Background: The use of steroids in pneumonia has long been controversial with conflicting data, and the recent ESCAPe randomized controlled trial by Meduri et al. showing no mortality benefit with their use, but likely underpowered due to recruitment issues. The recently published CAPE COD study by Dequin et al. may change the game.

Design: Double-blind, placebo-controlled, multicenter, RCT

• 31 hospitals in France, 2015 to March 2020
• Adults with severe (P:F <300 on 50% FiO2 or NRB, mechanical ventilation, or pulmonary severity index >130) CAP (+symptoms and imaging)
• Notable exclusion criteria: vasopressors, aspiration-related, influenza, chronic steroids (equiv to >15mg prednisolone)

Intervention: Early hydrocortisone within 24 hrs, 200mg/day x 4-8 days depending on improvement, then preset taper

• 800 patients: 401 hydrocortisone, 399 placebo

Primary outcome:  Death at 28 days

• Hydrocortisone 6% vs Placebo 12% (p = 0.006)

Secondary outcomes:

• Death at 90 days: Hydrocortisone 9.3% vs placebo 14.7%
• Decreased cumulative incidence of endotracheal intubation by day 28 (if not initially intubated)
• Decreased cumulative incidence of vasopressor initiation by day 28
• Higher median daily dose insulin in hydrocortisone group
• No difference in rate of hospital acquired infections or GIB

Bottom Line:  The addition of hydrocortisone to antibiotics in severe CAP may decrease need for intubation and development of shock, and in this well-done study, decreased 28 and 90-day mortality. 

References

Meduri GU, Shih MC, Bridges L, et al; ESCAPe Study Group. Low-dose methylprednisolone treatment in critically ill patients with severe community-acquired pneumonia. Intensive Care Med. 2022 Aug;48(8):1009-1023. doi: 10.1007/s00134-022-06684-3. Epub 2022 May 13. PMID: 35723686.

 doi: 10.1056/NEJMoa2215145. Epub ahead of print. PMID: 36942789.