CICM SAQ 2016.1 Q5

Question

Critically evaluate the role of corticosteroids in the management of severe community-acquired pneumonia.

Answer

Answer and interpretation

Rationale / Indications

Conventional & generally accepted indications include:

  • Pneumonia complicating exacerbated COPD
  • PJP infection with lung infiltrates (data from HIV population, and by extrapolation to other
    immunosuppressed groups)
  • Patients who are on long term corticosteroids or otherwise have adrenal suppression
  • (With less certainty) those with shock states and vasoplegia as a catecholamine sparing
    strategy

Outside of these groups, in a general population with CAP:

  • The basis for use is as an adjunctive therapy in hospitalised patients to reduce inflammation and improve morbidity or mortality.
  • Some patients with CAP fail to resolve, and progress to cryptogenic organising pneumonia, (COP) with case series showing response to corticosteroids (and relapse on early cessation
  • Conflicting evidence in the fibro-proliferative phase of ARDS
  • Now several studies randomising patients to early use in uncomplicated CAP

Potential adverse effects

  • Super-added infection
  • Muscle weakness / Proximal myopathy / Critical illness polyneuromyopathy
  • Difficulty weaning from ventilatory support

Evidence

A 2015 Meta-analyses (Siemieniuk et al, 2015):

  • 3% decrease in all-cause mortality,
  • 5% decrease rate of mechanical ventilation
  • Reduced hospital length of stay by 1 day.
  • Critique of metanalysis
    • Trials included in metanalyses have been small o had high heterogeneity
    • Insufficient power to analyse mortality.
    • Many exclusions
      • (e.g. immunocompromised patients at risk of superinfection, pregnant women, GI bleeding within 3 months as well as patients with neuropsychiatric conditions prone to psychotic side effects of steroids)
    • small overall effect

A recent RCT (Blum et al, Lancet 2015, 392 pt per group) showed a shorter time to reach a composite endpoint of ‘clinical stability’ with Prednisolone 50mg daily for 7 days.

Another RCT (Torres et al, JAMA 2015, 60 pt per group) showed that Methylprednisolone 0.5mg/kg 12h for 5 days reduced risk of “treatment failure” compared with placebo in patients with severe CAP and high CRP levels

Practical (Translational) Issues

  • No clear data on exact steroid and regimen
    • There is no definitive data on what type of steroid to give and whether to give
      continuously or in a tapering regimen and for how long.
    • In the idiopathic pneumonia group (COP) steroid tapering can be associated with
      abrupt relapse
  • Pathogen dependent response to steroids
    • Pneumonia due to pathogens like the influenza virus and aspergillus may be associated with worse outcomes with steroid use, PCP better
  • Studies in progress that may help
    • The ESCAPE study by the Department of Veterans affairs is assessing the role of
      steroids in CAP with either placebo, methyl prednisolone 40 mg per day or 20 mg per day for 7 days followed by tapering over 13 days on all cause 60 day mortality.

Summary statement (For example)

  • Subgroups where steroids would be conventional therapy (COPD, PJP)
  • Not yet accepted therapy
  • Treatment effect small
  • But no evidence of adverse effect and demonstrated safety
  • Listed as practice changing update in Up-to-Date
  • Should ideally be a conjoint decision with clinician responsible for post ICU management

Additional comments:

Candidates were lacking in knowledge relating to the evidence for steroids in severe CAP. The detail in above template was not required for a pass mark. Satisfactory answer for a pass mark was expected to include:

  • Accepted indications for steroids in CAP
  • Some reference to rationale for use in other groups with CAP
  • Potential adverse effects
  • Some reference to evidence

Pass rate: 34%

Highest mark: 7.0


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Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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