthalmic and neurological diseases, as well as after organ transplants. They are the most widely prescribed drugs in the world. The objective of this review is to provide an overview of the analytical methods in pharmaceutical matrices for determination of corticosteroids. In this study, the predominance of liquid chromatography methods for the analysis of corticosteroids from pharmaceutical products is evident for both liquid and semisolid dosage forms as well as for solids. The same can be said for topical, oral and parenteral formulations. Methods such as spectrophotometry are also used, but given the advantages of chromatographic methods such as better selectivity and sensitivity, they have become the choice for analysis of these drugs, however, most methods still do not meet the credentials of "green chemistry."
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Affiliation(s)
- Milena Carla Esposito
- Department of Food and Drug Administration, Faculty of Pharmaceutical Sciences, Federal University of Alfenas, Alfenas, Minas Gerais, Brazil
| | | | - Rudy Bonfilio
- Department of Food and Drug Administration, Faculty of Pharmaceutical Sciences, Federal University of Alfenas, Alfenas, Minas Gerais, Brazil
| | - Magali Benjamim de Araújo
- Department of Food and Drug Administration, Faculty of Pharmaceutical Sciences, Federal University of Alfenas, Alfenas, Minas Gerais, Brazil
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13
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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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14
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Torres A, Chalmers JD, Dela Cruz CS, Dominedò C, Kollef M, Martin-Loeches I, Niederman M, Wunderink RG. Challenges in severe community-acquired pneumonia: a point-of-view review. Intensive Care Med 2019; 45:159-171. [PMID: 30706119 PMCID: PMC7094947 DOI: 10.1007/s00134-019-05519-y] [Citation(s) in RCA: 91] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 01/04/2019] [Indexed: 12/28/2022]
Abstract
Purpose Severe community-acquired pneumonia (SCAP) is still associated with substantial morbidity and mortality. In this point-of-view review paper, a group of experts discuss the main controversies in SCAP: the role of severity scores to guide patient settings of care and empiric antibiotic therapy; the emergence of pathogens outside the core microorganisms of CAP; viral SCAP; the best empirical treatment; septic shock as the most lethal complication; and the need for new antibiotics. Methods For all topics, the authors describe current controversies and evidence and provide recommendations and suggestions for future research. Evidence was based on meta-analyses, most recent RCTs and recent interventional or observational studies. Recommendations were reached by consensus of all the authors. Results and conclusions The IDSA/ATS criteria remain the most pragmatic tool to predict ICU admission. The authors recommend a combination of a beta-lactam/beta-lactamase inhibitor or a third G cephalosporin plus a macrolide in most SCAP patients, and to empirically cover PES (P. aeruginosa, extended spectrum beta-lactamase producing Enterobacteriaceae, methicillin-resistant S. aureus) pathogens when at least two specific risk factors are present. In patients with influenza CAP, the authors recommend the use of oseltamivir and avoidance of the use of steroids. Corticosteroids can be used in case of refractory shock and high systemic inflammatory response.
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Affiliation(s)
- Antoni Torres
- Department of Pulmonary Medicine, Hospital Clinic of Barcelona, C/Villarroel 170, 08036, Barcelona, Spain.
- August Pi i Sunyer Biomedical Research Institute, IDIBAPS, University of Barcelona, Barcelona, Spain.
- Biomedical Research Networking Centres in Respiratory Diseases (Ciberes), Barcelona, Spain.
