Dexamethasone in community-acquired pneumonia
Authors: Nelson Lee, David SC Hui
Journal: The Lancet (2011)

In a double-blind, placebo-controlled trial, Sabine Meijvis and colleagues1Meijvis SC Hardeman H Remmelts HH et al.Dexamethasone and length of hospital stay in patients with community-acquired pneumonia: a randomised, double-blind, placebo-controlled trial.Lancet. 2011; 377: 2023-2030Summary Full Text Full Text PDF PubMed Scopus (271) Google Scholar found clinical benefit of reduced length of hospital stay when dexamethasone was added to antibiotic treatment in immunocompetent patients with community-acquired pneumonia. However, of the 304 recruited cases, most had bacterial infections such as Streptococcus pneumoniae, and only seven (2·3%) were diagnosed as having influenza pneumonia (nine others [3·0%] had mixed influenza-bacterial infections, mostly S pneumoniae). As such, the results cannot be generalised to community-acquired pneumonia with viral causes. Respiratory viruses are increasingly recognised as major causes of community-acquired pneumonia worldwide (up to about 20%),2Bartlett JG Diagnostic tests for agents of community-acquired pneumonia.Clin Infect Dis. 2011; 52: S296-S304Crossref PubMed Scopus (182) Google Scholar and influenza virus is the most important pathogen, causing excessive hospital admissions and deaths, particularly during the seasonal peaks and pandemics. Evidence suggests that corticosteroid use in influenza pneumonia cannot control excessive inflammation, but compromises the immune response, leading to longer viral shedding, secondary bacterial and fungal infections, and even increased mortality (webappendix).3Brun-Buisson C Richard JC Mercat A Thiébaut AC Brochard L for the REVA-SRLF A/H1N1v 2009 Registry GroupEarly corticosteroids in severe influenza A/H1N1 pneumonia and acute respiratory distress syndrome.Am J Respir Crit Care Med. 2011; 183: 1200-1206Crossref PubMed Scopus (284) Google Scholar, 4Lee N Chan PK Hui DS et al.Viral loads and duration of viral shedding in adult patients hospitalized with influenza.J Infect Dis. 2009; 200: 492-500Crossref PubMed Scopus (421) Google Scholar Controlled studies are needed to address the use of corticosteroids in viral pneumonia and its safety. Notably, in viral pneumonia caused by the coronavirus that causes severe acute respiratory syndrome, increased viral load has been documented with corticosteroid treatment in a randomised trial.5Lee N Chan KC Hui DS et al.Effects of early corticosteroid treatment on plasma SARS-associated coronavirus RNA concentrations in adult patients.J Clin Virol. 2004; 31: 304-309Crossref PubMed Scopus (491) Google Scholar Given the differences in immunopathogenesis between viral and bacterial pneumonia, and the uncertainties in efficacy and safety,4Lee N Chan PK Hui DS et al.Viral loads and duration of viral shedding in adult patients hospitalized with influenza.J Infect Dis. 2009; 200: 492-500Crossref PubMed Scopus (421) Google Scholar we recommend that corticosteroids should not be used routinely in known viral community-acquired pneumonia, especially influenza-related. In this regard, availability of rapid and reliable diagnostics for the causes of community-acquired pneumonia is important to guide antimicrobial treatments (targeted, susceptible antibacterials; or antivirals such as neuraminidase inhibitors), and the use of adjuvant corticosteroids.2Bartlett JG Diagnostic tests for agents of community-acquired pneumonia.Clin Infect Dis. 2011; 52: S296-S304Crossref PubMed Scopus (182) Google Scholar, 4Lee N Chan PK Hui DS et al.Viral loads and duration of viral shedding in adult patients hospitalized with influenza.J Infect Dis. 2009; 200: 492-500Crossref PubMed Scopus (421) Google Scholar We declare that we have no conflicts of interest. Download .pdf (.08 MB) Help with pdf files Supplementary webappendix Dexamethasone in community-acquired pneumonia – Authors' replyWe used Kaplan-Meier analysis to estimate the size of the primary outcome: length of hospital stay. From this same dataset, Bhavneet Bharti and Sahul Bharti have calculated the absolute risk reduction (ARR) and number needed to treat to benefit (NNTB) at days 8 and 12. However, at day 8, and certainly at day 12, most patients were already discharged from hospital, more from the dexamethasone group than the placebo group. We calculated that, on day 7, the ARR is 17% (95% CI 7–28) and the NNTB 6 (4–15). Full-Text PDF