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Meta-Analysis
. 2023 Aug;38(11):2593-2606.
doi: 10.1007/s11606-023-08203-6. Epub 2023 Apr 19.

Corticosteroids in Community-Acquired Bacterial Pneumonia: a Systematic Review, Pairwise and Dose-Response Meta-Analysis

Tyler Pitre  1 , Daniyal Abdali  1 , Dipayan Chaudhuri  1 , Stephen M Pastores  2 , Andrea M Nei  3 , Djillali Annane  4 , Bram Rochwerg  1   5 , Dena Zeraatkar  5   6
Affiliations
Meta-Analysis

Corticosteroids in Community-Acquired Bacterial Pneumonia: a Systematic Review, Pairwise and Dose-Response Meta-Analysis

Tyler Pitre et al. J Gen Intern Med. 2023 Aug.

Abstract

Introduction: International guidelines provide heterogenous guidance on use of corticosteroids for community-acquired pneumonia (CAP).

Methods: We performed a systematic review of randomized controlled trials examining corticosteroids in hospitalized adult patients with suspected or probable CAP. We performed a pairwise and dose-response meta-analysis using the restricted maximum likelihood (REML) heterogeneity estimator. We assessed the certainty of the evidence using GRADE methodology and the credibility of subgroups using the ICEMAN tool.

Results: We identified 18 eligible studies that included 4661 patients. Corticosteroids probably reduce mortality in more severe CAP (RR 0.62 [95% CI 0.45 to 0.85]; moderate certainty) with possibly no effect in less severe CAP (RR 1.08 [95% CI 0.83 to 1.42]; low certainty). We found a non-linear dose-response relationship between corticosteroids and mortality, suggesting an optimal dose of approximately 6 mg of dexamethasone (or equivalent) for a duration of therapy of 7 days (RR 0.44 [95% 0.30 to 0.66]). Corticosteroids probably reduce the risk of requiring invasive mechanical ventilation (RR 0.56 [95% CI 0.42 to 74] and probably reduce intensive care unit (ICU) admission (RR 0.65 [95% CI 0.43 to 0.97]) (both moderate certainty). Corticosteroids may reduce the duration of hospitalization and ICU stay (both low certainty). Corticosteroids may increase the risk of hyperglycemia (RR 1.76 [95% CI 1.46 to 2.14]) (low certainty).

Conclusion: Moderate certainty evidence indicates that corticosteroids reduce mortality in patients with more severe CAP, the need for invasive mechanical ventilation, and ICU admission.

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Conflict of interest statement

TP, DC, SMP, AMN, DN, and BR are members of the Society of Critical Care Medicine Corticosteroid Guidelines Focused Update Panel. SMP is the co-Chair of the Society of Critical Care Medicine Corticosteroid Guidelines Focused Update Panel. SMP discloses personal fees for advisory board work from AbbVie, royalty fees from McGraw Hill as textbook editor, and institutional grant support from the National Cancer Institute of the National Institutes of Health under Award Number P30CA008748, RevImmune, BioMerieux, and the Breast Cancer Research Foundation, outside the submitted work. No other authors made any disclosures.

Figures

Figure 1
Figure 1
PRISMA flow diagram for updated systematic reviews.
Figure 2
Figure 2
Forest plot for mortality based on severity subgroup. The left column shows the individual studies included in the meta-analysis, the middle column represents the effect sizes, and the right column shows the individual relative risks and their weight in contributing to the overall estimates.
Figure 3
Figure 3
Forest plot for mortality based on corticosteroid type subgroup. The left column shows the individual studies included in the meta-analysis, the middle column represents the effect sizes, and the right column shows the individual relative risks and their weight in contributing to the overall estimates.
Figure 4
Figure 4
Dose-response curve. The curved purple line represents the non-linear dose-response relationship, and the purple ribbons represent 95% confidence intervals (95% CI). The yellow linear line represents the linear dose-response relationship, and the ribbons represent 95% CI.
See this image and copyright information in PMC

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