| | - James D Chalmers
- Division of Molecular and Clinical Medicine, University of Dundee, Dundee, UK
| | - Charles S Dela Cruz
- Section of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine and Microbial Pathogenesis, Center of Pulmonary Infection Research and Treatment, Yale University School of Medicine, New Haven, CT, USA
| | - Cristina Dominedò
- Department of Anesthesiology and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Marin Kollef
- Division of Pulmonary and Critical Care Medicine, Barnes-Jewish Hospital, St. Louis, MO, USA
| | - Ignacio Martin-Loeches
- Biomedical Research Networking Centres in Respiratory Diseases (Ciberes), Barcelona, Spain
- St. James's Hospital, Multidisciplinary Intensive Care Research Organization (MICRO), Dublin, Ireland
| | - Michael Niederman
- Weill Cornell Medical College and New York Presbyterian/Weill Cornell Medical Center, New York City, USA
| | - Richard G Wunderink
- Pulmonary and Critical Care Division, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Pliakos EE, Andreatos N, Tansarli GS, Ziakas PD, Mylonakis E. The Cost-Effectiveness of Corticosteroids for the Treatment of Community-Acquired Pneumonia. Chest 2018; 155:787-794. [PMID: 30448195 DOI: 10.1016/j.chest.2018.11.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 10/12/2018] [Accepted: 11/05/2018] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The use of corticosteroids as adjunct treatment for community-acquired pneumonia (CAP) is associated with potential clinical benefits. The aim of this study was to evaluate the cost-effectiveness of this approach. METHODS We constructed a decision-analytic model comparing the use of corticosteroids + antibiotics with that of placebo + antibiotics for the treatment of CAP. Cost-effectiveness was determined by calculating deaths averted and incremental cost-effectiveness ratios. Uncertainty was addressed by plotting cost-effectiveness planes and acceptability curves for various willingness-to-pay thresholds. RESULTS In the base-case analysis, corticosteroids + antibiotics resulted in savings of $142,795 per death averted. In the probabilistic analysis, at a willingness to pay of $50,000, corticosteroids + antibiotics had a 86.4% chance of being cost-effective compared with placebo + antibiotics. In cost-effectiveness acceptability curves, the corticosteroids + antibiotics strategy was cost-effective in 87.6% to 94.3% of simulations compared with the placebo + antibiotics strategy for a willingness to pay ranging from $0 to $50,000. In patients with severe CAP (Pneumonia Severity Index classes IV/V) the corticosteroids + antibiotics strategy resulted in savings of $70,587 and had a 82.6% chance of being cost-effective compared with the placebo + antibiotics strategy. CONCLUSIONS The use of corticosteroids + antibiotics is a cost-effective strategy and results in considerable health care cost-savings, especially among patients with severe CAP (Pneumonia Severity Index classes IV/V).
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Affiliation(s)
- Elina Eleftheria Pliakos
- Infectious Diseases Division, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI
| | - Nikolaos Andreatos
- Infectious Diseases Division, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI
| | - Giannoula S Tansarli
- Infectious Diseases Division, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI
| | - Panayiotis D Ziakas
- Infectious Diseases Division, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI
| | - Eleftherios Mylonakis
- Infectious Diseases Division, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI.
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16
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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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17
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Garnacho-Montero J, Barrero-García I, Gómez-Prieto MDG, Martín-Loeches I. Severe community-acquired pneumonia: current management and future therapeutic alternatives. Expert Rev Anti Infect Ther 2018; 16:667-677. [DOI: 10.1080/14787210.2018.1512403] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Jose Garnacho-Montero
- Intensive Care Clinical Unit, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - Irene Barrero-García
- Intensive Care Clinical Unit, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | | | - Ignacio Martín-Loeches
- Department of Anaesthesia and Critical Care, St James University Hospital, Trinity Centre for Health Sciences, Multidisciplinary Intensive Care Research Organization (MICRO), Dublin, Ireland
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18
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Torres A, Ferrer M, Niederman MS. Adjuvant therapies in critical care: steroids in community-acquired pneumonia. Intensive Care Med 2018; 44:478-481. [PMID: 29071427 PMCID: PMC7095014 DOI: 10.1007/s00134-017-4967-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 10/11/2017] [Indexed: 12/15/2022]
Affiliation(s)
- Antoni Torres
- Department of Pneumology, Respiratory Institute, Hospital Clinic of Barcelona, University of Barcelona (UB), Villarroel 170, 08036, Barcelona, Spain.
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.
