Department of Medicine, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4L8, Canada.
Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, USA.
J Gen Intern Med. 2023 Aug;38(11):2593-2606. doi: 10.1007/s11606-023-08203-6. Epub 2023 Apr 19.
International guidelines provide heterogenous guidance on use of corticosteroids for community-acquired pneumonia (CAP).
We performed a systematic review of randomized controlled trials examining corticosteroids in hospitalized adult patients with suspected or probable CAP. We performed a pairwise and dose-response meta-analysis using the restricted maximum likelihood (REML) heterogeneity estimator. We assessed the certainty of the evidence using GRADE methodology and the credibility of subgroups using the ICEMAN tool.
We identified 18 eligible studies that included 4661 patients. Corticosteroids probably reduce mortality in more severe CAP (RR 0.62 [95% CI 0.45 to 0.85]; moderate certainty) with possibly no effect in less severe CAP (RR 1.08 [95% CI 0.83 to 1.42]; low certainty). We found a non-linear dose-response relationship between corticosteroids and mortality, suggesting an optimal dose of approximately 6 mg of dexamethasone (or equivalent) for a duration of therapy of 7 days (RR 0.44 [95% 0.30 to 0.66]). Corticosteroids probably reduce the risk of requiring invasive mechanical ventilation (RR 0.56 [95% CI 0.42 to 74] and probably reduce intensive care unit (ICU) admission (RR 0.65 [95% CI 0.43 to 0.97]) (both moderate certainty). Corticosteroids may reduce the duration of hospitalization and ICU stay (both low certainty). Corticosteroids may increase the risk of hyperglycemia (RR 1.76 [95% CI 1.46 to 2.14]) (low certainty).
Moderate certainty evidence indicates that corticosteroids reduce mortality in patients with more severe CAP, the need for invasive mechanical ventilation, and ICU admission.
国际指南对社区获得性肺炎（CAP）中皮质类固醇的使用提供了不同的指导意见。
我们对住院的疑似或可能患有 CAP 的成年患者使用皮质类固醇的随机对照试验进行了系统评价。我们使用受限最大似然（REML）异质性估计值进行了成对和剂量反应荟萃分析。我们使用 GRADE 方法评估证据的确定性，并使用 ICEMAN 工具评估亚组的可信度。
我们确定了 18 项符合条件的研究，共纳入 4661 名患者。皮质类固醇可能降低更严重 CAP 的死亡率（RR 0.62 [95% CI 0.45 至 0.85]；中等确定性），对不太严重的 CAP 可能没有影响（RR 1.08 [95% CI 0.83 至 1.42]；低确定性）。我们发现皮质类固醇与死亡率之间存在非线性剂量反应关系，表明治疗 7 天的最佳剂量约为 6 毫克地塞米松（或等效物）（RR 0.44 [95% 0.30 至 0.66]）。皮质类固醇可能降低需要有创机械通气的风险（RR 0.56 [95% CI 0.42 至 74]），可能降低入住重症监护病房（RR 0.65 [95% CI 0.43 至 0.97]）（均为中等确定性）。皮质类固醇可能缩短住院时间和 ICU 入住时间（均为低确定性）。皮质类固醇可能增加高血糖的风险（RR 1.76 [95% CI 1.46 至 2.14]）（低确定性）。
中等确定性证据表明，皮质类固醇可降低严重 CAP 患者的死亡率、有创机械通气的需求和 ICU 入住率。
