Department of Anesthesia and Perioperative Medicine, University of California San Francisco.
Associate Editor, JAMA.
JAMA. 2024 Jul 23;332(4):318-328. doi: 10.1001/jama.2024.6096.
Severe pulmonary infections, including COVID-19, community-acquired pneumonia, influenza, and Pneumocystis pneumonia, are a leading cause of death among adults worldwide. Pulmonary infections in critically ill patients may cause septic shock, acute respiratory distress syndrome, or both, which are associated with mortality rates ranging between 30% and 50%.
Corticosteroids mitigate the immune response to infection and improve outcomes for patients with several types of severe pulmonary infections. Low-dose corticosteroids, defined as less than or equal to 400 mg hydrocortisone equivalent daily, can reduce mortality of patients with severe COVID-19, community-acquired pneumonia, and Pneumocystis pneumonia. A randomized clinical trial of 6425 patients hospitalized with COVID-19 who required supplemental oxygen or noninvasive or invasive mechanical ventilation reported that dexamethasone 6 mg daily for 10 days decreased 28-day mortality (23% vs 26%). A meta-analysis that included 7 randomized clinical trials of 1689 patients treated in the intensive care unit for severe bacterial community-acquired pneumonia reported that hydrocortisone equivalent less than or equal to 400 mg daily for 8 days or fewer was associated with lower 30-day mortality compared with placebo (10% vs 16%). In a meta-analysis of 6 randomized clinical trials, low-dose corticosteroids were associated with lower mortality rates compared with placebo for patients with HIV and moderate to severe Pneumocystis pneumonia (13% vs 25%). In a predefined subgroup analysis of a trial of low-dose steroid treatment for septic shock, patients with community-acquired pneumonia randomized to 7 days of intravenous hydrocortisone 50 mg every 6 hours and fludrocortisone 50 μg daily had decreased mortality compared with the placebo group (39% vs 51%). For patients with acute respiratory distress syndrome caused by various conditions, low-dose corticosteroids were associated with decreased in-hospital mortality (34% vs 45%) according to a meta-analysis of 8 studies that included 1091 patients. Adverse effects of low-dose corticosteroids may include hyperglycemia, gastrointestinal bleeding, neuropsychiatric disorders, muscle weakness, hypernatremia, and secondary infections.
Treatment with low-dose corticosteroids is associated with decreased mortality for patients with severe COVID-19 infection, severe community-acquired bacterial pneumonia, and moderate to severe Pneumocystis pneumonia (for patients with HIV). Low-dose corticosteroids may also benefit critically ill patients with respiratory infections who have septic shock, acute respiratory distress syndrome, or both.
严重肺部感染，包括 COVID-19、社区获得性肺炎、流感和卡氏肺孢子虫肺炎，是全球成年人死亡的主要原因。危重症患者的肺部感染可导致脓毒症休克、急性呼吸窘迫综合征或两者兼有，死亡率在 30%至 50%之间。
皮质类固醇可减轻感染引起的免疫反应，并改善多种严重肺部感染患者的预后。低剂量皮质类固醇，定义为每日低于或等于 400mg 氢化可的松等效剂量，可降低严重 COVID-19、社区获得性肺炎和卡氏肺孢子虫肺炎患者的死亡率。一项纳入 6425 例因 COVID-19 住院需要补充氧气或无创或有创机械通气的患者的随机临床试验报告称，地塞米松 6mg 每日 10 天可降低 28 天死亡率（23%比 26%）。一项纳入 1689 例在重症监护病房因严重细菌性社区获得性肺炎接受治疗的患者的 7 项随机临床试验的荟萃分析报告称，每日氢化可的松等效量低于或等于 400mg 持续 8 天或更短时间与安慰剂相比，30 天死亡率较低（10%比 16%）。在一项针对 HIV 合并中度至重度卡氏肺孢子虫肺炎患者的 6 项随机临床试验的荟萃分析中，与安慰剂相比，低剂量皮质类固醇可降低死亡率（13%比 25%）。在一项关于败血症休克的低剂量类固醇治疗试验的预先设定亚组分析中，与安慰剂组相比，随机接受 7 天静脉注射氢化可的松 50mg 每 6 小时和氟氢可的松 50μg 每日的社区获得性肺炎患者死亡率降低（39%比 51%）。根据纳入 1091 例患者的 8 项研究的荟萃分析，对于各种原因导致的急性呼吸窘迫综合征患者，低剂量皮质类固醇与住院死亡率降低相关（34%比 45%）。低剂量皮质类固醇的不良反应可能包括高血糖、胃肠道出血、神经精神障碍、肌肉无力、高钠血症和继发感染。
对于严重 COVID-19 感染、严重社区获得性细菌性肺炎和中度至重度卡氏肺孢子虫肺炎（对于 HIV 患者）患者，低剂量皮质类固醇治疗与死亡率降低相关。对于患有败血症休克、急性呼吸窘迫综合征或两者兼有呼吸感染的危重症患者，低剂量皮质类固醇也可能有益。