- Centro de Investigación Biomedica En Red-Enfermedades Respiratorias (CibeRes, CB06/06/0028), Barcelona, Spain.
| | - Miquel Ferrer
- Department of Pneumology, Respiratory Institute, Hospital Clinic of Barcelona, University of Barcelona (UB), Villarroel 170, 08036, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Centro de Investigación Biomedica En Red-Enfermedades Respiratorias (CibeRes, CB06/06/0028), Barcelona, Spain
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19
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Skinner EH, Lloyd M, Janus E, Ong ML, Karahalios A, Haines TP, Kelly AM, Shackell M, Karunajeewa H. The IMPROVE-GAP Trial aiming to improve evidence-based management of community-acquired pneumonia: study protocol for a stepped-wedge randomised controlled trial. Trials 2018; 19:88. [PMID: 29402313 PMCID: PMC5800278 DOI: 10.1186/s13063-017-2407-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 12/13/2017] [Indexed: 12/20/2022] Open
Abstract
Background Community-acquired pneumonia is a leading worldwide cause of hospital admissions and healthcare resource consumption. The largest proportion of hospitalisations now occurs in older patients, with high rates of multimorbidity and complex care needs. In Australia, this population is usually managed by hospital inpatient general internal medicine units. Adherence to consensus best-practice guidelines is poor. Ensuring evidence-based care and reducing length of stay may improve patient outcomes and reduce organisational costs. This study aims to evaluate an alternative model of care designed to improve adherence to four Level 1 or 2 evidence-supported interventions (routine corticosteroids, early switch to oral antibiotics, early mobilisation and routine malnutrition screening). Methods/Design The IMPROVing Evidence-based treatment Gaps and outcomes in community-Acquired Pneumonia (IMPROVE-GAP) trial is a pragmatic, investigator-initiated, stepped-wedge randomised trial. Patients hospitalised under a general internal medicine unit who meet a standard case definition for community-acquired pneumonia will be included. Eight general internal medicine units at two Australian hospitals in a single health service will be randomised using concealed allocation to: (i) usual medical, nursing and allied health care delivered according to existing organisational practice or (ii) care supported by a dedicated “community-acquired pneumonia service”: a multidisciplinary team deploying algorithm-based implementation of a bundle of the four evidence-based interventions. The primary outcome measure will be length of hospital stay. Secondary outcome measures include inpatient mortality, 30 and 90 day readmission rates and mortality and health-service utilisation costs. Protocol adherence will be measured and reported, and serious adverse events (rates of hyperglycaemia requiring new insulin; falls during mobilisation) will be collected and reported. Discussion IMPROVE-GAP represents an important and unique precedent for testing a new service-delivery model for improving compliance with a number of evidence-based interventions. Its stepped-wedge randomised controlled trial design provides a means to address some significant ethical, organisational and other methodological challenges to evaluating the effectiveness of health-service interventions in complex hospital populations. The new service-delivery model will effectively be fully implemented by trial completion, facilitating rapid, seamless translation into practice should care outcomes be superior. This trial is currently recruiting. Trial registration ClinicalTrials.gov, NCT02835040. Prospectively registered on 22 May 2016. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2407-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Elizabeth H Skinner
- Department of Physiotherapy, Western Health, 160 Gordon St, Footscray, Victoria, 3011, Australia. .,Department of Physiotherapy, Melbourne School of Health Sciences, University of Melbourne, Parkville, Victoria, 3010, Australia. .,Department of Physiotherapy, School of Primary Care, Faculty of Medicine, Nursing and Health Sciences, Monash University, Frankston, Victoria, 3199, Australia.
