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Teaching Points on Hydrocortisone in Severe Community-Acquired Pneumonia (Dequin et al., NEJM 2023)

Clinical Question:

  • Q: Does hydrocortisone reduce 28-day mortality in patients with severe community-acquired pneumonia (CAP) compared to placebo?
    A: Yes, hydrocortisone was shown to reduce 28-day mortality in severe CAP patients in ICU, with 6.2% mortality in the hydrocortisone group versus 11.9% in the placebo group.

Background:

  • Q: Why has steroid use in CAP been controversial?
    A: Recommendations differ among guidelines. ATS/IDSA advises against steroids in severe CAP, while ESICM/SCCM supports their use due to potential benefits. Mixed results from prior studies, such as Meduri et al., have called for further large-scale trials.

Study Design:

  • Q: What type of study design was used?
    A: This was a double-blind, placebo-controlled, multi-center RCT with centralized randomization in a 1:1 ratio.

Population and Setting:

  • Q: What were the main inclusion criteria?
    A: Adults over 18 admitted to ICU with CAP, identified by symptoms like cough and chest pain, and severe criteria such as high pulmonary severity index (PSI > 130) or mechanical ventilation needs.
  • Q: Where and when was the study conducted?
    A: Conducted across 31 French centers from 2015 to 2020.

Intervention:

  • Q: What hydrocortisone regimen was used?
    A: 200 mg/day for 4 days, with possible continuation up to 8 or 14 days based on specific patient criteria and a pre-defined tapering plan.

Outcomes:

  • Q: What was the primary outcome, and what were the results?
    A: The primary outcome was 28-day mortality, which was significantly lower in the hydrocortisone group (6.2% vs 11.9% in placebo, p = 0.006).
  • Q: Did hydrocortisone have any significant effects on secondary outcomes?
    A: Yes, hydrocortisone reduced 90-day mortality, incidence of intubation, and need for vasopressor initiation. However, there was no significant difference in hospital-acquired infections or GI bleeding between groups.

Subgroup Findings:

  • Q: Which subgroups showed additional benefits from hydrocortisone?
    A: Benefits were observed in non-mechanically ventilated patients, those over 65, women, and patients without an identified pathogen.

Strengths and Limitations:

  • Q: What were the strengths of this study?
    A: The study was multi-center, had balanced baseline characteristics, a high adherence to protocol, and minimized selection bias.
  • Q: What were some weaknesses?
    A: It was limited to a single country, had lower mortality numbers than predicted, and faced questions on the optimal steroid regimen. Additionally, pathogen identification was not standardized.

Bottom Line:

  • Q: How might this study impact clinical practice?
    A: This study supports the use of hydrocortisone in severe CAP patients admitted to ICU. It suggests a mortality benefit, which may lead clinicians to consider steroid use in similar cases, pending further validation from larger platform trials.

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