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Association Between Systemic Corticosteroids and Outcomes of ICU-Acquired Pneumonia
Study Question: Do systemic corticosteroids affect the dynamics of infection, complications, and outcomes in patients with ICU-acquired pneumonia?
Study Description: This study was a single-centered, prospective, observational analysis that compared 28-day survival after the diagnosis of ICU-acquired pneumonia between patients exposed or unexposed to corticosteroids. Steroid-exposed patients received an equivalent dosage of at least 20 mg/day of systemic methylprednisolone 2 days prior to the development of pneumonia. Clinical suspicion of pneumonia was based on clinical assessment (imaging, secretions, SIRS) or a simplified Clinical Pulmonary Infectious Score ≥ 6. Cox regression with a propensity-to-treat-with-steroid score adjusted for lack of randomization.
Results: A total of 316 patients were analyzed, of which 125 patients received systemic corticosteroids at the moment of ICU-acquired pneumonia. Methylprednisolone and dexamethasone accounted for >75% of steroid use with a mean duration for six days. Patients who received steroids were less likely to be post-op (p = 0.008) more likely to have chronic heart disease (p = 0.005) and be admitted to the ICU for decreased consciousness (p = 0.022) or multiple traumas (p = 0.018). Steroid treatment was associated with decreased 28-day survival (HR 2.5; p = 0.017), higher microbial burden, and decreased systemic inflammatory response based on inflammatory biomarkers. In post hoc analyses, steroid treatment had a negative impact on survival in patients with non-VAP ICU-pneumonia, those with lower baseline severity / organ dysfunction, and those without etiologic diagnosis or bacteremia.
Conclusion(s): Systemic corticosteroids should be used cautiously in patients without established indications or lower baseline severity due to increased risk of death with ICU-acquired pneumonia.
Perspective: A lack of randomization to steroids, variability in indications, unknown dose or duration, and limitations with method to identify pneumonia continues to cloud the question of steroids’ utility. They may actually decrease the inflammatory response leading to delayed clinical suspicion and higher bacterial load. Until additional randomized trials are available, clinicians should continue to use them cautiously in the absence of clear indications.