| | - Melanie Lloyd
- Department of Physiotherapy, Western Health, 160 Gordon St, Footscray, Victoria, 3011, Australia
| | - Edward Janus
- General Internal Medicine Unit, Western Health, Sunshine Hospital, St Albans, Victoria, 3021, Australia.,Department of Medicine Melbourne Medical School - Western Precinct, University of Melbourne, Sunshine Hospital, St Albans, Victoria, 3021, Australia
| | - May Lea Ong
- General Internal Medicine Unit, Western Health, Sunshine Hospital, St Albans, Victoria, 3021, Australia
| | - Amalia Karahalios
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Parkville, Victoria, 3010, Australia
| | - Terry P Haines
- Department of Physiotherapy, School of Primary Care, Faculty of Medicine, Nursing and Health Sciences, Monash University, Frankston, Victoria, 3199, Australia
| | - Anne-Maree Kelly
- Department of Medicine Melbourne Medical School - Western Precinct, University of Melbourne, Sunshine Hospital, St Albans, Victoria, 3021, Australia.,Joseph Epstein Centre for Emergency Medicine Research, Western Health, Sunshine Hospital, St Albans, Victoria, 3021, Australia
| | - Melina Shackell
- Department of Physiotherapy, Western Health, 160 Gordon St, Footscray, Victoria, 3011, Australia.,Department of Physiotherapy, Melbourne School of Health Sciences, University of Melbourne, Parkville, Victoria, 3010, Australia
| | - Harin Karunajeewa
- General Internal Medicine Unit, Western Health, Sunshine Hospital, St Albans, Victoria, 3021, Australia.,Department of Medicine Melbourne Medical School - Western Precinct, University of Melbourne, Sunshine Hospital, St Albans, Victoria, 3021, Australia.,The Walter and Eliza Hall Institute of Medical Research, G Royal Parade, Parkville, Victoria, 3052, Australia
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20
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Badiei A, Chan KP, Lee YCG, Waterer GW. Corticosteroids in Lung and Pleural Infections. CURRENT PULMONOLOGY REPORTS 2018. [DOI: 10.1007/s13665-018-0197-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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21
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Wu WF, Fang Q, He GJ. Efficacy of corticosteroid treatment for severe community-acquired pneumonia: A meta-analysis. Am J Emerg Med 2018; 36:179-184. [DOI: 10.1016/j.ajem.2017.07.050] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Revised: 07/14/2017] [Accepted: 07/14/2017] [Indexed: 02/08/2023] Open
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Abstract
BACKGROUND Pneumonia is a common and potentially serious illness. Corticosteroids have been suggested for the treatment of different types of infection, however their role in the treatment of pneumonia remains unclear. This is an update of a review published in 2011. OBJECTIVES To assess the efficacy and safety of corticosteroids in the treatment of pneumonia. SEARCH METHODS We searched the Cochrane Acute Respiratory Infections Group's Specialised Register, CENTRAL, MEDLINE, Embase, and LILACS on 3 March 2017, together with relevant conference proceedings and references of identified trials. We also searched three trials registers for ongoing and unpublished trials. SELECTION CRITERIA We included randomised controlled trials (RCTs) that assessed systemic corticosteroid therapy, given as adjunct to antibiotic treatment, versus placebo or no corticosteroids for adults and children with pneumonia. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. Two review authors independently assessed risk of bias and extracted data. We contacted study authors for additional information. We estimated risk ratios (RR) with 95% confidence intervals (CI) and pooled data using the Mantel-Haenszel fixed-effect model when possible. MAIN RESULTS We included 17 RCTs comprising a total of 2264 participants; 13 RCTs included 1954 adult participants, and four RCTs included 310 children. This update included 12 new studies, excluded one previously included study, and excluded five new trials. One trial awaits classification.All trials limited inclusion to inpatients with community-acquired pneumonia (CAP), with or without healthcare-associated pneumonia (HCAP). We assessed the risk of selection bias and attrition bias as low or unclear overall. We assessed performance bias risk as low for nine trials, unclear for one trial, and high for seven trials. We assessed reporting bias risk as low for three trials and high for the remaining 14 trials.Corticosteroids significantly reduced mortality in adults with severe pneumonia (RR 0.58, 95% CI 0.40 to 0.84; moderate-quality evidence), but not in adults with non-severe pneumonia (RR 0.95, 95% CI 0.45 to 2.00). Early clinical failure rates (defined as death from any cause, radiographic progression, or clinical instability at day 5 to 8) were significantly reduced with corticosteroids in people with severe and non-severe pneumonia (RR 0.32, 95% CI 0.15 to 0.7; and RR 0.68, 95% CI 0.56 to 0.83, respectively; high-quality evidence). Corstocosteroids reduced time to clinical cure, length of hospital and intensive care unit stays, development of respiratory failure or shock not present at pneumonia onset, and rates of pneumonia complications.Among children with bacterial pneumonia, corticosteroids reduced early clinical failure rates (defined as for adults, RR 0.41, 95% CI 0.24 to 0.70; high-quality evidence) based on two small, clinically heterogeneous trials, and reduced time to clinical cure.Hyperglycaemia was significantly more common in adults treated with corticosteroids (RR 1.72, 95% CI 1.38 to 2.14). There were no significant differences between corticosteroid-treated people and controls for other adverse events or secondary infections (RR 1.19, 95% CI 0.73 to 1.93). AUTHORS' CONCLUSIONS Corticosteroid therapy reduced mortality and morbidity in adults with severe CAP; the number needed to treat for an additional beneficial outcome was 18 patients (95% CI 12 to 49) to prevent one death. Corticosteroid therapy reduced morbidity, but not mortality, for adults and children with non-severe CAP. Corticosteroid therapy was associated with more adverse events, especially hyperglycaemia, but the harms did not seem to outweigh the benefits.
