Chua Wei Yu, Chew Natalie, Iyer Shruthi C, Goh Rachel, Koh Wei Ren Ryanna, Vu Hong Lien, Yap Qai Ven, Samuel Miny, Soong John, Cove Matthew Edward
Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
Department of Medicine, National University Hospital, Singapore.
Ann Acad Med Singap. 2024 Nov 18;53(11):683-693. doi: 10.47102/annals-acadmedsg.2024159.
This systematic review and meta-analysis aimed to evaluate the effectiveness and safety of adjunct systemic corticosteroid therapy in patients admitted to the intensive care unit (ICU) with bacterial community-acquired pneumonia (CAP).
We searched MEDLINE, Embase and the Cochrane Library to identify randomised controlled trials (RCTs) published from the databases' inception to February 2024. All RCTs evaluating the effect of systemic corticosteroids on mortality, compared to standard of care among adult bacterial CAP patients admitted to ICU were included. Bayesian meta-analysis was conducted in line with the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Independent authors reviewed each study for eligibility, extracted data and assessed risk of bias in duplicate, with discrepancies referred to senior reviewers.
A total of 6 RCTs comprising 1585 patients were included for analysis. In ICU patients with severe CAP who were treated with corticosteroids, there was no significant reduction in hospital mortality (risk ratio [RR] 0.70, 95% confidence interval [CI] 0.39-1.14, certainty of evidence: ⊕⊕⊝⊝ low) or all-cause mortality (RR 0.68, 95% CI 0.34-1.22, ⊕⊕⊝⊝ low) compared with placebo. The use of corticosteroids showed a significant reduction in mechanical ventilation post-intervention (RR 0.58, 95% CI 0.37-0.86, ⊕⊕⊕⊕ high) compared with placebo. In a subgroup analysis of patients treated with hydrocortisone, hospital mortality was significantly reduced (RR 0.45, 95% CI 0.20-0.88, ⊕⊕⊝⊝ low) compared with placebo. There was no significant increase in gastrointestinal bleeding, secondary infections or hyperglycaemia in patients treated with corticosteroids.
Corticosteroids significantly reduced mechanical ventilation requirements, and hydrocor-tisone significantly reduced hospital mortality. Further work is required to determine whether other corticosteroids reduce mortality among ICU patients with CAP.
本系统评价和荟萃分析旨在评估在重症监护病房（ICU）收治的细菌性社区获得性肺炎（CAP）患者中，辅助全身性皮质类固醇治疗的有效性和安全性。
我们检索了MEDLINE、Embase和Cochrane图书馆，以识别从数据库建立至2024年2月发表的随机对照试验（RCT）。纳入所有评估全身性皮质类固醇对入住ICU的成年细菌性CAP患者死亡率影响的RCT，并与标准治疗进行比较。根据系统评价和荟萃分析的首选报告项目指南进行贝叶斯荟萃分析。独立作者对每项研究进行资格审查，重复提取数据并评估偏倚风险，如有差异则提交给高级审查员。
共纳入6项RCT，涉及1585例患者进行分析。在接受皮质类固醇治疗的重症CAP的ICU患者中，与安慰剂相比，医院死亡率（风险比[RR]0.70，95%置信区间[CI]0.39 - 1.14，证据确定性：⊕⊕⊝⊝低）或全因死亡率（RR 0.68，95% CI 0.34 - 1.22，⊕⊕⊝⊝低）没有显著降低。与安慰剂相比，使用皮质类固醇显示干预后机械通气显著减少（RR 0.58，95% CI 0.37 - 0.86，⊕⊕⊕⊕高）。在接受氢化可的松治疗的患者亚组分析中，与安慰剂相比，医院死亡率显著降低（RR 0.45，95% CI 0.20 - 0.88，⊕⊕⊝⊝低）。接受皮质类固醇治疗的患者胃肠道出血、继发感染或高血糖症没有显著增加。
皮质类固醇显著降低了机械通气需求，氢化可的松显著降低了医院死亡率。需要进一步研究以确定其他皮质类固醇是否能降低CAP的ICU患者的死亡率。