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Affiliation(s)
- Anat Stern
- Rambam Health Care CampusDivision of Infectious DiseasesHa‐aliya 8 StHaifaIsrael33705
| | - Keren Skalsky
- Beilinson Hospital, Rabin Medical CenterDepartment of Medicine E39 Jabotinski StreetPetah TikvaIsrael49100
| | - Tomer Avni
- Beilinson Hospital, Rabin Medical CenterDepartment of Medicine E39 Jabotinski StreetPetah TikvaIsrael49100
| | - Elena Carrara
- Policlinico San Matteo HospitalInfectious DiseasesUniversity of PaviaPaviaLombardyItaly27100
| | - Leonard Leibovici
- Beilinson Hospital, Rabin Medical CenterDepartment of Medicine E39 Jabotinski StreetPetah TikvaIsrael49100
| | - Mical Paul
- Rambam Health Care CampusDivision of Infectious DiseasesHa‐aliya 8 StHaifaIsrael33705
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Adjuvant therapies in critical care: steroids to treat infectious diseases. Intensive Care Med 2017; 44:1306-1309. [DOI: 10.1007/s00134-017-5020-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 12/04/2017] [Indexed: 10/18/2022]
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24
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Briel M, Spoorenberg SMC, Snijders D, Torres A, Fernandez-Serrano S, Meduri GU, Gabarrús A, Blum CA, Confalonieri M, Kasenda B, Siemieniuk RAC, Boersma W, Bos WJW, Christ-Crain M. Corticosteroids in Patients Hospitalized With Community-Acquired Pneumonia: Systematic Review and Individual Patient Data Metaanalysis. Clin Infect Dis 2017; 66:346-354. [DOI: 10.1093/cid/cix801] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Accepted: 09/08/2017] [Indexed: 12/14/2022] Open
Affiliation(s)
- Matthias Briel
- Department of Clinical Research, Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Switzerland
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Ontario, Canada
| | | | - Dominic Snijders
- Department of Pulmonology, Spaarne Gasthuis Hospital, Hoofddorp, The Netherlands
| | - Antoni Torres
- Department of Pulmonology, Respiratory Institute, Hospital Clinic of Barcelona, Institut d’Investigacions Biomèdiques August Pi i Sunyer, Ciber de Enfermedades Respiratorias, University of Barcelona
| | - Silvia Fernandez-Serrano
- Department of Respiratory Medicine, Hospital Universitari de Bellvitge, Institut d’Investigació Biomèdica de Bellvitge, University of Barcelona, Spain
| | - G Umberto Meduri
- Department of Pneumology and Respiratory Intensive Care Unit, University Hospital of Cattinara, Trieste, Italy
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Memphis Veterans Affairs Medical Center, Tennessee
| | - Albert Gabarrús
- Department of Pulmonology, Respiratory Institute, Hospital Clinic of Barcelona, Institut d’Investigacions Biomèdiques August Pi i Sunyer, Ciber de Enfermedades Respiratorias, University of Barcelona
| | - Claudine A Blum
- Endocrinology, Diabetology and Metabolism, Department of Internal Medicine and Department of Clinical Research, University Hospital Basel
- Medical University Clinic, Kantonsspital Aarau, Switzerland
| | - Marco Confalonieri
- Department of Pneumology and Respiratory Intensive Care Unit, University Hospital of Cattinara, Trieste, Italy
| | - Benjamin Kasenda
- Department of Clinical Research, Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Switzerland
| | - Reed AC Siemieniuk
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Ontario, Canada
- Department of Medicine, University of Toronto, Ontario, Canada
| | - Wim Boersma
- Department of Pulmonary Diseases, Noordwest Hospital Alkmaar, The Netherlands
| | - Willem Jan W Bos
- Department of Internal Medicine, St. Antonius Hospital, Nieuwegein
| | - Mirjam Christ-Crain
- Endocrinology, Diabetology and Metabolism, Department of Internal Medicine and Department of Clinical Research, University Hospital Basel
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25
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Treat elderly patients hospitalized for community-acquired pneumonia early based on infection severity and risk factors. DRUGS & THERAPY PERSPECTIVES 2017. [DOI: 10.1007/s40267-017-0430-x] [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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26
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Arnold FW. How Antibiotics Should be Prescribed to Hospitalized Elderly Patients with Community-Acquired Pneumonia. Drugs Aging 2017; 34:13-20. [PMID: 27928779 DOI: 10.1007/s40266-016-0423-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Elderly patients hospitalized with community-acquired pneumonia (CAP) should be administered antimicrobials in the emergency department prior to transfer to the ward or intensive care unit (ICU). For ward patients, a β-lactam with a macrolide or a respiratory fluoroquinolone alone should be given to cover typical and atypical pathogens. For ICU patients, a β-lactam with either a macrolide or a fluoroquinolone should be given. Other regimens are indicated if methicillin-resistant Staphylococcus aureus or Pseudomonas aeruginosa is a concern. Patients who are hemodynamically stable and can tolerate oral intake can be considered for switch therapy as well as discharge if other co-morbidities are stable and a safe disposition plan exists. A number of special concerns for the elderly include noting adverse effects from antimicrobials, being watchful of comorbidity exacerbations, and vaccinating for pneumococcus and influenza.
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Affiliation(s)
- Forest W Arnold
- Division of Infectious Diseases, School of Medicine, University of Louisville, 501 E. Broadway, Suite 140 B, Louisville, KY, 40202, USA.
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27
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Boyles TH, Brink A, Calligaro GL, Cohen C, Dheda K, Maartens G, Richards GA, van Zyl Smit R, Smith C, Wasserman S, Whitelaw AC, Feldman C. South African guideline for the management of community-acquired pneumonia in adults. J Thorac Dis 2017; 9:1469-1502. [PMID: 28740661 DOI: 10.21037/jtd.2017.05.31] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Tom H Boyles
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Adrian Brink
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, University of Cape Town, Cape Town, South Africa.,Ampath National Laboratory Services, Milpark Hospital, Johannesburg, South Africa
| | - Greg L Calligaro
- Lung Infection and Immunity Unit, Division of Pulmonology and UCT Lung Institute, University of Cape Town, Cape Town, South Africa
| | - Cheryl Cohen
- Centre for Respiratory Disease and Meningitis, National Institute for Communicable Diseases, Johannesburg, South Africa.,School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Keertan Dheda
- Lung Infection and Immunity Unit, Division of Pulmonology and UCT Lung Institute, University of Cape Town, Cape Town, South Africa
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Guy A Richards
- Department of Critical Care, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Richard van Zyl Smit
- Lung Infection and Immunity Unit, Division of Pulmonology and UCT Lung Institute, University of Cape Town, Cape Town, South Africa
| | | | - Sean Wasserman
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Andrew C Whitelaw
- Division of Medical Microbiology, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa.,National Health Laboratory Service, Tygerberg Hospital, Cape Town, South Africa
| | - Charles Feldman
- Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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28
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Corticosteroids in treating community-acquired pneumonia: has the time really come? Clin Microbiol Infect 2017; 23:276-278. [DOI: 10.1016/j.cmi.2016.09.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Revised: 09/07/2016] [Accepted: 09/10/2016] [Indexed: 11/20/2022]
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29
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Sparham S, Charles PG. Controversies in diagnosis and management of community-acquired pneumonia. Med J Aust 2017; 206:316-319. [PMID: 28403766 DOI: 10.5694/mja16.01463] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Accepted: 02/10/2017] [Indexed: 12/23/2022]
Abstract
Community-acquired pneumonia (CAP) is a common condition; however, it appears to be overdiagnosed. Diagnosing CAP too frequently may be adding to the problems of overuse of antibiotics, such as bacterial resistance in the community and greater costs and complications in individuals. Data support that most patients with non-severe CAP can be treated for 3-5 days; however, most patients with CAP are receiving much longer courses of therapy. Macrolides such as azithromycin have the potential to prolong the QT interval, although large population studies show that this does not appear to result in excess cardiac mortality. CAP is associated with an increase in a variety of cardiac complications, most notably infarctions and worsening cardiac failure, so clinicians should be vigilant for signs and symptoms of these complications, particularly in patients with a history of ischaemic cardiac disease or the presence of cardiac risk factors. Cardiac risk factors should be assessed and managed in patients with CAP over 40 years of age, although there are yet to be data to show that this approach reduces deaths. Corticosteroids may have a slight effect on reducing deaths in patients with severe CAP, but this must be balanced against the significant potential for side effects.
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30
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Chahin A, Opal SM. Severe Pneumonia Caused by Legionella pneumophila: Differential Diagnosis and Therapeutic Considerations. Infect Dis Clin North Am 2017; 31:111-121. [PMID: 28159171 PMCID: PMC7135102 DOI: 10.1016/j.idc.2016.10.009] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Severe legionella pneumonia poses a diagnostic challenge and requires early intervention. Legionnaire's disease can have several presenting signs, symptoms, and laboratory abnormalities that suggest that Legionella pneumophila is the pathogen, but none of these are sufficient to distinguish L pneumophila pneumonia from other respiratory pathogens. L pneumophila is primarily an intracellular pathogen and needs treatment with antibiotics that efficiently enter the intracellular space.
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Affiliation(s)
- Abdullah Chahin
- Critical Care Division, Miriam Hospital, Brown University Alpert School of Medicine, Providence, RI, USA; Infectious Disease Division, Rhode Island Hospital, Brown University Alpert School of Medicine, Providence, RI, USA.
| | - Steven M Opal
- Critical Care Division, Miriam Hospital, Brown University Alpert School of Medicine, Providence, RI, USA; Infectious Disease Division, Rhode Island Hospital, Brown University Alpert School of Medicine, Providence, RI, USA
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31
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Lee KY. Pneumonia, Acute Respiratory Distress Syndrome, and Early Immune-Modulator Therapy. Int J Mol Sci 2017; 18:ijms18020388. [PMID: 28208675 PMCID: PMC5343923 DOI: 10.3390/ijms18020388] [Citation(s) in RCA: 86] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Revised: 01/14/2017] [Accepted: 02/06/2017] [Indexed: 12/21/2022] Open
Abstract
Acute respiratory distress syndrome (ARDS) is caused by infectious insults, such as pneumonia from various pathogens or related to other noninfectious events. Clinical and histopathologic characteristics are similar across severely affected patients, suggesting that a common mode of immune reaction may be involved in the immunopathogenesis of ARDS. There may be etiologic substances that have an affinity for respiratory cells and induce lung cell injury in cases of ARDS. These substances originate not only from pathogens, but also from injured host cells. At the molecular level, these substances have various sizes and biochemical characteristics, classifying them as protein substances and non-protein substances. Immune cells and immune proteins may recognize and act on these substances, including pathogenic proteins and peptides, depending upon the size and biochemical properties of the substances (this theory is known as the protein-homeostasis-system hypothesis). The severity or chronicity of ARDS depends on the amount of etiologic substances with corresponding immune reactions, the duration of the appearance of specific immune cells, or the repertoire of specific immune cells that control the substances. Therefore, treatment with early systemic immune modulators (corticosteroids and/or intravenous immunoglobulin) as soon as possible may reduce aberrant immune responses in the potential stage of ARDS.
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Affiliation(s)
- Kyung-Yil Lee
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea.
- Department of Pediatrics, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Daejeon 34943, Korea.
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32
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Sibila O, Rodrigo-Troyano A, Torres A. Nonantibiotic Adjunctive Therapies for Community-Acquired Pneumonia (Corticosteroids and Beyond): Where Are We with Them? Semin Respir Crit Care Med 2016; 37:913-922. [PMID: 27960215 PMCID: PMC7171709 DOI: 10.1055/s-0036-1593538] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Community-acquired pneumonia (CAP) is a leading cause of hospitalization, morbidity, and mortality. Despite advances in antibiotic treatments, mortality among patients with CAP is still high. For this reason, interest has been focused on nonantibiotic therapeutic measures directed to the host response rather than the microorganism. The development of an efficacious adjunctive treatment has important implications for reducing mortality in CAP. Some clinical studies performed in the last decade have shown a clinically beneficial effect of corticosteroids, possibly by diminishing local and systemic inflammatory host response. Recent meta-analyses showed faster resolution of symptoms, shorter time to clinically stability, reduction of mechanical ventilation needed, and reduction of mortality in the most severe population, although some methodological limitations must be taken into account. In addition, some studies using statins also suggested improved outcomes due to its anti-inflammatory effect in CAP, although this requires further research. Other adjunctive therapies such as immunoglobulins and stem cells are being explored, but are not yet in the stage of clinical trials. In summary, the use of corticosteroids and other adjuvant treatments are promising in CAP, but more studies are needed to determine their impact on mortality.
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Affiliation(s)
- Oriol Sibila
- Respiratory Department, Hospital de la Santa Creu i Sant Pau, Autonomous University of Barcelona (UAB), Barcelona, Spain
- Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain
| | - Ana Rodrigo-Troyano
- Respiratory Department, Hospital de la Santa Creu i Sant Pau, Autonomous University of Barcelona (UAB), Barcelona, Spain
- Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain
| | - Antoni Torres
- Pulmonolgy Department, Respiratory Institute (ICR), Hospital Clinic of Barcelona, Spain
- Centro de Investigación Biomedica En Red - Enfermedades Respiratorias, Barcelona, Spain
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Abstract
PURPOSE OF REVIEW This review covers the outpatient management of pediatric community-acquired pneumonia (CAP), discussing the changing microbiology of CAP since the introduction of the 13-valent pneumococcal conjugate vaccine in 2010, and providing an overview of national guideline recommendations for diagnostic evaluation and treatment. RECENT FINDINGS Rates of invasive pneumococcal disease and pneumococcal antibiotic resistance have plummeted since widespread 13-valent pneumococcal conjugate vaccine immunization. Viruses remain the most common cause of CAP in young children; children over age 5 years have increased rates of Mycoplasma pneumoniae. A recent national guideline offers recommendations for office-based diagnostic evaluation and treatment of pediatric CAP. SUMMARY This review offers a discussion of the above findings with practical recommendations for the office-based practitioner in the evaluation and treatment of an infant (>3 months) or child with suspected CAP.
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Singh K, Jagadeesan R. Controversies in the Management of Community-Acquired Pneumonia. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2016. [DOI: 10.1007/s40138-016-0107-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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35
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Feldman C, Anderson R. Corticosteroids in the adjunctive therapy of community-acquired pneumonia: an appraisal of recent meta-analyses of clinical trials. J Thorac Dis 2016; 8:E162-71. [PMID: 27076965 PMCID: PMC4805802 DOI: 10.21037/jtd.2016.02.43] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Accepted: 01/20/2016] [Indexed: 12/12/2022]
Abstract
Improving the outcome of patients with community-acquired pneumonia (CAP) is an ongoing challenge, even in the setting of significant advances in antimicrobial chemotherapy and critical care. Recognition of the underlying involvement of inflammation-mediated organ dysfunction as a determinant of adverse outcomes in CAP has aroused intense interest in the protective potential of adjunctive anti-inflammatory therapies in CAP, particularly the role of corticosteroids (CS). This is the primary topic of the current review which is focused on an evaluation of the latest meta-analyses encompassing both recent and earlier clinical trials, with particular emphasis on the stringent meta-analysis undertaken by Siemieniuk and colleagues (Ann Intern Med 2015;163:519-528). The review highlights the findings and recommendations of these and related published commentaries/critiques, while providing a brief description of those sub-groups of patients who seemingly stand to benefit most from CS therapy. This is preceded by an overview of the mechanisms of the anti-inflammatory activities of CS, the interactions of these agents with macrolide antibiotics, and the potential benefits and risks of short-term administration of CS, concluding with a succinct appraisal of priority issues for ongoing and future research.
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